Cost-effectiveness of spinal manipulation therapy for neck or back pain

Abstract

Chronic pain is a major public health problem, affecting more adults in the United States than heart disease, diabetes, and cancer combined. Low back and neck pain are the most common chronic pain conditions and are two of the most disabling and costly conditions in the U.S. Approximately 4% of all healthcare spending in the U.S. is directed towards the management of back and neck pain, more than any other condition. Spine pain management has gathered increased scrutiny amidst concerns about overutilization of costly and potentially harmful interventions such as opioids, injections, and surgeries. Complementary and integrative interventions may reduce the clinical and cost burden of spine pain and are now recommended by clinical guidelines, but their use remains limited.This dissertation addresses the cost-effectiveness of spinal manipulation therapy and other complementary and integrative therapies for neck or back pain. First, we used individual patient data from eight randomized trials to conduct standardized cost-effectiveness analyses of spinal manipulation therapy (SMT), one of the most common complementary and integrative interventions, compared to home exercise or supervised exercise approaches. We found the cost-effectiveness of SMT varied by population and comparison. When compared to or added to home exercise, cost-effectiveness findings were favorable for acute neck pain, chronic neck pain in older adults, and chronic back-related leg pain; however, SMT was not likely cost-effective for chronic back pain. When compared to or added to supervised exercise, cost-effectiveness findings were favorable for chronic back pain in multiple age groups (adolescents, adults, older adults) and older adults with chronic neck pain. For adults with chronic neck pain, findings were mixed where SMT was not likely cost-effective relative to supervised exercise, but maybe cost-effective when added to supervised exercise. Next, we assessed the generalizability of the randomized clinical trial populations by comparing socio-demographic characteristics and clinical features to representative samples of US adults with chronic spine pain using data from the National Health Interview and Medical Expenditure Panel Surveys. We found the clinical trials had an under-representation of individuals from underserved communities with lower percentages of racial and ethnic minorities, less educated, and unemployed adults relative to the U.S. population with spine pain. While the odds of chiropractic use in the U.S. were lower for individuals from underserved communities, the trial populations also under-represented these populations relative to U.S. adults with chronic spine pain who visit a chiropractor. Finally, we estimated the cost-effectiveness of spinal manipulation and other complementary and integrative approaches for spine pain using a decision analysis model incorporating multiple sources of evidence. We found that yoga resulted in the lowest costs and largest health benefits relative to all other treatments across multiple populations. Other complementary and integrative approaches such as massage, mindfulness-based stress reduction, cognitive behavioral therapy, and SMT were also shown to be cost-effective options relative to home exercise and advice for chronic spine pain across different populations. Findings for these treatments were not sensitive to changes in key model parameters impacting costs or effectiveness. In summary, our work contributes to the understanding of the cost-effectiveness of complementary and integrative approaches including spinal manipulation in U.S. healthcare settings. We used both clinical trial-based and decision model analyses to assess cost-effectiveness and found general consistency of findings across the two approaches. There is a need to better understand the impact of these approaches in populations most severely impacted who are often under-represented in clinical trials.