Health economic aspects of low back pain

Sammanfattning: Four out of five people experience low back pain sometime during their lifetime. Problems of the back—and to a less extent of the neck—are consistently in the top seats among the most burdensome diseases in the developed world. In addition to its often-debilitating pain, low back pain is a major contributor to health care costs and lost productivity. Health economics is the study of how the health care system’s scarce resources can and should be used to maximise health. The objective of this thesis is to enhance the understanding of the economic aspects of low back pain. The overarching research themes are two. First, are surgical interventions for low back pain cost-effective? Second, what is its burden in Sweden? The first two papers present results from analyses of a vast database assembled from a range of Swedish institutions covering health care consumption of all patients with low back pain in the Västra Götaland region during 2000–2012. The former paper shows that the national cost of all patients that experienced an episode of low back pain in 2011 was €739 million or €78 per capita. Of this, 65% were due to indirect costs such as absence from work. The second paper draws on the dataset to create an economic model. It shows that although the majority of patients improve within a few months at a relatively low cost, the sheer number of patients experiencing back pain make the disease costly. Narrowing down, using results from a randomised controlled trial, the third paper shows that under certain assumptions, surgical treatment of degenerative disc disease is cost-effective when compared to multidisciplinary treatment involving physical therapy and cognitive behavioural therapy. The results are not robust to different assumptions and the interpretation of the results should take that into account. The fourth and last paper also uses results from a randomised controlled trial of decompression surgery for spinal stenosis. This type of surgery, the most common of all spinal surgeries, involves treating the spinal stenosis—painful narrowing of the spinal canal—with decompression, where parts of bone and soft tissue are removed to make room for the nerves. The study shows with robust results that fusing vertebra together as part of decompression surgery increases costs with neither short-term nor long-term benefits. This dissertation shows that the burden of low back pain, including lumbar spinal stenosis and lumbar disc herniation, is not only heavy but distributed widely within and outside of the health care system. Although most treatments are effective, this thesis shows an example of treatments that are being used extensively but are in fact quite wasteful. This could not have been shown without careful research and robust methodology. In order to improve the use of money within the health care, research needs to be conducted to assess where to spend it.