Cost-effectiveness of Early Interventions for Non-specific Low Back Pain

Critical Appraisal of an Economic Evaluation:

Cost-effectiveness of Early Interventions for Non-specific Low Back Pain: A Randomised Controlled Study Investigating Medical Yoga, Exercise Therapy and Self-care Advice

1. What is the economic research question in this paper?

The paper has evaluated the cost-effectiveness of medical yoga, which is an early intervention that is compared to evidence-based studies on selfcare advice and exercise therapy for non-low back pain (Aboagye et al., 2015). Low back pain is “activity-limiting low back pain referred to in one or both lower limbs that lasts for at least one day” (Hoy et al., 2010, p.28).

2. What was the intervention being compared with?

The paper has shown medical yoga as an early intervention in comparison with exercise therapy and self-care advice. In fact, medical yoga could be an effective intervention for low back pain. Even though exercise therapy could be widely used in the case of back pain with positive results as well, yoga could help with low back pain (Aboagye et al., 2015).

3. What is the clinical basis for the effectiveness of the intervention in this paper?

The basis for the effectiveness of this intervention is the significant results of studies evaluating the effectiveness of yoga for controlling LBP (low back pain). These include reducing pain depth and higher development in physical and functional disabilities (Bussing et al., 2010). On the other hand, there has not enough research on the development of related quality of life to find out how could this intervention can be cost effective for Low back pain (Chuang et al., 2012).  The most important point is to conduct studies on the outcome and cost effectiveness of intervention such as medical yoga from an early stage to prevent low back pain.

 (Chuang et al., 2012). According to Jensen et al. (2012), the self-care advice group obtained short oral advice from specialists about remaining active. They also received booklets containing self-care advice and a brief recommendation about staying energetic,

which has explained the benefits on back pain and physical activities among who suffer from back pain

4. Describe the perspective from which the economic analysis was conducted.

The Statistics Central Bureau (2012) found that the evaluation was managed from the social group perspective. Moreover, the societal standpoint covered all charges associated with the intervention and production loss as a result of ailment absence. Production losses resulting from illness absences have been estimated as the mean hourly income of the employee expanded with the aid of the wide variety of days off work.

The connect with intervention

“In addition to the hourly income additional compensation-holiday allowances (13%), labour (31.42%) and pension contributions (10%) paid on top of employee revenue were included.” These payments in themselves will no longer symbolise any extra consumption of sources from the standpoint of society. However, this revenue is blanketed as charges to society solely as a proxy of misplaced productivity and reduced work production due to health problem absences (Aboagye et al., 2015). The analysis was additionally carried out from the employer’s perspective and included the intervention costs (Drummond et al., 2005).

5. What type of economic evaluation was conducted and were a comprehensive range of costs and outcomes considered given the choice of type of study?

According to Aboagye et al. (2015) the study conducted a cost-effectiveness analysis and outcome measure on all subjects.  The survey carried out a sensitivity analysis that focused on the productivity losses, the costs of intervention and the outcome measurements. The direct and indirect costs, including production losses of each in intervention in the study, were analysed. The cost of resources, the length of time and the quantity of resources used were also analysed. Also, the study took into consideration both the individual, societal, employee and employer’s perspective to ensure the creation of a more cost-effective treatment plan.  The productivity benefits were measured for each group, and the incremental cost was analysed. The impact of lost production from the employer’s perspective and how it influenced decision-making was also considered in the study.  For instance, the study examined the cost of the trainer, the cost of materials used and the physician assessment cost on the medical yoga group. The exercise therapy group included the cost of the physician assessment, the cost of the first and repeat visit, the cost of exercise training sessions, the back book and exercise ball.  Therefore, it is evident that a comprehensive range of costs and outcomes were considered by this current study. Aboagye et al. (2015) found that no side effects were acknowledged in all intervention agencies about cure outcomes, which have been viewed as fees rather than benefits. Participants in the exercise therapy and self-care advice groups had greater implied EQ-5d ratings at baseline than individuals in the medical yoga group. However, during each follow-up period, individuals in the medical yoga group had higher suggested rankings than those in the exercise therapy and self-care advice groups. The baseline EQ-5d ratings were then used as coverage for the adjustment (Aboagye et al., 2015).

6. What range and in what units were the costs and outcomes measured?

Kind et al. (2005) defined the EQ-5D as a general and broadly used health status instrument. It was developed by using the EuroQol Group in the 1980s to create a concise, common instrument that could be used to measure, examine and assess health popularity across disease areas. In this study, the result of the HRQL was measured with EQ-5d as a guideline, and measurement occurred each week, after six and 12 months. In fact, this instrument measures the individual’s health area on five scales: mobility, self-care, common activities, pain discomfort and anxiety/depression. The responses had been weighted with the time trade-off method, which offers first-rate adjusted existence (QALY) values anchored between zero and 1. Place 1 is 12 months lived in full fitness and 0 (zero) represents death (Kind et al., 2005). It seems clear that EQ-5D is the most common approach to examining costs and health status across disease.

7. How were costs and outcomes valued?

Aboagye et al. (2015) have shown that unit costs had been priced in Euros and that estimated fees were based on the wide variety and type of activities in each remedy group, the amount of assets consumed and the period in which the resources were used. The fee in the clinical yoga crew protected the price of the yoga trainer, the cost of the substances used and the physician assessment screening cost based totally on the most important care reference fee per visit to a physician. It also included the cost of the first visit to a physiotherapist and repeat visits, the cost of a study coaching exercise based primarily on the market price if the participant acquired bodily exercise on prescription, the returned E-book and the workout ball. The fee in the self-care advice team was once primarily based on medical doctor evaluation and self-care recommendation as properly as the returned book. The intervention prices have incurred regardless of the range of instructions individuals had after allocation to a cure group. Moreover, participants had been assigned identical charges based primarily on allocation to a treatment group (Aboagye et al., 2015).

8- Were costs and/or outcomes discounted?

In this study “discounting was not compulsory as value, and impact appeared with an engaged participant a year later because the whole cost of sources used in the trial displayed 2011/2012 prices, considering the follow-up duration that occurred within this interval” (Drummond et al., 2005, p.22). It seems clear that the discounting might be necessary in some studies when it is important to discount costs or outcomes.

9- Was an incremental or marginal analysis undertaken?

Aboagye et al. (2015) have shown the analysis was once additionally carried out from the employer’s perspective. For instance, an analysis of the intervention costs was carried out by the employer because uncertainty can occur about the use of, for instance, negative ICER in a cost-effectiveness analysis for decision-making. Moreover, Incremental internet gain (INB) was once also estimated. The INB is a linear expression of the cost-effectiveness choice rule that can hint at the internet benefits of the intervention after accounting for the additional value of enforcing an intervention. The most important feature by which INB was estimated was by multiplying the adjusted incremental QALY through the willingness to pay less than the suggested incremental value. The INB gives proof that an intervention is cost-effective if the net benefit is greater than zero. The willingness to pay the assumed cost was EUR 11,500, equal to SEk 100,000 per QALY, which is the decrease limit steady with the guidelines of the Swedish National Board of Health and Welfare for a cost-effective intervention (Drummond et al., 2005).

10. What sensitivity analysis was conducted?

A study by Aboagye et al. (2015) has demonstrated how the one-way sensitivity analysis was used to estimate the whole absenteeism cost by multiplying a wide variety of days off work by means of the median multiplier 1.28 by the mean of each day’s wage price. The median multiplier was once used due to the nature and variety of jobs that individuals had been engaged in at the beginning of the study. The sensitivity analysis showed that the cost-effectiveness results, which covered the estimation of the multiplier’s impact on manufacturing losses ensuing from disease absence, suggests that the incremental value is normally sensitive to changes in the price of productiveness. In addition, the evaluation suggests that it will cost EUR 1,887 and EUR 2,761 less per person to treat LBP with clinical yoga, in contrast with exercise therapy and self-care advice, respectively. Sensitivity evaluation then shows that medical yoga remains an economical intervention in contrast with exercise therapy and self-care advice (Aboagye et al., 2015).

11. Were the results compared with findings from other studies?

The results emphasise the significance of adherence to treatment recommendations; in this case, training a minimal of two instances per week and the relevance of accounting for adherence in the evaluation when looking at the effects on HRQL. Variations between intervention companies are shown in the adherence rate. The variations may also suggest that the motivation of subjects in the intervention’s organisations differed in addition to their desire for a specific kind of training. Another possibility is that it is simpler to adhere to clinical yoga than to exercise intervention (Aboagye et al., 2015). However, in this study, it was difficult to differentiate the fee of forgone production borne through the employer from the typical societal cost. Therefore, no reduction or expansion in price is covered from this perspective. In line with preceding studies, we discovered that yoga treatments have positive outcomes for managing physical pain and functional disabilities related to LBP (Aboagye et al., 2015).

12. What policy implications of the findings of this study were discussed and would the study provide useful information to health service commissioners?

This study provides a contribution to research on early interventions for non-specific LBP. The study attaches significance to participant adherence to cure and concludes that with respect to an early intervention for LBP, the usage of medical yoga can have far-reaching advantages for employees who exhibit early symptoms of LBP (Aboagye et al., 2015). The study also highlights the essential determinants of fees to the organisation and to society as they relate to treatment of LBP with medical yoga. In summary, the result of this financial contrast supports the use of medical yoga as an early intervention for treating LBP in an OHS placing. The treatment choice to which a decision-maker can channel assets is medical yoga, which is related to better improvement in HRQL and high-quality incremental net benefits. The fitness features from medical yoga are also reasonably priced from the societal perspective, albeit marginally in contrast with exercise therapy and self-care advice. Based on these results, if all three interventions are restrained by using resources, medical yoga therapy is the most effective preference (Aboagye et al., 2015). It seems clear from this study that the government should help and support an intervention such as medical yoga because it is more cost-effective than other kinds of treatment.


  • Aboagye, E. Karlsson, M. Hagberg, J.  & Jensen, I. (2012) “Cost-effectiveness of Early Interventions for Non-specific Low Back Pain: A Randomized Controlled Study Investigating Medical Yoga, Exercise Therapy and Self-care Advice.” Journal of Rehabilitation Medicine 47. (2), 167-173. Web.
  • Bussing A, ostermann t, Ludtke R, Michalsen A. (2012). Effects of yoga interventions on pain and pain-associated disability: a metaanalysis; 13: 1–9.
  • Chuang L, Soares M, tilbrook H, cox H, Hewitt C, Aplin J, et al. (2012) A pragmatic multicentered randomized controlled trial of yoga for chronic low back pain: economic evaluation. Spine (Phila Pa 1976) 37: 1593–1601.
  • Drummond, M. F., Sculpher, M. J., Torrance, G. W., O’Brien, B. J., & Stoddart, G. L. (2005). Methods for the economic evaluation of health care programme. Third edition. Oxford: Oxford University Press.
  • Jensen Ld, Maribo t, Schiottz-christensen B, Madsen fH, gonge B, christensen M. (2012) counselling low-back-pain patients in secondary healthcare: a randomised trial addressing experienced workplace barriers and physical activity. occup Environ Med; 69: 21–28.
  • Kind P, Brooks R, Rabin R, editors. (2005) EQ-5d concepts and methods: A development history. dordrecht, Netherlands: Springer.
  • Statistics Central Bureau, Statistics Sweden. (2012). Average hourly and monthly earnings of manual and non-manual workers Sweden. 


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