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Cost of manipulation is bearable for back pain

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Manipulation for low back pain is an effective and cost effective treatment for public sector primary care in the United Kingdom, according to an economic evaluation in a randomised trial.

However, it requires the health service to spend £10 000 or more for each extra quality of life year (QUALY) achieved by the treatment—actually less than recommended by NICE (National Institute for Clinical Excellence)—but offers better value than manipulation plus exercise.

The trial compared patient outcomes and costs of adding manipulation or exercise or manipulation followed by exercise (combined treatment) to “best care in general practice”—consisting of practice teams trained in active management of back pain and giving patients the Back Book. Almost 1300 patients in 181 practices or 63 community settings around 14 centres took part for one year, and the number of patients per group ranged from 297 to 342.

Each extra QUALY delivered was costed to give an incremental cost effectiveness ratio. This value was £3800 for combined treatment over best care, when exercise and manipulation were available, and £8700 for manipulation alone, which produced a higher level of benefit over combined treatment. It was £4800 for manipulation over best care, if exercise was not available, and £8300 for exercise over best care if manipulation was not available.

Depending on the value accorded to extra QUALYs, future treatment policy might vary, possibly stretching staff resources. Further analysis showed that purchasing manipulation entirely from the private sector would not change cost effectiveness much, or patient outcomes.

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