Elsevier

The Spine Journal

Volume 16, Issue 12, December 2016, Pages 1582-1597
The Spine Journal

Review Article
Which interventions are cost-effective for the management of whiplash-associated and neck pain-associated disorders? A systematic review of the health economic literature by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

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Abstract

Background Context

Whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD) are prevalent conditions that impact society and impose a significant economic burden on health-care systems. Health economic evidence on WAD and NAD interventions has been sparse: only three economic evaluations of interventions for NAD were identified by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders (NPTF). An updated overview is needed to inform health-care policy and guidelines.

Purpose

This study aimed to determine the cost-effectiveness of interventions for grades I–III WAD and NAD in children and adults.

Study Design

Systematic review of health economic literature, best-evidence synthesis.

Methods

We systematically searched CINAHL, the Cochrane economic databases (Health Technology Assessment, NHS Economic Evaluation Database), EconLit, EMBASE, MEDLINE, PsycINFO, and Tufts CEA Registry from 2000 to 2015 for economic evaluations of WAD and NAD interventions. We appraised relevant evaluations using the Scottish Intercollegiate Guidelines Network Methodology Criteria for Economic Evaluations. We extracted data, including mean costs (standardized to 2013 Canadian dollars [CAD]) and quality-adjusted life years (QALYs), from studies with adequate methodological quality. We recalculated cost-effectiveness statistics based on the standardized currency using a willingness-to-pay of CAD $50,000 per additional QALY. Funding was provided by the Ministry of Finance.

Results

Our search identified 1,616 citations. Six studies fulfilled our selection criteria, including three studies previously reviewed by the NPTF. Structured education appears cost-effective for adults with WAD. For adults with NAD, acupuncture added to routine medical care; manual therapy; multimodal care that includes manual therapy; advice and exercise; and psychological care using cognitive-behavioral therapy appear cost-effective. In contrast, adding manual therapy or diathermy to advice and exercise; multimodal care by a physiotherapist or physician; and behavioral-graded activity do not appear cost-effective for adults with NAD.

Conclusions

Our review adds to the findings of the NPTF. Recent evidence suggests that structured education is cost-effective for WAD, whereas advice and exercise and multimodal care that include manual therapy are cost-effective for NAD. Obtaining more robust health economic evidence for non-invasive interventions for WAD and NAD in children and adults remains an essential research priority.

Introduction

Whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD) are prevalent health concerns that impose a significant economic burden on health-care systems [1], [2], [3]. Whiplash-associated disorders affect 83% of persons involved in traffic collisions, whereas the 12-month prevalence of NAD in the general population ranges from 30% to 50% [3], [4]. Recovery from these conditions can be prolonged and associated with high health resource use [5]. Costs related to managing these conditions are substantial because of medical costs and costs associated with productivity changes [6], [7].

Health economic evidence on the management of WAD and NAD is sparse. A 2008 systematic review by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders (NPTF) identified only three economic evaluations of interventions for NAD and none for WAD [8]. This gap in the health economic evidence prompted the NPTF to recommend cost-effectiveness analyses of WAD and NAD interventions as important research priorities [9].

For the management of NAD in adults, the NPTF found that

  • Acupuncture added to routine medical care appeared to be cost-effective [10];

  • Manual therapy appeared to be cost-effective [11];

  • Psychological care consisting of self-management using cognitive-behavioral therapy principles appeared to be cost-effective [12]; and

  • Multimodal care by a physiotherapist or physician appeared not to be cost-effective [10], [11], [12].

Increasing health resource use has led governments to identify the appropriate management of WAD as a health policy priority [13], [14], [15], [16], [17]. An updated overview of the health economic literature is needed to inform imminent health-care policy decisions and guidelines. Accordingly, the aim of our systematic review was to determine the cost-effectiveness of non-invasive interventions for the treatment of grades I–III WAD and NAD.

Section snippets

Methods

We conducted and reported this review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the Cochrane Handbook for Systematic Reviews of Interventions [18], [19].

Study selection

Our search identified 1,616 citations (Fig. 1). From these, six met our eligibility criteria and had a low risk of bias (Table 3) [10], [11], [12], [35], [36], [37]. Three of these six studies were previously included in the NPTF's review of non-invasive interventions [10], [11], [12]. Inter-rater agreement for screening citations for relevant studies was k=0.92 (95% CI: 0.82, 1.00). The percentage agreement for the independent critical appraisal of studies was 100%.

All six economic evaluations

Discussion

Since the NPTF review was published in 2008, the literature on the cost-effectiveness of interventions for WAD and NAD has advanced. Our systematic search identified the first economic evaluation of interventions for grades I–III WAD in adults [36], and a further two economic evaluations of interventions for grades I–II NAD in adults [35], [37]. Collectively, these provide evidence on the cost-effectiveness of acupuncture, education, manual therapy, pulsed shortwave diathermy, and selected

Conclusions

Our review identified new evidence on the cost-effectiveness of interventions for WAD and NAD, including the first economic evaluation of interventions for grades I–III WAD in adults. Obtaining more robust health economic evidence on the efficiency of non-invasive interventions for WAD and NAD in children and adults is an essential research priority.

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    Author disclosures: GV: Nothing to disclose. HY: Nothing to disclose. MP: Nothing to disclose. PC: Grants: Ontario Ministry of Finance (I, Paid directly to institution/employer), pertaining to the submitted work; Consulting: Canadian Chiropractic Protective Association (B); Speaking and/or Teaching Arrangements: National Judicial Institute (A), Societe des Medecins Experts du Quebec (A); Trips/Travel: European Spine Society (B, Paid directly to institution/employer); Grants: Canada Research Chair—Canadian Institutes of Health Research (F, Paid directly to institution/employer), outside the submitted work. SV: Nothing to disclose. HMS: Nothing to disclose. JJW: Nothing to disclose. KR: Nothing to disclose. DaS: Nothing to disclose. SM: Consulting Fee or Honorarium: MIG Project (B, Guideline Expert Panel member), pertaining to the submitted work. DeS: Nothing to disclose. CJ: Nothing to disclose. ATV: Nothing to disclose.

    The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

    This study was funded by the Ontario Ministry of Finance (RFP# No.: OSS_00267175) and the Financial Services Commission of Ontario. The funding agency was not involved in the collection of data, data analysis, interpretation of data, or drafting of the paper. This research was undertaken, in part, thanks to funding from the Canada Research Chairs program (#950-228941).

    Systematic Review Registration Number: CRD42013004354.

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