Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial

doi:10.1136/bmj.39583.709074.BE

BMJ 2008;336:1351-1354 (14 June), doi:10.1136/bmj.39583.709074.BE (published 23 May 2008)

Research

Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial

Wilbert B van den Hout, health economist¹, Wilco C Peul, neurosurgeon²^,3, Bart W Koes, professor of general practice⁴, Ronald Brand, statistician⁵, Job Kievit, professor¹, Ralph T W M Thomeer, neurosurgeon², for the Leiden-The Hague Spine Intervention Prognostic Study Group

¹ Department of Medical Decision Making, Leiden University Medical Center, PO Box 9600, 2300RC Leiden, Netherlands, ² Department of Neurosurgery, Leiden University Medical Center, ³ Department of Neurosurgery, Medical Center Haaglanden, the Hague, Netherlands, ⁴ Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Netherlands, ⁵ Department of Medical Statistics, Leiden University Medical Center

Correspondence to: W B van den Hout hout{at}lumc.nl

research article, doi:10.1136/bmj.a143

Objective To determine whether the faster recovery after earlysurgery for sciatica compared with prolonged conservative careis attained at reasonable costs.

Design Cost utility analysis alongside a randomised controlledtrial.

Setting Nine Dutch hospitals.

Participants 283 patients with sciatica for 6-12 weeks, causedby lumbar disc herniation.

Interventions Six months of prolonged conservative care comparedwith early surgery.

Main outcome measures Quality adjusted life years (QALYs) atone year and societal costs, estimated from patient reportedutilities (UK and US EuroQol, SF-6D, and visual analogue scale)and diaries on costs (healthcare, patient’s costs, andproductivity).

Results Compared with prolonged conservative care, early surgeryprovided faster recovery, with a gain in QALYs according tothe UK EuroQol of 0.044 (95% confidence interval 0.005 to 0.083),the US EuroQol of 0.032 (0.005 to 0.059), the SF-6D of 0.024(0.003 to 0.046), and the visual analogue scale of 0.032 (–0.003to 0.066). From the healthcare perspective, early surgery resultedin higher costs (difference ${euro}$ 1819 (£1449; $2832), 95% confidenceinterval ${euro}$ 842 to ${euro}$ 2790), with a cost utility ratio per QALY of ${euro}$ 41 000 ( ${euro}$ 14 000 to ${euro}$ 430 000). From the societal perspective, savingson productivity costs led to a negligible total difference incost ( ${euro}$ –12, ${euro}$ –4029 to ${euro}$ 4006).

Conclusions Faster recovery from sciatica makes early surgerylikely to be cost effective compared with prolonged conservativecare. The estimated difference in healthcare costs was acceptableand was compensated for by the difference in absenteeism fromwork. For a willingness to pay of ${euro}$ 40 000 or more per QALY, earlysurgery need not be withheld for economic reasons.

Trial registration Current Controlled Trials ISRCTN 26872154.

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Rapid Responses:

Read all Rapid Responses

Does the evidence really support surgery at 8 weeks for radicular pain?: Geetha Gunaratnam, et al.
bmj.com, 19 Jun 2008 [Full text]
Is early surgery for radicular pain really better?: stuart harrison james, et al.
bmj.com, 3 Jul 2008 [Full text]
Author's reply to quick responses: Wilbert van den Hout, et al.
bmj.com, 16 Jan 2009 [Full text]