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Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomised controlled trial

BMJ 2010; 341 doi: (Published 01 December 2010) Cite this as: BMJ 2010;341:c6414
  1. Ludeke C Lambeek, researcher12,
  2. Judith E Bosmans, senior researcher3,
  3. Barend J Van Royen, professor45,
  4. Maurits W Van Tulder, professor3,
  5. Willem Van Mechelen, professor126,
  6. Johannes R Anema, professor126
  1. 1Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, Netherlands
  2. 2Body@Work, Research Center Physical Activity, Work and Health, TNO-VU-University Medical Center
  3. 3Department of Health Sciences and EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University
  4. 4Department of Orthopaedic Surgery, VU University Medical Center
  5. 5Research Institute MOVE, Amsterdam
  6. 6Research Center for Insurance Medicine, AMC-UMCG-UWV-VU University Medical Center
  1. Correspondence to: J R Anema, VU University Medical Center, Van der Boechorststraat 7 1081 BT, Amsterdam, Netherlands h.anema{at}
  • Accepted 9 September 2010


Objective To evaluate the cost effectiveness, cost utility, and cost-benefit of an integrated care programme compared with usual care for sick listed patients with chronic low back pain.

Design Economic evaluation alongside a randomised controlled trial with 12 months’ follow-up.

Setting Primary care (10 physiotherapy practices, one occupational health service, one occupational therapy practice) and secondary care (five hospitals) in the Netherlands, 2005-9.

Participants 134 adults aged 18-65 sick listed because of chronic low back pain: 66 were randomised to integrated care and 68 to usual care.

Interventions Integrated care consisted of a workplace intervention based on participatory ergonomics, with involvement of a supervisor, and a graded activity programme based on cognitive behavioural principles. Usual care was provided by general practitioners and occupational physicians according to Dutch guidelines.

Main outcome measures The primary outcome was duration until sustainable return to work. The secondary outcome was quality adjusted life years (QALYs), measured using EuroQol.

Results Total costs in the integrated care group (£13 165, SD £13 600) were significantly lower than in the usual care group (£18 475, SD £13 616). Cost effectiveness planes and acceptability curves showed that integrated care was cost effective compared with usual care for return to work and QALYs gained. The cost-benefit analyses showed that every £1 invested in integrated care would return an estimated £26. The net societal benefit of integrated care compared with usual care was £5744.

Conclusions Implementation of an integrated care programme for patients sick listed with chronic low back pain has a large potential to significantly reduce societal costs, increase effectiveness of care, improve quality of life, and improve function on a broad scale. Integrated care therefore has large gains for patients and society as well as for employers.


  • Contributors: LCL and JRA were responsible for the general coordination of the study and implemented the integrated care programme. LCL collected the data. WvM is guarantor. All authors designed the study, helped to write the manuscript, and read and approved the final version of the manuscript.

  • Funding: This study was supported by VU University Medical Center, TNO Work and Employment, Dutch Health Insurance Executive Council, Stichting Instituut GAK, and the Netherlands Organisation for Health Research and Development. This research was carried out within the framework of the Work Disability Prevention Canadian Institutes of Health Research strategic training programme, which supported LCL (grant FRN: 53909). The authors were independent of the funders and the funders had no role in the project.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any company for the submitted work; no financial relationships with any companies that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the medical ethics committees of the participating hospitals (VU University Medical Centre, Slotervaart Hospital, Amstelland Hospital, Onze Lieve Vrouwe Gasthuis, all based in Amsterdam, and Spaarne Hospital based in Hoofddorp).

  • Data sharing: No additional data available.

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