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United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care [with consumer summary]
UK BEAM Trial Team
BMJ 2004 Dec 11;329(7479):1381-1386
clinical trial
4/10 [Eligibility criteria: No; Random allocation: Yes; Concealed allocation: No; Baseline comparability: No; Blind subjects: No; Blind therapists: No; Blind assessors: No; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been confirmed*

OBJECTIVE: To assess the cost effectiveness of adding spinal manipulation, exercise classes, or manipulation followed by exercise ("combined treatment") to "best care" in general practice for patients consulting with low back pain. DESIGN: Stochastic cost utility analysis alongside pragmatic randomised trial with factorial design. SETTING: 181 general practices and 63 community settings for physical treatments around 14 centres across the United Kingdom. PARTICIPANTS: 1,287 (96%) of 1,334 trial participants. MAIN OUTCOME MEASURES: Healthcare costs, quality adjusted life years (QALYs), and cost per QALY over 12 months. RESULTS: Over one year, mean treatment costs relative to "best care" were Great British Pounds 195 ($360; Euro 279; 95% credibility interval 85 to 308) for manipulation, Great British Pounds 140 (3 to 278) for exercise, and Great British Pounds 125 (21 to 228) for combined treatment. All three active treatments increased participants' average QALYs compared with best care alone. Each extra QALY that combined treatment yielded relative to best care cost Great British Pounds 3,800; in economic terms it had an "incremental cost effectiveness ratio" of Great British Pounds 3,800. Manipulation alone had a ratio of Great British Pounds 8,700 relative to combined treatment. If the NHS was prepared to pay at least Great British Pounds 10,000 for each extra QALY (lower than previous recommendations in the United Kingdom), manipulation alone would probably be the best strategy. If manipulation was not available, exercise would have an incremental cost effectiveness ratio of Great British Pounds 8,300 relative to best care. CONCLUSIONS: Spinal manipulation is a cost effective addition to "best care" for back pain in general practice. Manipulation alone probably gives better value for money than manipulation followed by exercise.
Reproduced with permission from the BMJ Publishing Group.

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