Early versus late initiation of rehabilitation after lumbar spinal fusion: economic evaluation alongside a randomized controlled trial.
METHODS
Economic evaluation conducted alongside a randomized controlled trial with 1-year follow-up.


OBJECTIVE
To examine the cost-effectiveness of initiating rehabilitation 6 weeks after surgery as opposed to 12 weeks after surgery.


BACKGROUND
In a previously reported randomized controlled trial, we assessed the impact of timing of rehabilitation after a lumbar spinal fusion and found that a fast-track strategy led to poorer functional ability. Before making recommendations, it seems relevant to address the societal perspective including return to work, quality of life, and costs.


METHODS
A cost-effectiveness analysis and a cost-utility analysis were conducted. Eighty-two patients undergoing instrumented lumbar spinal fusion due to degenerative disc disease or spondylolisthesis (grade I or II) were randomized to an identical protocol of 4 sessions of group-based rehabilitation and were instructed in home exercises focusing on active stability training. Outcome parameters included functional disability (Oswestry Disability Index) and quality-adjusted life years. Health care and productivity costs were estimated from national registries and reported in euros. Costs and effects were transformed into net benefit. Bootstrapping was used to estimate 95% confidence intervals (95% CI).


RESULTS
The fast-track strategy tended to be costlier by €6869 (95% CI, -4640 to 18,378) while at the same time leading to significantly poorer outcomes of functional disability by -9 points (95% CI, -18 to -3) and a tendency for a reduced gain in quality-adjusted life years by -0.04 (95% CI, -0.13 to 0.01). The overall probability for the fast-track strategy being cost-effective does not reach 10% at conventional thresholds for cost-effectiveness.


CONCLUSIONS
Initiating rehabilitation at 6 weeks as opposed to 12 weeks after surgery is on average more costly and less effective. The uncertainty of this result did not seem to be sensitive to methodological issues, and clinical managements who have already adapted fast-track rehabilitation strategies have reason to reconsider their choice. .
From the Departments of *Physiotherapy and Occupational Therapy Department, Aarhus University Hospital, Denmark †Department of Orthopaedic Surgery, Aarhus University Hospital, Denmark ‡Region Hospital of Silkeborg, Orthopaedic Department, Denmark §Section of Social Medicine and Rehabilitation, Institute of Public Health, Aarhus University, Denmark ¶Public Health and Quality Improvement, Central Denmark Region, Denmark ‖CAST-Centre for Applied Health Services Research, University of Southern Denmark, Denmark; and **Institute for Public Health, Aarhus University, Denmark.
Lisa G
LG
Oestergaard
Finn B
FB
Christensen
Claus V
CV
Nielsen
Cody E
CE
Bünger
Soeren
S
Fruensgaard
Rikke
R
Sogaard
D000041:Absenteeism; D000328:Adult; D017281:Cost of Illness; D003362:Cost-Benefit Analysis; D003718:Denmark; D004185:Disability Evaluation; D004526:Efficiency; D005081:Exercise Therapy / Q000191:economics* / Q000379:methods*; D005260:Female; D017048:Health Care Costs; D006801:Humans; D055959:Intervertebral Disc Degeneration / Q000175:diagnosis / Q000191:economics / Q000503:physiopathology / Q000601:surgery*; D008159:Lumbar Vertebrae / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D020127:Recovery of Function; D062707:Return to Work / Q000191:economics; D018582:Sick Leave / Q000191:economics; D013123:Spinal Fusion / Q000009:adverse effects / Q000191:economics* / Q000534:rehabilitation*; D013168:Spondylolisthesis / Q000175:diagnosis / Q000191:economics / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D061665:Time-to-Treatment / Q000191:economics*; D016896:Treatment Outcome