Principal Findings
’ self-management behavior, presenteeism, LBP
SECONDARY
This study evaluated the long-term effectiveness and cost-effectiveness of the stratified blended physiotherapy intervention e-Exercise LBP in comparison with face-to-face physiotherapy in patients with nonspecific LBP. Both interventions were associated with improved clinical outcomes from baseline to the 12-month follow-up, but the study results showed neither a clinically relevant nor a statistically substantial between-group difference in the primary outcome of physical functioning and in most secondary outcomes. Over 12 months, and for each time point, only fear avoidance beliefs improved substantially more in patients who were allocated to the e-Exercise LBP group. At 3 months, patients who were allocated to the e-Exercise LBP group reported a better adherence to prescribed home exercises. However, the overall between-group difference and the differences in improvement per time point in both fear avoidance beliefs and self-reported adherence to prescribed home exercises were not considered clinically relevant. Regarding the intervention’s cost-effectiveness, from both the societal and health care perspectives, a considerable amount of money must be paid per additional QALY or 1-point improvement in physical functioning to reach a relatively low to moderate probability of e-Exercise LBP being cost-effective compared with face-to-face physiotherapy. To illustrate, e-Exercise LBP had a low probability (ie, 0.29 and 0.60) of cost-effectiveness at the upper and lower bounds, respectively, of the informal Dutch willingness-to-pay threshold for QALYs (ie, €10,000 to €80,000 [US $10,564 to $84,513] per QALY). From the health care perspective and the outcome of physical functioning, willingness-to-pay thresholds were lacking. However, we consider the maximum probability of e-Exercise LBP being cost-effective compared with face-to-face physiotherapy for both outcomes to be moderate at best (ie, <0.81). Hence, from both the societal and health care perspectives, e-Exercise LBP does not seem to be cost-effective compared with face-to-face physiotherapy among patients with nonspecific LBP. Between-group differences in costs and effects as estimated in the sensitivity analyses were not completely in line with our main analysis. In particular, the point estimates of the cost differences in the complete-case analysis were more positive than those in the main analysis and showed that e-Exercise LBP was dominant over face-to-face physiotherapy. However, the uncertainty surrounding the point estimates of the complete-case analysis was large, resulting in a relatively low probability of e-Exercise LBP being cost-effective compared with face-to-face physiotherapy, a conclusion that is similar to that of the main analysis. This was also the case for the other sensitivity analyses.From a clinical perspective, the results of this study for the primary and secondary clinical outcomes are in line with the short-term results of the e-Exercise LBP study [Although several studies [A possible explanation for the lack of effectiveness and cost-effectiveness of e-Exercise LBP might be that, in contrast to our expectations, e-Exercise LBP did not result in a change in patients’ self-management behavior when compared with face-to-face physiotherapy. This is in line with our short-term results [The comparison with face-to-face physiotherapy in our study might also be an important reason why we were not able to demonstrate better effectiveness and cost-effectiveness of our stratified blended physiotherapy intervention e-Exercise LBP. Despite the reasonably strong evidence that some physiotherapy interventions (compared with minimal or no intervention) for patients with nonspecific LBP are effective, the effect sizes are typically small [A final observation regarding our results is that presenteeism costs contributed substantially to the total societal costs (ie, 50.4% for stratified blended physiotherapy and 58.9% for face-to-face physiotherapy). This finding is in line with previous studies showing that, in many chronic conditions, presenteeism constitutes the greatest proportion of the overall associated costs [