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Is an enhanced behaviour change intervention cost-effective compared with physiotherapy for patients with chronic low back pain? Results from a multicentre trial in Israel
  1. Alastair Canaway1,
  2. Tamar Pincus2,
  3. Martin Underwood1,
  4. Yair Shapiro3,
  5. Gabriel Chodick4,5,
  6. Noa Ben-Ami3
  1. 1 Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
  2. 2 Department of Psychology, Royal Holloway University of London, London, UK
  3. 3 Faculty of Health Sciences, Ariel University, Ariel, Israel
  4. 4 Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
  5. 5 Maccabi Healthcare Services, Tel-Aviv, Israel
  1. Correspondence to Dr Alastair Canaway; a.canaway{at}


Objective To assess the cost-effectiveness of an enhanced transtheoretical model of behaviour change in conjunction with physiotherapy compared with standard care (physiotherapy) in patients with chronic lower back pain (CLBP).

Design Cost-utility and cost-effectiveness analyses alongside a multicentre controlled trial from a healthcare perspective with a 1-year time horizon.

Setting The trial was conducted in eight centres within the Sharon district in Israel.

Participants 220 participants aged between 25 and 55 years who suffered from CLBP for a minimum of 3 months were recruited.

Interventions The intervention used a model of behaviour change that sought to increase the adherence and implementation of physical activity in conjunction with physiotherapy. The control arm received standard care in the form of physiotherapy.

Primary and secondary measures The primary outcome was the incremental cost per quality-adjusted life year (QALY) of the intervention arm compared with standard care. The secondary outcome was the incremental cost per Roland-Morris Disability Questionnaire point.

Results The cost per QALY point estimate was 10 645 New Israeli shekels (NIS) (£1737.11). There was an 88% chance the intervention was cost-effective at NIS50 000 per QALY threshold. Excluding training costs, the intervention dominated the control arm, resulting in fewer physiotherapy and physician visits while improving outcomes.

Conclusions The enhanced transtheoretical model intervention appears to be a very cost-effective intervention leading to improved outcomes for low cost. Given limitations within this study, there is justification for examining the intervention within a larger, long-term randomised controlled trial.

Trial registration number NCT01631344; Pre-results.

  • lower back pain
  • economic evaluation
  • QALYs
  • cost-utility analysis
  • cost-effectiveness analysis
  • physiotherapy

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  • Contributors AC conducted the economic analysis and drafted the paper. NB-A was responsible for setting up the trial and conducting the data collection under the supervision and guidance of TP, YS and GC. MU, TP and NB-A contributed to the drafting and editing of the manuscript.

  • Funding The study was supported by Maccabi Healthcare Services (an Israeli public health organisation).

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Ethics approval was obtained from the ethics committees of both Tel-Aviv University and Maccabi Healthcare Services (a public health organisation).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data requests relating to the ETMI trial should be made to