A Systematic Review Of Low Back Pain Cost Of Illness Studies In The United States And Internationally.
Introduction
The medical challenge in the part of low back pain (commonly abbreviated as LBP) is on an increase. Due to requirement of attention it costs the economy dearly where the value of cost is in both time and money. Diagnosis methods and equipment, and medical improvements have been seen, but still LBP remain a menace, with the worst part being that number of patients are increasing per unit time. Developed countries face the problem of an equal magnitude to that of developing countries in this. America is also facing an economic challenge due to LBP even after large investments on health by individuals and the government. It becomes a health cost since we pay more than we could have paid if the diseases did not exist. This argument is from the fact of economy that cost is anything extra paid, and could not have been paid for.
In case a patient suffers LBP and seeks for medical attention, like any other disease, they undergo direct and indirect costs. Paying for medical services, medication, diagnostic testing and other medical attention costs that involve cash exchange in a hospital or medical clinic constitutes direct medical cost. Other cost that also require cash exchange and revolve around the LBP diagnosis and treatment are termed as direct non-medical costs (Ekman, Johnell & Lidgren, 2005). They include transport cost and meals eaten outside home.
Costs due to conditions like LBP in the economy identified by the two terms; absenteeism and presenteeism, are termed as indirect costs. presenteeism is a situation where employees are in their job domains but cannot deliver to the best of their capacity. Absenteeism is where the employees miss work due to conditions, for this case LBP.
Research shows that, when evaluating the cost, it is easier to evaluate direct costs. Due to record keeping, direct medical coast are even easier to deduce than direct non-medical costs. Direct cost information should be gathered from clinical officers and the patient. On the other hand, it is a bit more challenging to collect indirect costs since the only available source of information is the patient (Ekman, Johnell & Lidgren, 2005). This paper goes, mainly, into details of indirect costs, since the aim is to come up with a generalized report.
Justification of Importance
Despite the improvement in technological advances medicine, many studies show an increasing socioeconomic burden brought about by LBP. One study showed that each year, about $50 billion is spent by Americans on LBP (NIH, 2013). Also according to a study carried out in 2000 about 49% of the UK adult population has been identified with LBP showing that back pain is a common phenomenon (Backcare, 2013). There have been great efforts towards understanding and recommending independent approaches towards LBP management. Many education programs have been conducted on LBP.
Despite all this the cost impacts of LBP continue to rise. The above studies show that LBP is a critical issue which calls for attention in terms of allocation of sufficient healthcare facilities. To allocate these healthcare facilities a precise magnitude of costs that result due to LBP needs to be known. The cost figures are supplied by the surveys carried out hence the need to review the approaches used by these surveys to come up with the figures. Precise cost figures would also help in knowing possible cost saving solutions.
There is a wide variation through which various studies come up with cost estimates. One variation is in terms of cost used. Since there are many ways of categorizing cost, there is a challenge in estimating cost due to a disease. The cost of sickness can be broken down into 3 components: direct costs, indirect costs and intangible costs.
Direct costs can be both medical and non-medical. Direct medical costs are those incurred by patients while they acquire health services such as physician services, disease diagnosis and medications. The direct medical costs can be easily estimated as transaction records kept by clinicians and patients are available (Hicks, 2008). Direct non-medical costs are those that are associated with goods and services used by patients while accessing the health services. An example is the cost of travel to access the services; cost of meals they may be taken away from home among others. Direct non-medical costs can easily be disregarded while estimating the cost of LBP while in fact they have a significant portion in the overall economic burden of LBP.
Indirect costs consider a more general or wider economic impact of LBP. There is no direct money transaction due to these costs. They consider the cost of LBP for example in terms of declined productivity at work or home. This declines productivity is brought about by instances such as absenteeism, lower performance by employees which in general result to lower production and consequently a drawback to the overall economy of a country(Hicks, 2008). These costs are difficult to estimate compared to direct costs especially when narrowed down to a specific disease like LBP. For instance measuring presenteeism is a difficult task as the specific medical condition is not responsible for it cannot be known easily (Hicks, 2008). There may not be readily available records on a specific disease and as such it would involve interviewing the workers and supervisors on the subject. There are generally two methods of estimating indirect costs namely the human capital approach and the friction cost approach.
The human capital method is the most common and is based on an assumption that the economic value of an employee is equivalent to the earnings by the employee. Lost productivity as such is arrived at by estimating the earning lost by the employee due to the particular disease. The friction period approach on the other hand holds the assumption that productivity is actually only lost when the employee is absent from work due to sickness. The loss stops when the employer hires a new employee who has a work capacity equal or greater his/her predecessor. Training may be a requirement for the new employee to reach this capacity. This method focuses on this period when the employee leaves the job due to illness till the time the employer hires a new employee of equal capacity for replacement(Hicks, 2008). This period is referred to as the friction period. The productivity losses incurred during this period is measured. These methods usually give varying results and in some cases this variation is significant.
Intangible costs take into consideration the total cost of a sickness and such costs include enjoyment of life.
Different studies use different classes of costs to come up with cost estimates of LBP. Based on the above information on costs it would be necessary to review which costs are actually necessary to estimate the total economic burden of LBP and also which costs are best to use as a basis of allocating healthcare facilities (Hicks, 2008).
Another variation in coming up with estimates is the cost perspective. Cost can be measured from the patient perspective, government perspective and employer perspectives among others. The perspective is essentially the sources of cost data. Different sources give different estimates and therefore this would be an important area of reviewing the studies.
Some studies done are in the end deemed irrelevant therefore rendering them useless. Such studies utilize money and therefore there is need to review the already done studies to reduce the number of studies that are dismissed as irrelevant in future.
Alternative Perspective of the Issue
There are many arguments regarding estimation of economic burden of LBP. One argument would be that there is no use of reviewing studies since such a review would never come up with one study that is 100% accurate. The studies carried out are complementary and therefore a review is not necessary.
The issue of estimating indirect costs is where most arguments lie. Medline search was done on July, 2007 on 147 studies revolving around LBP costs. Various strategies were used to determine the eligibility. Three studies showed that the estimates derived using the friction period approach of indirect cost estimation had by 56% a lower value than the human capital approach. A debate on which method is best is bound to occur. While it is clear that such difference is significant and thus the need to review these methods others may argue that no estimates on either methods should be dismissed as long as both methods of estimation remain valid (Dunn & Croft, 2004).
Another argument is on cost perspective. Some would argue that the cost perspective of a study is not necessary to look at as all perspectives are important representations of the estimates. In contrast others would argue that the societal perspective is most important as it combines all the perspectives and would be most important in allocating health service facilities to LBP. Others argue that the societal cost perspective is hard to derive hence largely inaccurate thus should not be considered.
My Position
On the issue of estimation of indirect costs a combination of both human capital approach and the friction period approach would be most appropriate. The human capital approach would be used where the leave period by an employee due to sickness is short and therefore amounting to temporary productivity losses. Friction period on the other hand would be used to estimate cases of long-term productivity losses. The cost figures are supplied by the surveys carried out hence the need to review the approaches used by these surveys to come up with the figures. Precise cost figures would also help in knowing possible cost saving solutions.
A societal cost perspective is also necessary as it is a representative of the various perspectives. The total cost perspective from a societal perspective would provide better understanding of the LBP costs. Some of the individual cost estimates may be overlooked if analyzed alone. The bottom-up method where cost estimates from patient themselves are collected and the top-bottom method, where data is collected from large databases such as the government and insurances, can be combined to give the societal perspective (Ekman M, Johnell, Lidgren and Orthop, 2005). This would incorporate more data which is also very useful.
It also important to point out that the methods used to estimate the indirect costs are more of a theoretical nature and thus the certainty of such estimates cannot be guaranteed. Direct costs are more accurate as records by physicians and employers are always available.
It is correct to agree with these studies that direct costs are the most appropriate in allocating healthcare resources in cases of critical and urgent situations such as those of LBP.
Implication
There is need to carry out fresh studies that target total LBP costs from the societal perspective seeing that no study has no such data. However fresh studies may take time yet the menace due to LBP continues to deteriorate. Studies that incorporate direct cost estimates need to be used to allocate healthcare services so as to first salvage the situation (Kim, Choi, Chang & Lee, 2005). This would first cater for the patients before the effects of LBP on productivity (direct costs) can be taken into consideration.
It is also important for users of LBP cost data from studies to review the studies in terms of the methodology used to come up with the estimates before using such data. This is to avoid the problem of being misled by data from some studies in future. This is because this study has revealed that different methodologies give different estimates that may vary significantly.
References
NIH (2013). low back pain fact sheet. NIH publication. Retrieved from http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm
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Kim HS, Choi JW, Chang SH, Lee KS, Oh JY (2005). Treatment duration and cost of work-related low back pain in Korea. J Korean Med Sci:127–31
Backcare (2013). www.backcare.org. Retrieved 21, 2013, from http://www.backcare.org.uk/factsandfigures
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