Dinámica de los modelos de agua tip3p, spc, y spc/e a 298 o k

The resources used to deliver the CBA were obtained from administration and visit records. CBA resource use included duration of the

assessment visit, number and duration of scheduled CBA sessions (contact time) and non-contact time, equipment, consumables, educational materials and items and resources used during the training of CBA therapists. Non-contact time included the time used to contact participants and set up the sessions, writing clinical notes, administration and record-keeping. Support and supervision time provided by the intervention support team were incorporated. Travel time was calculated for therapists seconded to the programme using actual travel time reimbursed by the trial.

We collected other health-care resource use and participant costs from participant questionnaires at baseline, 3, 6 and 12 months. Participants were asked to keep a record of type and quantity of each resource item used, for services provided by the NHS and for services either privately purchased or funded by private health insurance.

Other NHS resource use data included the number of contacts with GPs, nurses, physiotherapists, psychologists, other health-care consultations, diagnostic tests [including X-ray, magnetic resonance imaging (MRI) scan, computerised tomography (CT) scan and blood tests], accident and emergency (A&E) attendances, and hospital admissions.

Chapter 6

Economic analysis

We also collected data on the provision of drugs used in the treatment of back pain from participants’ questionnaires. These included painkillers, anti-inflammatory tablets, anti- inflammatory gels and creams, sleeping tablets and antidepressants, and other drugs indicated by participants as having been prescribed for back pain.

We sought data on out-of-pocket expenses, as well as on back care sourced from the private (non- NHS) sector. This included the resource use and costs of services such as aromatherapy, chiropractic, counselling, massage, private orthopaedic surgery, osteopathy, psychology, physiotherapy and the number of items and cost of any equipment item, housing adaptations and aids. We asked participants to indicate the type and quantity and, where appropriate, unit cost for each item of privately purchased health-care resources. We also asked participants to indicate where these costs had been paid for either in total or in part by a private insurance policy.

We verified both NHS and private hospital admissions data. A researcher (E.W.) contacted the patients who had declared any hospital admission and collected data on cause of admission, ward of admission (to determine the Health Resource Group), procedures received and length of stay.

Unit costs

The total cost of health care was calculated by multiplying resource use data by their

respective unit costs. Unit costs were the cost of AM or AM+CBA, the cost of primary care and community-based services, the cost of hospital- based services, admissions and A&E services, the cost of drug prescriptions, and the cost of private health-care items and equipment. All unit costs reported in this section are 2006 prices, with the exception of private consultations and tests (Table 36), and were actualised to the year 2008 for the cost–utility analysis using the appropriate inflation index.

NHS health-care unit costs

Unit costs for any of the resources consumed and consultations within the NHS were obtained from published sources pertinent to the UK.134–136 _Unit costs for these items are reported in Table 36. Unit costs for pharmacological agents were the average cost for one prescription of each drug type consumed in the trial, including painkillers, anti-inflammatory drugs, anti-inflammatory gels and creams, sleeping tablets and antidepressants. Unit costs were calculated based on the typical drugs commonly prescribed for back pain, based on a consensus exercise amongst six academic GPs working in the localities from which we recruited the sample. The average cost of the prescriptions was then computed from the Prescription Cost Analysis (PCA) database.136

Participants were asked to report if they were dispensing any drugs in addition to the categories described above. Costs for these additional drugs were calculated using the frequency of use reported

TABLE 36 Unit costs for NHS consultations and drugs (2006 prices)

Item Unit cost (£) Source

GP visit (surgery) 34.00 Curtis 2007134

Nurse visit (surgery) 9.00 Curtis 2007134

Physiotherapy visit 31.80 Curtis 2007134

Outpatient consultation (back pain problems) 112.70 NHS Reference Costs135

Psychologist consultation 67.00 Curtis 2007134

Painkillers 4.57 PCA database136

Anti-inflammatory drugs 8.22 PCA database136

Gels, creams and ointments 5.75 PCA database136

Sleeping pills 3.66 PCA database136

Antidepressants 5.86 PCA database136

69 by respondents, when available, or assuming

occasional consumption of one dispensing unit (prescription). These additional items were yearly treatment with paracetamol at £12.00 assuming one box per week, pain control (fentanyl) patches, at the cost of £86.70 per prescription, and muscle relaxants at £11.90 per prescription.136

The costs of diagnostic tests and of hospital and A&E admissions were obtained from the NHS Reference Costs database.135 _{The cost of blood tests} was calculated using the average cost of blood tests (Speciality codes DAP823 and DAP839). This was £3.10. The costs of other diagnostics were CT scan (£117.90), MRI scan (£203.80) and X-ray (£28.00). The unit cost of hospital admissions was obtained from the category HD26C Musculoskeletal Signs and Symptoms Without Complications. The cost of a day case was £529.50 and the cost of an extended-stay case was £572.00. The cost of an A&E attendance without a subsequent admission was £170.10.

Private health-care unit costs

Private costs were estimated based on resource consumption indicated in participants’

questionnaires multiplied by the respective unit cost.

The unit costs of private consultations included a range of services (shown in Table 37). These costs were obtained from a telephone survey of six providers of each type of service, based in Coventry, Manchester, Newcastle, Essex, Liverpool and London, conducted between 1 February and 5 February 2008 (Table 37).

Private costs also included the cost of privately paid diagnostic tests, including X-ray, MRI scan, CT scan and blood testing. Unit costs for private tests and diagnostics were obtained from the same telephone survey and are detailed in Table 37. Medications (painkillers, anti-inflammatory drugs, anti-inflammatory gels and creams, sleeping tablets and antidepressants) purchased privately were valued at the same NHS cost for similar preparations obtained from the PCA database.136

TABLE 37 Unit costs of community- and hospital-based private consultations

Item Unit cost (£) Source

Hospital-based fees Outpatient consultation with

NHS consultant 182.50 Phone survey of six consultants’ private consultation fees for patients with LBP, at BMI Alexandra Hospital (Cheadle); BMI Meriden Hospital (Coventry); BMI Sarum Road Hospital (Winchester); Spire Bristol; Spire Gatwick Park; Spire Leicester. Conducted in February 2008. Estimates are the average cost

X-ray 86.20

CT scan 551.60

MRI scan 597.90

Blood tests 109.80

Community-based fees

Physiotherapy 38.20 Phone survey of six specialists’ private consultation fees for patients with LBP, at Coventry, Essex, Liverpool, London, Manchester and Newcastle. Conducted between 1 February and 5 February 2008. Estimates are the average cost

Osteopath 44.30 Chiropractor 35.30 Psychologist 70.40 Counsellor 50.00 Massage therapist 24.80 Aromatherapist 25.30 Dietician 55.80 Acupuncture 34.50

For hospital consultations, participants were asked to indicate whether the cost was disbursed directly by the participant or reimbursed by health insurance, while equipment costs, housing adaptations and aids, all purchased privately, were estimated using the amounts declared by participants only. Finally, we computed participant travel cost for all visits, consultations and hospital admissions declared as either NHS or private services using unit costs obtained from one published study for the UK.137 _{Travel to} community-based services was estimated at £3.50 and that to hospital-based services was estimated at £6.50 per trip.