Trial-based cost-effectiveness analysis finds no economic preference for team-based rehabilitation in at-risk musculoskeletal patients

A one-year cost-effectiveness analysis conducted alongside a randomised controlled trial found that team-based rehabilitation for adults screened as at risk of long-term musculoskeletal problems produced health outcomes and societal costs similar to treatment as usual. From the healthcare perspective, the PREVSAM model was somewhat more expensive, while lower production losses largely offset its higher rehabilitation costs when broader societal costs were considered.

The analysis included 253 adults who sought primary care rehabilitation for musculoskeletal disorders at eight public and private clinics in western Sweden between May 2019 and June 2022. Participants were deemed to be at risk of long-term health problems and sickness absence after screening with the Örebro Musculoskeletal Pain Screening Questionnaire–Short Form; a score of at least 40 was required for inclusion. The randomised groups comprised 128 participants assigned to PREVSAM and 125 to treatment as usual.

PREVSAM provided person-centred team-based rehabilitation in primary care. Physiotherapists and occupational therapists conducted their own assessments but collaborated in interdisciplinary meetings and co-created health plans with patients. Participants also had timely access to a psychotherapist and, according to patient preference, possible collaboration with employers. Most treatment sessions were individual, while psychotherapist sessions were generally digital. Treatment as usual consisted of standard physiotherapy and occupational therapy determined by the individual caregiver, without a particular focus on interdisciplinary collaboration or access to the programme’s psychotherapist resource.

Quality-adjusted life-years over one year, derived from EuroQol-5 Dimensions-5 Level measurements at baseline and at one, three, six and 12 months, were the principal health outcome. Healthcare costs included rehabilitation, other primary care, specialised care and medication. Societal costs additionally incorporated production losses from sickness absence and healthcare visits, valued through a human capital approach. The analysis followed the Consolidated Health Economic Evaluation Reporting Standards 2022, used multiple imputation for missing health-outcome data and had complete cost data for all 253 participants.

Health-related quality of life improved in both groups over the study year. The mean EQ-5D-5L index rose from 0.73 at baseline to 0.85 at 52 weeks in the PREVSAM group and from 0.72 to 0.86 in the treatment-as-usual group. The respective improvements were 0.126 and 0.134, both with p-values below 0.001, but the between-group difference was small and not statistically significant at −0.008 (95% confidence interval, −0.077 to 0.060; p=0.81). Each group accumulated approximately 0.84 quality-adjusted life-years during the year.

Under the healthcare perspective, PREVSAM cost an estimated €526 more per participant than treatment as usual over one year, with a 95% confidence interval of −€390 to €1,442 and no corresponding gain in quality-adjusted life-years. Lower costs for other primary care, specialised care and medication did not fully offset the higher rehabilitation expenditure. Because the difference in quality-adjusted life-years was close to zero, the incremental cost-effectiveness ratio was not meaningfully defined and was not reported.

When production losses were included, the estimated societal cost difference was −€37 per participant, with a 95% confidence interval of −€2,772 to €2,698, indicating essentially no difference in total societal costs. Higher rehabilitation costs were offset principally by lower production-loss costs, estimated at €563 less per participant, together with lower costs for other care and medication. Among 1,000 bootstrapped and imputed replicates from the societal perspective, 31.5% placed PREVSAM in the quadrant where it was less costly and more effective, while 28.7% placed it where it was more costly and less effective.

The probability that PREVSAM was cost-effective remained close to one half across the reported Swedish threshold range: 51.5% at €43,000 per quality-adjusted life-year and 51.3% at €86,000. The near-horizontal acceptability curve reflected the very small difference in mean quality-adjusted life-years between the groups. The findings are bounded by the trial’s one-year horizon, its setting in western Swedish primary care rehabilitation clinics and substantial variation in patients’ needs and responses.

Self-reported sickness absence was less complete in the treatment-as-usual group, potentially underestimating its production-loss costs, and the study did not collect data on participants’ health problems for analysis. Missing repeated health-outcome measurements also increased uncertainty. Although the complete-case analysis included 159 participants, the authors regarded the multiple-imputation analysis retaining all 253 randomised participants as the more appropriate basis for inference. They concluded that neither strategy was preferable on economic grounds and that further refinement of screening may be needed to identify patients truly in need of team-based care and support appropriate resource allocation.

Subject of Research: One-year cost-effectiveness of team-based primary care rehabilitation for adults at risk of long-term musculoskeletal problems and sickness absence

Article Title: Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal disorders (PREVSAM): a cost-effectiveness analysis comparing team-based rehabilitation in primary care vs treatment as usual

Article References: Bornhöft, L., Ekhammar, A., Svensson, M., Dottori, M., & Larsson, M. E. H. (2026). Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal disorders (PREVSAM): a cost-effectiveness analysis comparing team-based rehabilitation in primary care vs treatment as usual. BMC Health Services Research, 26(1), Article 1319. https://doi.org/10.1186/s12913-026-15652-2

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15652-2

Keywords: PREVSAM, musculoskeletal disorders, team-based rehabilitation, primary care, cost-effectiveness analysis, randomised controlled trial, quality-adjusted life-years, sickness absence, health economics, Prevention, sickness, absence