SPINE Volume 35, Number 18, pp 1714 –1720 ©2010, Lippincott Williams & Wilkins Low Back Pain in Primary Care Costs of Care and Prediction of Future Health Care Utilization Annette Becker, MD, MPH,* Heiko Held, MD,* Marcus Redaelli, MD,† Konstantin Strauch, PhD,‡ Jean F. Chenot, MD, MPH,§ Corinna Leonhardt, PhD,¶ Stefan Keller, PhD, Erika Baum, MD, PhD,* Michael Pfingsten, PhD,** Jan Hildebrandt, MD, PhD,** Heinz-Dieter Basler, PhD,¶ Michael M. Kochen, MD, MPH, PhD, FRCGP,§ and Norbert Donner-Banzhoff, MD, MHSc, PhD* Study Design. Cost of illness study alongside a ran- domized controlled trial. Objective. To describe the costs of care for patients with low back pain (1) and to identify patient characteris- tics as predictors for high health care cost during a 1-year follow-up (2). Summary of Background Data. Low back pain (LBP) is one of the leading causes of high health care costs in industrialized countries (Life time prevalence, 70%). A lot of research has been done to improve primary health care and patients' prognosis. However, the cost of health care does not necessarily follow changes in patient outcomes. Methods. General practitioners (n = 126) recruited 1378 patients consulting for LBP. Sociodemographic data, pain characteristics, and LBP-related cost data were col- lected by interview at baseline and after 6 and 12 months. Costs were evaluated from the societal perspective. Pre- dictors of high cost during the subsequent year were studied using logistic regression analysis. Results. Mean direct and indirect costs for LBP care are about twice as high for patients with chronic LBP compared to acutely ill patients. Indirect costs account for more than 52% to 54% of total costs. About 25% of direct costs refer to therapeutic procedures and hospital or re- habilitational care. Patients with high disability and limi- tations in daily living show a 2- to 5-fold change for sub- sequent high health care costs. Depression seems to be highly relevant for direct health care utilization. Conclusion. Interventions designed to reduce high health care costs for LBP should focus on patients with severe LBP and depressive comorbidity. Our results add to the economic understanding of LBP care and may give guidance for future actions on health care improvement and cost reduction. Key words: back pain, primary care, cost-of-illness, severity of low back, depression. Spine 2010;35:1714 –1720 Low back pain (LBP) poses a major health burden on industrialized countries with a point prevalence of 15% to 30% and a life time prevalence between 50% and 85%. 1–3 About 10% of patients develop chronic pain, which leads to early retirement and high health care costs. LBP is 1 of the 7 most expensive illnesses in Ger- many. 4 In 1998, about 17.4 billion Euros per year of the total costs went to treat LBP. 5 Several European cost of illness studies underline the burden of the illness on so- ciety, showing mean total costs of €211 per person in Sweden 6 or €260 per person in the United Kingdom. 7 Health care for patients with LBP is characterized by the variability of providers offering a spectrum of thera- pies, which are mostly not evidence based. A lot of re- search has been done to improve treatment effectiveness and efficiency. However, even though intervention stud- ies often show mild effects on clinical outcomes, these effects do not necessarily correlate with economic bene- fits. The identification and description of subgroups of LBP patients who are likely to induce high cost of care in the future and who would gain most by cost saving ac- tions is mandatory. 8,9 But even though the majority of patients are seen in primary care settings, 10 the distribu- tion and factors associated with high primary health care costs are hardly known. In fact most cost of illness stud- ies refer to databases of communities or specialized health care settings based on a top down approach with often limited information on patient or illness-related factors. 6,7,11,12 The aim of our study was (1) to describe the compo- sition of LBP-related costs of patients having consulta- tions in general practice and (2) to identify patient- and disease-related predictors of high health care costs dur- ing a 1-year follow-up. We refer to a secondary analysis of patient interrogation data drawn from a cluster- randomized controlled trial in primary care. From the *Department of General Practice, Preventive, and Rehabilitation Medicine, University of Marburg, Marburg, Germany; †Institute of Gen- eral Practice and Family Medicine, Private University Witten/Herdecke gGmbH, Witten, Germany; ‡Institute of Medical Biometry and Epidemi- ology, University of Marburg, Marburg, Germany; §Department of Gen- eral Practice, University of Go ¨ ttingen, Go ¨ ttingen, Germany; ¶Institute of Medical Psychology, University of Marburg, Marburg, Germany; De- partment of Public Health Sciences, University of Hawaii at Manoa, Ho- nolulu, HI; and **Department of Anaesthesiology, Pain Clinic, University of Go ¨ ttingen, Go ¨ ttingen, Germany. Acknowledgment date: October 30, 2008. Revision date: September 23, 2009. Acceptance date: September 28, 2009. The manuscript submitted does not contain information about medical device(s)/drug(s). Fedral funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Supported by the German Ministry for Education and Research (BMBF, FKZ 01 EM 0113). The study was approved by the institutional review boards of the Go ¨ t- tingen university and Marburg university, Germany. Address correspondence and reprint requests to Annette Becker, MD, MPH, Department of General Practice, Preventive, and Rehabilitation Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35032 Mar- burg, Germany; E-mail: annette.becker@staff.uni-marburg.de 1714