Cost-effectiveness of duloxetine in chronic low back pain: a Quebec societal perspective

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

Cost Effectiveness of Pharmacological Management for Osteoarthritis: A Systematic Review

BACKGROUND AND OBJECTIVE

Osteoarthritis (OA) is a highly prevalent, disabling disease requiring chronic management that is associated with an enormous individual and societal burden. This systematic review provides a global cost-effectiveness evaluation of pharmacological therapy for the management of OA.

METHODS

Following Center for Reviews and Dissemination (CRD) guidance, a literature search strategy was undertaken using PubMed, EMBASE, Cochrane Library, Health Technology Assessment (HTA) database, and National Health Service Economic Evaluation database (NHS EED) to identify original articles containing cost-effectiveness evaluation of OA pharmacological treatment published before 4 November 2021. Risk of bias was assessed by two independent reviewers using the Joanna Briggs Institute (JBI) critical appraisal checklist for economic evaluations. The Quality of Health Economic Studies (QHES) instrument was used to assess the reporting quality of included articles.

RESULTS

Database searches identified 43 cost-effectiveness analysis studies (CEAs) on pharmacological management of OA that were conducted in 18 countries and four continents, with one study containing multiple continents. A total of four classes of drugs were assessed, including non-steroidal anti-inflammatory drugs (NSAIDs), opioid analgesics, symptomatic slow-acting drugs for osteoarthritis (SYSADOAs), and intra-articular (IA) injections. The methodological approaches of these studies showed substantial heterogeneity. The incremental cost-effectiveness ratios (ICERs) per quality-adjusted life-year (QALY) were (in 2021 US dollars) US$44.40 to US$307,013.56 for NSAIDS, US$11,984.84 to US$128,028.74 for opioids, US$10,930.17 to US$27,799.73 for SYSADOAs, and US$258.36 to US$58,447.97 for IA injections in different continents. The key drivers of cost effectiveness included medical resources, productivity, relative risks, and selected comparators.

CONCLUSION

This review showed substantial heterogeneity among studies, ranging from a finding of dominance to very high ICERs, but most studies found interventions to be cost effective based on specific ICER thresholds. Important challenges in the analysis were related to the standardization and methodological quality of studies, as well as the presentation of results.

Cost-effectiveness analysis of the pharmacological management of chronic low back pain with four leading drugs

BACKGROUND

Chronic low back pain is a major health problem that has a substantial effect on people's quality of life and places a significant economic burden on healthcare systems. However, there has been little cost-effectiveness analysis of the treatments for it. Therefore, the purpose of this prospective observational study was to evaluate the cost-effectiveness of the pharmacological management of chronic low back pain.

METHODS

A total of 474 patients received pharmacological management for chronic low back pain using four leading drugs for 6 months at 28 institutions in Japan. Outcome measures, including EQ-5D, the Japanese Orthopaedic Association (JOA) score, the JOA back pain evaluation questionnaire (BPEQ), the Roland-Morris Disability Questionnaire, the Medical Outcomes Study SF-8, and the visual analog scale, were investigated at baseline and every one month thereafter. The incremental cost-utility ratio (ICUR) was calculated as drug cost over the quality-adjusted life years. An economic estimation was performed from the perspective of a public healthcare payer in Japan. Stratified analysis based on patient characteristics was also performed to explore the characteristics that affect cost-effectiveness.

RESULTS

The ICUR of pharmacological management for chronic low back pain was JPY 453,756. Stratified analysis based on patient characteristics suggested that the pharmacological treatments for patients with a history of spine surgery or cancer, low frequency of exercise, long disease period, low scores in lumbar spine dysfunction and gait disturbance of the JOA BPEQ, and low JOA score at baseline were not cost-effective.

CONCLUSIONS

Pharmacological management for chronic low back pain is cost-effective from the reference willingness to pay. Further optimization based on patient characteristics is expected to contribute to the sustainable development of a universal insurance system in Japan.

Systematic Review of Decision Analytic Modelling in Economic Evaluations of Low Back Pain and Sciatica

BACKGROUND

Low back pain (LBP) and sciatica place significant burden on individuals and healthcare systems, with societal costs alone likely to be in excess of £15 billion. Two recent systematic reviews for LBP and sciatica identified a shortage of modelling studies in both conditions.

OBJECTIVES

The aim of this systematic review was to document existing model-based economic evaluations for the treatment and management of both conditions; critically appraise current modelling techniques, analytical methods, data inputs, and structure, using narrative synthesis; and identify unresolved methodological problems and gaps in the literature.

METHODS

A systematic literature review was conducted whereby 6512 records were extracted from 11 databases, with no date limits imposed. Studies were abstracted according to a predesigned protocol, whereby they must be economic evaluations that employed an economic decision model and considered any management approach for LBP and sciatica. Study abstraction was initially performed by one reviewer who removed duplicates and screened titles to remove irrelevant studies. Overall, 133 potential studies for inclusion were then screened independently by other reviewers. Consensus was reached between reviewers regarding final inclusion.

RESULTS

Twenty-one publications of 20 unique models were included in the review, five of which were modelling studies in LBP and 16 in sciatica. Results revealed a poor standard of modelling in both conditions, particularly regarding modelling techniques, analytical methods, and data quality. Specific issues relate to inappropriate representation of both conditions in terms of health states, insufficient time horizons, and use of inappropriate utility values.

CONCLUSION

High-quality modelling studies, which reflect modelling best practice, as well as contemporary clinical understandings of both conditions, are required to enhance the economic evidence for treatments for both conditions.

Therapeutic lumbar facet joint nerve blocks in the treatment of chronic low back pain: cost utility analysis based on a randomized controlled trial

Background

Related to escalating health care costs and the questionable effectiveness of multiple interventions including lumbar facet joint interventions, cost effectiveness or cost utility analysis has become the cornerstone of evidence-based medicine influencing coverage decisions.

Methods

Cost utility of therapeutic lumbar facet joint nerve blocks in managing chronic low back pain was performed utilizing data from a randomized, double-blind, controlled trial with a 2-year follow-up, with direct payment data from 2016. Based on the data from surgical interventions, utilizing the lowest proportion of direct procedural costs of 60%, total cost utility per quality adjusted life year (QALY) was determined by multiplying the derived direct cost at 1.67.

Results

Patients in this trial on average received 5.6 ± 2.6 procedures over a period of 2 years, with average relief over a period of 2 years of 82.8 ± 29.6 weeks with 19 ± 18.77 weeks of improvement per procedure. Procedural cost for one-year improvement in quality of life showed USD $2,654.08. Estimated total costs, including indirect costs and drugs with multiplication of direct costs at 1.67, showed a cost of USD $4,432 per QALY.

Conclusions

The analysis of therapeutic lumbar facet joint nerve blocks in the treatment of chronic low back pain shows clinical effectiveness and cost utility at USD $2,654.08 for the direct costs of the procedures, and USD $4,432 for the estimated overall cost per one year of QALY, in chronic persistent low back pain non-responsive to conservative management.

Health economic evidence gaps and methodological constraints in low back pain and neck pain: Results of the Research Agenda for Health Economic Evaluation (RAHEE) project

Despite the increased interest in economic evaluations, there are difficulties in applying the results of such studies in practice. Therefore, the "Research Agenda for Health Economic Evaluation" (RAHEE) project was initiated, which aimed to improve the use of health economic evidence in practice for the 10 highest burden conditions in the European Union (including low back pain [LBP] and neck pain [NP]). This was done by undertaking literature mapping and convening an Expert Panel meeting, during which the literature mapping results were discussed and evidence gaps and methodological constraints were identified. The current paper is a part of the RAHEE project and aimed to identify economic evidence gaps and methodological constraints in the LBP and NP literature, in particular. The literature mapping revealed that economic evidence was unavailable for various commonly used LBP and NP treatments (e.g., injections, traction, and discography). Even if economic evidence was available, many treatments were only evaluated in a single study or studies for the same intervention were highly heterogeneous in terms of their patient population, control condition, follow-up duration, setting, and/or economic perspective. Up until now, this has prevented economic evaluation results from being statistically pooled in the LBP and NP literature, and strong conclusions about the cost-effectiveness of LBP and NP treatments can therefore not be made. The Expert Panel identified the need for further high-quality economic evaluations, especially on surgery versus conservative care and competing treatment options for chronic LBP. Handling of uncertainty and reporting quality were considered the most important methodological challenges.

Socioeconomic value of intervention for chronic pain

PURPOSE

The purpose of this study was to examine the cost-effectiveness of pain treatments in two pain centers in Japan.

METHODS

The study population comprised 91 patients receiving various treatments for chronic pain, which were divided into three categories: (1) medication, (2) medication + nerve block, and (3) other modalities (exercise and/or pain education). Pain was assessed using the Pain Disability Assessment Scale (PDAS) score, Hospital Anxiety and Depression Scale (HADS) score, Pain Catastrophizing Scale (PCS) score, and EQ-5D score. First, the reliability of the EQ-5D score first assessed by evaluating the correlation this score with those of the other pain-related evaluation instruments, and then the cost effectiveness of the pain treatments was evaluated. Evaluation of medical costs was based on data provided from the Management Services of the hospital, which in turn were based on national health scheme medical treatment fees. The quality-adjusted life year (QALY) value was calculated from the EQ-5D score, converted to 12 months, and then used for cost-benefit analysis along with medical treatment fees.

RESULTS

According to the recent IASP classification, more patients had chronic neuropathic pain (41) than chronic primary pain (37 patients) or chronic musculoskeletal pain (27 patients). There was a significant correlation between the EQ-5D score and the PDAS, HADS, and PCS scores, which demonstrated the reliability of the EQ-5D score. Significant improvement in the HADS, PCS, and EQ-5D scores was noted after 3 months of pain treatment. Calculation of the cost-effectiveness based on the estimated annual medical treatment cost and QALY revealed a mean value of US $45,879 ± 103,155 per QALY (median US $16,903), indicating adequate socioeconomic utility.

CONCLUSION

Based on our results, the EQ-5D is reliable for evaluating chronic pain in patients. The medico-economic balance was appropriate for all treatments provided in two comprehensive pain centers in Japan.

Pharmacological management of chronic lower back pain: a review of cost effectiveness

Lower back pain is one of the most prevalent musculoskeletal conditions in the developed world and accounts for significant health services use. The American College of Physicians and the American Pain Society have published a joint clinical guideline that recommends providing patients with information on prognosis and self-management, the use of medications with proven benefits and, for those who do not improve, consideration be given to the use of spinal manipulation (for acute lower back pain only), interdisciplinary rehabilitation, exercise, acupuncture, massage, yoga, cognitive behavioural therapy or relaxation. The purpose of this review was to evaluate published economic evaluations of pharmacological management for chronic lower back pain. A total of seven studies were eligible for inclusion in there view. The quality of the economic evaluations undertaken in the included studies was not high. This was primarily because of the nature of the underlying clinical evidence, most of which did not come from rigorous randomised controlled trials (RCTs), and the manner in which it was incorporated into the economic evaluations. All studies provided reasonable information about what aspects of healthcare and other resource use were identified, measured and valued. However, the reporting of total costs was not uniform across studies. Measures of pain and disability were the most commonly collected outcomes measures. Two studies collected information on quality of life directly from participants while two studies modelled this information based on the literature. Future economic evaluations of interventions for chronic lower back pain, including pharmacological interventions, should be based on the results of well-conducted RCTs where the measurement of costs and outcomes such as quality of life and quality-adjusted life-years is included in the trial protocol, and which have a follow-up period sufficient to capture meaningful changes in both costs and outcomes. In the absence of RCT data, economic models should be used to estimate future costs and outcomes using robust methods.