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Whittaker SL, Brusco NK, Hill KD, Taylor NF. Self-management Programs Within Rehabilitation Yield Positive Health Outcomes at a Small Increased Cost Compared With Usual Care: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil 2024:S0003-9993(24)00995-X. [PMID: 38729404 DOI: 10.1016/j.apmr.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 04/09/2024] [Accepted: 05/02/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE To determine if self-management programs, supported by a health professional, in rehabilitation are cost effective. DATA SOURCES Six databases were searched until December 2023. STUDY SELECTION Randomized controlled trials with adults completing a supported self-management program while participating in rehabilitation or receiving health professional input in the hospital or community settings were included. Self-management programs were completed outside the structured, supervised therapy and health professional sessions. Included trials had a cost measure and an effectiveness outcome reported, such as health-related quality of life or function. Grading of Recommendations, Assessment, Development, and Evaluations was used to determine the certainty of evidence across trials included in each meta-analysis. Incremental cost-effectiveness ratios were calculated based on the mean difference from the meta-analyses of contributing health care costs and quality of life. DATA EXTRACTION After application of the search strategy, two independent reviewers determined eligibility of identified literature, initially by reviewing the title and/or abstract before full-text review. Using a customized form, data were extracted by one reviewer and checked by a second reviewer. DATA SYNTHESIS Forty-three trials were included, and 27 had data included in meta-analyses. Where self-management was a primary intervention, there was moderate certainty of a meaningful positive difference in quality-of-life utility index of 0.03 units (95% confidence interval, 0.01-0.06). The cost difference between self-management as the primary intervention and usual care (comprising usual intervention/therapy, minimal intervention [including education only], or no intervention) potentially favored the comparison group (mean difference=Australian dollar [AUD]90; 95% confidence interval, -AUD130 to AUD310). The cost per quality-adjusted life year (QALY) gained for self-management programs as a stand-alone intervention was AUD3000, which was below the acceptable willingness-to-pay threshold in Australia per QALY gained (AUD50,000/QALY gained). CONCLUSIONS Self-management as an intervention is low cost and could improve health-related quality of life.
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Affiliation(s)
- Sara L Whittaker
- Rehabilitation, Ageing and Independent Living (RAIL) Research Centre, School of Primary and Allied Health Care, Monash University, Melbourne, Victoria.
| | - Natasha K Brusco
- Rehabilitation, Ageing and Independent Living (RAIL) Research Centre, School of Primary and Allied Health Care, Monash University, Melbourne, Victoria
| | - Keith D Hill
- Rehabilitation, Ageing and Independent Living (RAIL) Research Centre, School of Primary and Allied Health Care, Monash University, Melbourne, Victoria
| | - Nicholas F Taylor
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria; Eastern Health, Allied Health Clinical Research Office, Box Hill, Victoria, Australia
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Cochrane M, Mitchell E, Hollingworth W, Crawley E, Trépel D. Cost-effectiveness of Interventions for Chronic Fatigue Syndrome or Myalgic Encephalomyelitis: A Systematic Review of Economic Evaluations. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2021; 19:473-486. [PMID: 33646528 PMCID: PMC7917957 DOI: 10.1007/s40258-021-00635-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/03/2021] [Indexed: 05/13/2023]
Abstract
INTRODUCTION Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) has profound quality of life and economic consequences for individuals, their family, formal services and wider society. Little is known about which therapeutic interventions are more cost-effective. OBJECTIVE A systematic review was carried out to identify and critically appraise the evidence on the cost-effectiveness of CFS/ME interventions. METHODS The review protocol was prespecified (PROSPERO: CRD42018118731). Searches were carried out across two databases-MEDLINE (1946-2020) and EMBASE (1974-2020). Additional studies were identified by searching reference lists. Only peer-reviewed journal articles of full economic evaluations examining CFS/ME interventions were included. Trial- and/or model-based economic evaluations were eligible. Data extraction and screening were carried out independently by two reviewers. The methodological quality of the economic evaluation and trial were assessed using the Consensus Health Economic Criteria checklist (CHEC-list) and Risk of Bias-2 (RoB-2) tool, respectively. A narrative synthesis was used to summarise the economic evidence for interventions for adults and children in primary and secondary care settings. RESULTS Ten economic evaluations, all based on data derived from randomised controlled trials, met our eligibility criteria. Cognitive behavioural therapy (CBT) was evaluated across five studies, making it the most commonly evaluated intervention. There was evidence from three trials to support CBT as a cost-effective treatment option for adults; however, findings on CBT were not uniform, suggesting that cost-effectiveness may be context-specific. A wide array of other interventions were evaluated in adults, including limited evidence from two trials supporting the cost effectiveness of graded exercise therapy (GET). Just one study assessed intervention options for children. Our review highlighted the importance of informal care costs and productivity losses in the evaluation of CFS/ME interventions. CONCLUSIONS We identified a limited patchwork of evidence on the cost-effectiveness of interventions for CFS/ME. Evidence supports CBT as a cost-effective treatment option for adults; however, cost-effectiveness may depend on the duration and frequency of sessions. Limited evidence supports the cost effectiveness of GET. Key weaknesses in the literature included small sample sizes and short duration of follow-up. Further research is needed on pharmacological interventions and therapies for children.
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Affiliation(s)
- M Cochrane
- Bristol Medical School, University of Bristol, Bristol, UK.
| | - E Mitchell
- Global Brain Health Institute, Trinity College Institute for Neuroscience, Trinity College Dublin, Dublin, Ireland
- School of Biological Sciences, IGFS, Gibson Institute, Queen's University Belfast, Belfast, UK
| | - W Hollingworth
- Bristol Medical School, University of Bristol, Bristol, UK
| | - E Crawley
- Bristol Medical School, University of Bristol, Bristol, UK
| | - D Trépel
- School of Biological Sciences, IGFS, Gibson Institute, Queen's University Belfast, Belfast, UK
- School of Medicine, Trinity College Dublin, Dublin, Ireland
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Leaviss J, Davis S, Ren S, Hamilton J, Scope A, Booth A, Sutton A, Parry G, Buszewicz M, Moss-Morris R, White P. Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation. Health Technol Assess 2020; 24:1-490. [PMID: 32975190 PMCID: PMC7548871 DOI: 10.3310/hta24460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The term 'medically unexplained symptoms' is used to cover a wide range of persistent bodily complaints for which adequate examination and appropriate investigations do not reveal sufficiently explanatory structural or other specified pathologies. A wide range of interventions may be delivered to patients presenting with medically unexplained symptoms in primary care. Many of these therapies aim to change the behaviours of the individual who may have worsening symptoms. OBJECTIVES An evidence synthesis to determine the clinical effectiveness and cost-effectiveness of behavioural modification interventions for medically unexplained symptoms delivered in primary care settings was undertaken. Barriers to and facilitators of the effectiveness and acceptability of these interventions from the perspective of patients and service providers were evaluated through qualitative review and realist synthesis. DATA SOURCES Full search strategies were developed to identify relevant literature. Eleven electronic sources were searched. Eligibility criteria - for the review of clinical effectiveness, randomised controlled trials were sought. For the qualitative review, UK studies of any design were included. For the cost-effectiveness review, papers were restricted to UK studies reporting outcomes as quality-adjusted life-year gains. Clinical searches were conducted in November 2015 and December 2015, qualitative searches were conducted in July 2016 and economic searches were conducted in August 2016. The databases searched included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and EMBASE. Updated searches were conducted in February 2019 and March 2019. PARTICIPANTS Adult participants meeting the criteria for medically unexplained symptoms, including somatoform disorders, chronic unexplained pain and functional somatic syndromes. INTERVENTIONS Behavioural interventions were categorised into types. These included psychotherapies, exercise-based interventions, multimodal therapies (consisting of more than one intervention type), relaxation/stretching/social support/emotional support, guided self-help and general practitioner interventions, such as reattribution. Evidence synthesis: a network meta-analysis was conducted to allow a simultaneous comparison of all evaluated interventions in a single coherent analysis. Separate network meta-analyses were performed at three time points: end of treatment, short-term follow-up (< 6 months since the end of treatment) and long-term follow-up (≥ 6 months after the end of treatment). Outcomes included physical and psychological symptoms, physical functioning and impact of the illness on daily activities. Economic evaluation: within-trial estimates of cost-effectiveness were generated for the subset of studies where utility values (or quality-adjusted life-years) were reported or where these could be estimated by mapping from Short Form questionnaire-36 items or Short Form questionnaire-12 items outcomes. RESULTS Fifty-nine studies involving 9077 patients were included in the clinical effectiveness review. There was a large degree of heterogeneity both between and within intervention types, and the networks were sparse across all outcomes. At the end of treatment, behavioural interventions showed some beneficial effects when compared with usual care, in particular for improvement of specific physical symptoms [(1) pain: high-intensity cognitive-behavioural therapy (CBTHI) standardised mean difference (SMD) 0.54 [95% credible interval (CrI) 0.28 to 0.84], multimodal SMD 0.52 (95% CrI 0.19 to 0.89); and (2) fatigue: low-intensity cognitive-behavioural therapy (CBTLI) SMD 0.72 (95% CrI 0.27 to 1.21), relaxation/stretching/social support/emotional support SMD 0.87 (95% CrI 0.20 to 1.55), graded activity SMD 0.51 (95% CrI 0.14 to 0.93), multimodal SMD 0.52 (95% CrI 0.14 to 0.92)] and psychological outcomes [(1) anxiety CBTHI SMD 0.52 (95% CrI 0.06 to 0.96); (2) depression CBTHI SMD 0.80 (95% CrI 0.26 to 1.38); and (3) emotional distress other psychotherapy SMD 0.58 (95% CrI 0.05 to 1.13), relaxation/stretching/social support/emotional support SMD 0.66 (95% CrI 0.18 to 1.28) and sport/exercise SMD 0.49 (95% CrI 0.03 to 1.01)]. At short-term follow-up, behavioural interventions showed some beneficial effects for specific physical symptoms [(1) pain: CBTHI SMD 0.73 (95% CrI 0.10 to 1.39); (2) fatigue: CBTLI SMD 0.62 (95% CrI 0.11 to 1.14), relaxation/stretching/social support/emotional support SMD 0.51 (95% CrI 0.06 to 1.00)] and psychological outcomes [(1) anxiety: CBTHI SMD 0.74 (95% CrI 0.14 to 1.34); (2) depression: CBTHI SMD 0.93 (95% CrI 0.37 to 1.52); and (3) emotional distress: relaxation/stretching/social support/emotional support SMD 0.82 (95% CrI 0.02 to 1.65), multimodal SMD 0.43 (95% CrI 0.04 to 0.91)]. For physical functioning, only multimodal therapy showed beneficial effects: end-of-treatment SMD 0.33 (95% CrI 0.09 to 0.59); and short-term follow-up SMD 0.78 (95% CrI 0.23 to 1.40). For impact on daily activities, CBTHI was the only behavioural intervention to show beneficial effects [end-of-treatment SMD 1.30 (95% CrI 0.59 to 2.00); and short-term follow-up SMD 2.25 (95% CrI 1.34 to 3.16)]. Few effects remained at long-term follow-up. General practitioner interventions showed no significant beneficial effects for any outcome. No intervention group showed conclusive beneficial effects for measures of symptom load (somatisation). A large degree of heterogeneity was found across individual studies in the assessment of cost-effectiveness. Several studies suggested that the interventions produce fewer quality-adjusted life-years than usual care. For those interventions that generated quality-adjusted life-year gains, the mid-point incremental cost-effectiveness ratios (ICERs) ranged from £1397 to £129,267, but, where the mid-point ICER fell below £30,000, the exploratory assessment of uncertainty suggested that it may be above £30,000. LIMITATIONS Sparse networks meant that it was not possible to conduct a metaregression to explain between-study differences in effects. Results were not consistent within intervention type, and there were considerable differences in characteristics between studies of the same type. There were moderate to high levels of statistical heterogeneity. Separate analyses were conducted for three time points and, therefore, analyses are not repeated-measures analyses and do not account for correlations between time points. CONCLUSIONS Behavioural interventions showed some beneficial effects for specific medically unexplained symptoms, but no one behavioural intervention was effective across all medically unexplained symptoms. There was little evidence that these interventions are effective for measures of symptom load (somatisation). General practitioner-led interventions were not shown to be effective. Considerable heterogeneity in interventions, populations and sparse networks mean that results should be interpreted with caution. The relationship between patient and service provider is perceived to play a key role in facilitating a successful intervention. Future research should focus on testing the therapeutic effects of the general practitioner-patient relationship within trials of behavioural interventions, and explaining the observed between-study differences in effects within the same intervention type (e.g. with more detailed reporting of defined mechanisms of the interventions under study). STUDY REGISTRATION This study is registered as PROSPERO CRD42015025520. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 46. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanna Leaviss
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Shijie Ren
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alison Scope
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Glenys Parry
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Marta Buszewicz
- Department of Primary Care and Population Health, University College London Medical School, London, UK
| | | | - Peter White
- Barts and The London School of Medicine and Dentistry, London, UK
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Pheby DF, Araja D, Berkis U, Brenna E, Cullinan J, de Korwin JD, Gitto L, Hughes DA, Hunter RM, Trepel D, Wang-Steverding X. The Development of a Consistent Europe-Wide Approach to Investigating the Economic Impact of Myalgic Encephalomyelitis (ME/CFS): A Report from the European Network on ME/CFS (EUROMENE). Healthcare (Basel) 2020; 8:healthcare8020088. [PMID: 32272608 PMCID: PMC7349118 DOI: 10.3390/healthcare8020088] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/31/2020] [Indexed: 12/21/2022] Open
Abstract
We have developed a Europe-wide approach to investigating the economic impact of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), facilitating acquisition of information on the economic burden of ME/CFS, and international comparisons of economic costs between countries. The economic burden of ME/CFS in Europe appears large, with productivity losses most significant, giving scope for substantial savings through effective prevention and treatment. However, economic studies of ME/CFS, including cost-of-illness analyses and economic evaluations of interventions, are problematic due to different, arbitrary case definitions, and unwillingness of doctors to diagnose it. We therefore lack accurate incidence and prevalence data, with no obvious way to estimate costs incurred by undiagnosed patients. Other problems include, as for other conditions, difficulties estimating direct and indirect costs incurred by healthcare systems, patients and families, and heterogeneous healthcare systems and patterns of economic development across countries. We have made recommendations, including use of the Fukuda (CDC-1994) case definition and Canadian Consensus Criteria (CCC), a pan-European common symptom checklist, and implementation of prevalence-based cost-of-illness studies in different countries using an agreed data list. We recommend using purchasing power parities (PPP) to facilitate international comparisons, and EuroQol-5D as a generic measure of health status and multi-attribute utility instrument to inform future economic evaluations in ME/CFS.
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Affiliation(s)
- Derek F.H. Pheby
- Society and Health, Buckinghamshire New University, High Wycombe HP11 2JZ, UK
- Correspondence:
| | - Diana Araja
- Department of Dosage Form Technology, Faculty of Pharmacy, Riga Stradins University, Dzirciema Street 16, LV-1007 Riga, Latvia;
| | - Uldis Berkis
- Institute of Microbiology and Virology, Riga Stradins University, Dzirciema Street 16, LV-1007 Riga, Latvia;
| | - Elenka Brenna
- Department of Economics and Finance, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 1, 20123 Milan, Italy;
| | - John Cullinan
- School of Business & Economics, National University of Ireland Galway, University Road, H91 TK33 Galway, Ireland;
| | - Jean-Dominique de Korwin
- Internal Medicine Department, University of Lorraine, 34, cours Léopold, CS 25233, F-54052 Nancy CEDEX, France;
- University Hospital of Nancy, Rue du Morvan, 54511 Nancy, France; jd.dekorwin@chru-nancy
| | - Lara Gitto
- Department of Economics, University of Messina, Piazza Pugliatti 1, 98122 Messina, Italy;
| | - Dyfrig A Hughes
- Centre for Health Economics & Medicines Evaluation, Bangor University, Bangor LL57 2PZ, UK;
| | - Rachael M Hunter
- Institute of Epidemiology & Health, Royal Free Medical School, University College London, London NW3 2PF, UK;
| | - Dominic Trepel
- School of Medicine, Trinity College Dublin, College Green, D02 PN40 Dublin 2, Ireland;
- Global Brain Health Institute, School of Medicine, Trinity College Dublin, College Green, D02 PN40 Dublin 2, Ireland
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General medical services by non-medical health professionals: a systematic quantitative review of economic evaluations in primary care. Br J Gen Pract 2020; 69:e304-e313. [PMID: 31015223 DOI: 10.3399/bjgp19x702425] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/12/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Previous systematic reviews have found that nurses and pharmacists can provide equivalent, or higher, quality of care for some tasks performed by GPs in primary care. There is a lack of economic evidence for this substitution. AIM To explore the costs and outcomes of role substitution between GPs and nurses, pharmacists, and allied health professionals in primary care. DESIGN AND SETTING A systematic review of economic evaluations exploring role substitution of allied health professionals in primary care was conducted. Role substitution was defined as 'the substitution of work that was previously completed by a GP in the past and is now completed by a nurse or allied health professional'. METHOD The following databases were searched: Ovid MEDLINE, CINAHL, Cochrane Library, National Institute for Health and Care Excellence (NICE), and the Centre for Reviews and Dissemination. The review followed guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). RESULTS Six economic evaluations were identified. There was some limited evidence that nurse-led care for common minor health problems was cost-effective compared with GP care, and that nurse-led interventions for chronic fatigue syndrome and pharmacy-led services for the medicines management of coronary heart disease and chronic pain were not. In South Korea, community health practitioners delivered primary care services for half the cost of physicians. The review did not identify studies for other allied health professionals such as physiotherapists and occupational therapists. CONCLUSION There is limited economic evidence for role substitution in primary care; more economic evaluations are needed.
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Wortman MSH, Lokkerbol J, van der Wouden JC, Visser B, van der Horst HE, olde Hartman TC. Cost-effectiveness of interventions for medically unexplained symptoms: A systematic review. PLoS One 2018; 13:e0205278. [PMID: 30321193 PMCID: PMC6188754 DOI: 10.1371/journal.pone.0205278] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 09/22/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In primary and secondary care medically unexplained symptoms (MUS) or functional somatic syndromes (FSS) constitute a major burden for patients and society with high healthcare costs and societal costs. Objectives were to provide an overview of the evidence regarding the cost-effectiveness of interventions for MUS or FSS, and to assess the quality of these studies. METHODS We searched the databases PubMed, PsycINFO, the National Health Service Economic Evaluation Database (NHS-EED) and the CEA registry to conduct a systematic review. Articles with full economic evaluations on interventions focusing on adult patients with undifferentiated MUS or fibromyalgia (FM), irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS), with no restrictions on comparators, published until 15 June 2018, were included. We excluded preventive interventions. Two reviewers independently extracted study characteristics and cost-effectiveness data and used the Consensus on Health Economic Criteria Checklist to appraise the methodological quality. RESULTS A total of 39 studies out of 1,613 articles met the inclusion criteria. Twenty-two studies reported costs per quality-adjusted life year (QALY) gained and cost-utility analyses (CUAs). In 13 CUAs the intervention conditions dominated the control conditions or had an incremental cost-effectiveness ratio below the willingness-to-pay threshold of € 50,000 per QALY, meaning that the interventions were (on average) cost-effective in comparison with the control condition. Group interventions focusing on MUS (n = 3) or FM (n = 4) might be more cost-effective than individual interventions. The included studies were heterogeneous with regard to the included patients, interventions, study design, and outcomes. CONCLUSION This review provides an overview of 39 included studies of interventions for patients with MUS and FSS and the methodological quality of these studies. Considering the limited comparability due to the heterogeneity of the studies, group interventions might be more cost-effective than individual interventions. REGISTRATION Study methods were documented in an international prospective register of systematic reviews (PROSPERO) protocol, registration number: CRD42017060424.
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Affiliation(s)
- Margreet S. H. Wortman
- ACHIEVE – Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- * E-mail:
| | - Joran Lokkerbol
- Centre of Economic Evaluation, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Johannes C. van der Wouden
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Bart Visser
- ACHIEVE – Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Henriëtte E. van der Horst
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Tim C. olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Vos-Vromans D, Evers S, Huijnen I, Köke A, Hitters M, Rijnders N, Pont M, Knottnerus A, Smeets R. Economic evaluation of multidisciplinary rehabilitation treatment versus cognitive behavioural therapy for patients with chronic fatigue syndrome: A randomized controlled trial. PLoS One 2017; 12:e0177260. [PMID: 28574985 PMCID: PMC5456034 DOI: 10.1371/journal.pone.0177260] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 04/25/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A multi-centre RCT has shown that multidisciplinary rehabilitation treatment (MRT) is more effective in reducing fatigue over the long-term in comparison with cognitive behavioural therapy (CBT) for patients with chronic fatigue syndrome (CFS), but evidence on its cost-effectiveness is lacking. AIM To compare the cost-effectiveness of MRT versus CBT for patients with CFS from a societal perspective. METHODS A multi-centre randomized controlled trial comparing MRT with CBT was conducted among 122 patients with CFS diagnosed using the 1994 criteria of the Centers for Disease Control and Prevention and aged between 18 and 60 years. The societal costs (healthcare costs, patient and family costs, and costs for loss of productivity), fatigue severity, quality of life, quality-adjusted life-year (QALY), and cost-effectiveness ratios (ICERs) were measured over a follow-up period of one year. The main outcome of the cost-effectiveness analysis was fatigue measured by the Checklist Individual Strength (CIS). The main outcome of the cost-utility analysis was the QALY based on the EuroQol-5D-3L utilities. Sensitivity analyses were performed, and uncertainty was calculated using the cost-effectiveness acceptability curves and cost-effectiveness planes. RESULTS The data of 109 patients (57 MRT and 52 CBT) were analyzed. MRT was significantly more effective in reducing fatigue at 52 weeks. The mean difference in QALY between the treatments was not significant (0.09, 95% CI: -0.02 to 0.19). The total societal costs were significantly higher for patients allocated to MRT (a difference of €5,389, 95% CI: 2,488 to 8,091). MRT has a high probability of being the most cost effective, using fatigue as the primary outcome. The ICER is €856 per unit of the CIS fatigue subscale. The results of the cost-utility analysis, using the QALY, indicate that the CBT had a higher likelihood of being more cost-effective. CONCLUSIONS The probability of being more cost-effective is higher for MRT when using fatigue as primary outcome variable. Using QALY as the primary outcome, CBT has the highest probability of being more cost-effective. TRIAL REGISTRATION ISRCTN77567702.
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Affiliation(s)
| | - Silvia Evers
- Department of Health Services Research, Research School CAPHRI Maastricht University, Maastricht, The Netherlands.,Trimbos Institute, National Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Ivan Huijnen
- Department of Rehabilitation Medicine, Research School CAPHRI Maastricht University, Maastricht, The Netherlands.,Department of Rehabilitation Medicine, Academic Hospital Maastricht, Maastricht, The Netherlands.,Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Albère Köke
- Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Minou Hitters
- Libra Rehabilitation and Audiology, Eindhoven, The Netherlands
| | | | - Menno Pont
- Reade Centre of Rheumatology and Rehabilitation, Amsterdam, The Netherlands
| | - André Knottnerus
- Department of General Practice, Research School CAPHRI Maastricht University, Maastricht, The Netherlands
| | - Rob Smeets
- Department of Rehabilitation Medicine, Research School CAPHRI Maastricht University, Maastricht, The Netherlands.,Department of Rehabilitation Medicine, Academic Hospital Maastricht, Maastricht, The Netherlands.,Libra Rehabilitation and Audiology, Eindhoven, The Netherlands
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Meng H, Friedberg F. Cost-Utility of Home-Based Fatigue Self-Management versus Usual Care for the Treatment of Chronic Fatigue Syndrome. FATIGUE-BIOMEDICINE HEALTH AND BEHAVIOR 2017; 5:202-214. [PMID: 30931176 DOI: 10.1080/21641846.2017.1343171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background Chronic fatigue syndrome is a complex chronic condition with large negative impact on patients' function and quality of life. Efficacy and cost-effectiveness of cognitive behavioral intervention remain inconclusive. Objective To evaluate the cost-utility of a home-based fatigue self-management (FSM) intervention as compared to usual care among primary care patients with severe chronic fatigue syndrome (CFS). Methods An economic evaluation alongside of a randomized controlled study design was used. Cost and utility data were collected from 137 patients with severe CFS at baseline and 1-year follow-up. The FSM group (n=89) received self-delivered cognitive behavioral self-management intervention and the usual care group (n=48) received regular medical care. Cost was measured by total costs (direct, indirect, and intervention costs) during the follow-up period. Quality-adjusted life years (QALY), as the utility measure, were derived from the Medical Outcomes Survey Short Form-36. A societal perspective was adopted. Bootstrapped incremental cost-utility ratios (ICURs) and net monetary benefit were calculated as measures of cost-effectiveness. Results Baseline individual characteristics were similar between the two groups. The intervention was well-received by the participants with only minimum attrition. At the end of one year post-intervention, FSM dominated usual care in terms of ICUR in both the intention-to-treat analysis and the complete-cases-only analysis. Net monetary benefit analysis showed that FSM has higher probability of achieving positive net monetary across the entire range of possible societal willingness-to-pay for fatigue symptom management. CONCLUSIONS In primary care patients with severe CFS, the low-cost FSM appears to be a cost-effective treatment.
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Affiliation(s)
- Hongdao Meng
- School of Aging Studies, University of South Florida
| | - Fred Friedberg
- Department of Psychiatry, Stony Brook University Medical Center
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9
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Bansal AS. Investigating unexplained fatigue in general practice with a particular focus on CFS/ME. BMC FAMILY PRACTICE 2016; 17:81. [PMID: 27436349 PMCID: PMC4950776 DOI: 10.1186/s12875-016-0493-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 07/13/2016] [Indexed: 01/23/2023]
Abstract
Unexplained fatigue is not infrequent in the community. It presents a number of challenges to the primary care physician and particularly if the clinical examination and routine investigations are normal. However, while fatigue is a feature of many common illnesses, it is the main problem in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). This is a poorly understood condition that is accompanied by several additional symptoms which suggest a subtle multisystem dysfunction. Not infrequently it is complicated by sleep disturbance and alterations in attention, memory and mood. Specialised services for the diagnosis and management of CFS/ME are markedly deficient in the UK and indeed in virtually all countries around the world. However, unexplained fatigue and CFS/ME may be confidently diagnosed on the basis of specific clinical criteria combined with the normality of routine blood tests. The latter include those that assess inflammation, autoimmunity, endocrine dysfunction and gluten sensitivity. Early diagnosis and intervention in general practice will do much to reduce patient anxiety, encourage improvement and prevent expensive unnecessary investigations. There is presently an on-going debate as to the precise criteria that best confirms CFS/ME to the exclusion of other medical and psychiatric/psychological causes of chronic fatigue. There is also some disagreement as to best means of investigating and managing this very challenging condition. Uncertainty here can contribute to patient stress which in some individuals can perpetuate and aggravate symptoms. A simple clinical scoring system and a short list of routine investigations should help discriminate CFS/ME from other causes of continued fatigue.
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Affiliation(s)
- Amolak S Bansal
- Department of Immunology and Allergy, St. Helier Hospital, Carshalton, Surrey, SM5 1AA, UK. .,The Sutton CFS Service, Sutton Hospital, Cotswold Rd, Sutton, SM2 5NF, UK.
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ECONOMIC EVALUATION STUDIES OF SELF-MANAGEMENT INTERVENTIONS IN CHRONIC DISEASES: A SYSTEMATIC REVIEW. Int J Technol Assess Health Care 2016; 32:16-28. [DOI: 10.1017/s0266462316000027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: To our knowledge, there has been no overall systematic review focusing on the methodological quality of full economic evaluation studies of self-management interventions. Our objective was to systematically review the literature of full economic evaluation studies of self-management interventions in adult chronic patients and to investigate their methodological quality and cost-effectiveness.Methods: A data extraction form was developed to assess general and randomized controlled trial (RCT) -related characteristics, quality, of the RCTs, economic information and quality of the economic evaluation studies by means of a quality assessment (CHEC-list for trial-based studies, adjusted CHEC-list for model-based studies).Results: Twenty-three reports were found. Sixteen studies (73 percent) lack information on the control intervention(s). Only one study fulfilled all three criteria for quality of RCTs and five studies (23 percent) did not meet any of these criteria. This review included one model-based study; the other studies were trial-based economic evaluation studies based on a RCT. Eight studies (35 percent) used a societal perspective and 12 (60 percent) synthesized costs and effects. Seven studies were categorized into the highest category (<15 score), nine studies into the “moderate” group (9–14 score), six studies received a “low” score (<8) on the CHEC-list. Eighteen studies found the self-management intervention(s) to be cost-effective compared with other interventionsConclusions: Self-management interventions for adult chronic patients were heterogeneous and there was no clear, well-considered definition of self-management. Overall, the methodological quality of the full economic evaluation studies was moderate and, therefore, cost-effectiveness results must be interpreted with caution. Future research will benefit from further improvements in methodological quality of both economic study design and analysis, as well as a taxonomy for describing self-management interventions and their contents.
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Keidser G, Convery E. Self-Fitting Hearing Aids: Status Quo and Future Predictions. Trends Hear 2016; 20:2331216516643284. [PMID: 27072929 PMCID: PMC4871211 DOI: 10.1177/2331216516643284] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 03/14/2016] [Accepted: 03/15/2016] [Indexed: 11/27/2022] Open
Abstract
A self-contained, self-fitting hearing aid (SFHA) is a device that enables the user to perform both threshold measurements leading to a prescribed hearing aid setting and fine-tuning, without the need for audiological support or access to other equipment. The SFHA has been proposed as a potential solution to address unmet hearing health care in developing countries and remote locations in the developed world and is considered a means to lower cost and increase uptake of hearing aids in developed countries. This article reviews the status of the SFHA and the evidence for its feasibility and challenges and predicts where it is heading. Devices that can be considered partly or fully self-fitting without audiological support were identified in the direct-to-consumer market. None of these devices are considered self-contained as they require access to other hardware such as a proprietary interface, computer, smartphone, or tablet for manipulation. While there is evidence that self-administered fitting processes can provide valid and reliable results, their success relies on user-friendly device designs and interfaces and easy-to-interpret instructions. Until these issues have been sufficiently addressed, optional assistance with the self-fitting process and on-going use of SFHAs is recommended. Affordability and a sustainable delivery system remain additional challenges for the SFHA in developing countries. Future predictions include a growth in self-fitting products, with most future SFHAs consisting of earpieces that connect wirelessly with a smartphone and providers offering assistance through a telehealth infrastructure, and the integration of SFHAs into the traditional hearing health-care model.
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Affiliation(s)
- Gitte Keidser
- National Acoustic Laboratories and the Hearing CRC, New South Wales, Australia
| | - Elizabeth Convery
- National Acoustic Laboratories and the Hearing CRC, New South Wales, Australia
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Informing disinvestment with limited evidence: cobalamin deficiency in the fatigued. Int J Technol Assess Health Care 2015; 31:188-96. [PMID: 26179277 DOI: 10.1017/s0266462315000331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Health technology reassessment and disinvestment can be difficult due to uncertainties regarding available evidence. Pathology testing to investigate cobalamin (vitamin B12) deficiency is a strong case in point. We conducted a 3-month economic evaluation of five strategies for diagnosing and treating cobalamin deficiency in adult patients hypothetically presenting with new unexplained fatigue in the primary care setting. The first consultation per patient was considered. Screening tests other than serum cobalamin were not included. METHODS A cost-effectiveness analysis was undertaken using a decision tree to represent the diagnostic / treatment pathways, with relevant cost and utility scores assigned to different stages in the evaluation process. Input parameter values were estimated from published evidence, supplemented by expert opinion, with sensitivity analysis undertaken to represent parameter uncertainty. RESULTS Ordering serum vitamin B12 to assess cobalamin deficiency among patients with unexplained fatigue was not cost-effective in any patient population, irrespective of pretest prevalence of this deficiency. For patients with a pretest prevalence above 1 percent, treating all with oral vitamin B12 supplements without testing was most cost-effective, whereas watchful waiting with symptoms monitoring was most cost-effective for patients with lower pretest prevalence probabilities. CONCLUSIONS Substantial evidence gaps exist for parameter estimation: questionable cobalamin deficiency levels in the fatigued; debatable treatment methods; unknown natural history of the condition. Despite this, we reveal a robust path for disinvestment decision making in the face of a paradox between the evidence required to inform disinvestment compared with its paucity in informing initial funding decisions.
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Meng H, Friedberg F, Castora-Binkley M. Cost-effectiveness of chronic fatigue self-management versus usual care: a pilot randomized controlled trial. BMC FAMILY PRACTICE 2014; 15:184. [PMID: 25421363 PMCID: PMC4260238 DOI: 10.1186/s12875-014-0184-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 10/24/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Fatigue is a common yet difficult to treat condition in primary care. The objective of this study is to evaluate the cost-effectiveness of a brief cognitive behavioral therapy (CBT) based fatigue self-management (FSM) intervention as compared to usual care among patients with chronic fatigue in primary care. METHODS An economic evaluation alongside of a parallel randomized controlled study design was used. Computer-generated variable-sized block randomization plan was used to assign patients into treatment groups and data collection staff were blinded to group assignments. Patients aged between 18 and 65 years with at least six months of persistent fatigue and no medical or psychiatric exclusions were enrolled from a large primary care practice in Stony Brook, New York. The FSM group (n = 37) received two sessions of a nurse-delivered, fatigue self-management protocol and a self-help book and the usual care group (n = 36) received regular medical care. The effectiveness measure was the Fatigue Severity Scale and the cost measure was total health care expenditures derived from monthly health services use diaries during follow-up. A societal perspective was adopted and bootstrapped incremental cost-effectiveness ratios (ICERs) and net monetary benefit (NMB) were calculated as measures of cost-effectiveness. RESULTS The ICER for FSM was -$$2358, indicating that FSM dominates UC and it may generate societal cost savings as compared to usual care. Complete case analysis yielded smaller ICER (-$1199) with greater uncertainties. Net monetary benefit analysis showed that FSM has a probability of 0.833 (95% CI: 0.819, 0.847) to achieve positive NMB and the favorable results were not sensitive to assumptions about informal care or treatment costs. CONCLUSION This economic evaluation found initial evidence that a two-session brief CBT-based FSM may be cost-effective as compared to usual care over 12 months. The FSM intervention is potentially a promising intervention for chronic fatigue patients in primary care. Additional research is needed to examine the reproducibility and generalizability of these findings. TRIAL REGISTRATION ClinicalTrials.gov (NCT00997451, March 28, 2009).
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