Economic evaluation of multidisciplinary rehabilitation treatment versus CBT for patients with CFS

[Dolphin]

It is disappointing that we don't get information* on baseline levels of "informal care" and "productivity costs" to see if there was any change and if so in what direction.

*I suppose there is a chance these were given in another paper though I doubt it.

 

[Dolphin]

Interesting how MRT had quite the dramatic effect on QALY using one method of calculating it but much less using the other one.

 

[Dolphin]

A reminder:

Results of the FINE trial indicated that pragmatic rehabilitation was not cost-effective when looking at the costs per QALY measured by the EuroQol-5D-3L (EQ-5D-3L). The rehabilitation treatment studied in the FINE trial was different and not comparable to MRT, making it difficult to generalize the results of the FINE trial to all rehabilitation treatments

 

[Dolphin]

The EQ-5D-3L, which is a generic measure, assesses five domains of the quality of life, with only three scoring levels. Recently, in studies of patients with chronic illnesses in which fatigue is a common complaint, the use of disease-specific outcome measures in addition to generic measures is advised, since the generic measures might not be sensitive enough to measure change after treatment [16±18]. To provide a more disease-specific outcome, the fatigue severity measured by the Checklist Individual Strength (CIS) [19], subscale fatigue and quality of life measured with the Short-Form 36 (SF-36) [20] were included.

These aren't really that CFS-specific.

 

[Dolphin]

Interventions

In MRT, a consultant in rehabilitation medicine, social worker, psychologist, physical therapist and occupational therapist worked as an interdisciplinary team together with the patient for 6 months. The protocol prescribed a total of 44.5 face-to-face contact hours. Gradual reactivation, pacing, mindfulness, body awareness therapy, normalising sleep-wake rhythm and social reintegration were combined with CBT and tailored to the individual needs and goals of the patient.

CBT is a psychotherapeutic approach in which elements of behavioural and cognitive therapy approaches are incorporated to change behavioural and cognitive factors, which are assumed to perpetuate the symptoms of CFS [24]. CBT was delivered by a psychologist or cognitive behavioural therapist. The protocol of CBT prescribed a total of 16 face-to-face contact hours during 6 months. Both treatments aimed at decreasing the severity of fatigue and increasing quality of life. Treatments have been described earlier [14].

 

[Dolphin]

For the utility analysis, QALYs were generated from the standard Dutch version of the EQ- 5D-3L [26]. The EQ-5D-3L contains five dimensions of health-related quality of life: mobility, self-care, daily activities, pain/discomfort and depression/anxiety. Each dimension can be rated on one of three levels: no problem, some problems and major problems

Does anybody have the exact questionnaire wording as I would like to think about them.

The five dimensions were aggregated into a health state. Utility values were calculated for these health states, using preferences elicited from a general population from the UK, the so-called Dolan algorithm [27]. Utilities were calculated for every assessment. The accrual of QALYs from baseline to the 52 week follow-up was calculated using the area under the curve, assuming a linear change between each available time point.

 

[Dolphin]

To measure the opinion of the patient regarding his/her improvement, the patient was asked to fill in the Improvement and satisfaction questionnaire (EET). Question 4 of the EET: ªIs there a difference in your daily activities now compared to your situation before treatment startedº, was used in the sensitivity analysis to give an indication of the extent to which a patient feels he or she has improved [14].

Improvement was measured by the Improvement and satisfaction questionnaire (EET), question 4 ªIs there a difference in your daily activities now compared to your situation before treatment started? (`1' = improved and `0' = not improved) [14].

Given all the therapy they had, it seems possible they could imagine whatever they did before therapy is bad and what to do now as good/better.

 

[Dolphin]

Treatment hours for MRT and CBT were registered by the therapist and the consultant in rehabilitation medicine after each treatment session. The duration of the treatment sessions was added up and costs calculated using the Dutch diagnosis-dependent treatment combination for cost-pricing the interventions (www. dbconderhoud.nl). Following this procedure, the following costs per treatment category were used: 0-2 hours of outpatient rehabilitation treatment €200, 2-6 hours of treatment €539, 6-18 hours €1,364, 18-49 hours €3,557, 49-129 hours €8,620, 129-299 hours €19,392, 299 hours and more €37,268.

Given that the MRT therapy was scheduled for 44.5 hours, using an average from 18-49 hours seems like it might underestimate the cost in this case.

 

[Dolphin]

Every month the patient reported the days lost from work due to fatigue as well as his/her wages (TiC-P, part II). Following the human capital approach, the total hours of absenteeism was multiplied by the hourly wages and afterwards multiplied by a factor of 0.8. The 0.8 factor is a correction because productivity in the Netherlands decreases by a factor of 0.8 as working hours decrease due to absenteeism [29]. The national mean age and gender-specific wages were used when the patient preferred not to fill in his/her wages.

I'm not sure I definitely understand why they did this. But it does mean that one probably needs to multiply by 1.25 the productivity costs to compare them with other studies' figures.

I wonder was the term "due to fatigue" used? People might miss work due to muscle pain, headaches/migraines, et cetera which can be part of ME/CFS.

 

[Dolphin]

During the base-case analysis it was noticed that as patients had to fill in their hours of absence while reintegrating or working part-time due to their illness, inconsistencies were found within the answers. Assumptions had to be made in order to calculate the correct hours of absence. The estimated minimum hours of absence was used in the base-case analysis. The estimated maximum hours of absence was used in sensitivity analysis (3a-b).

Again this means one probably needs to be careful when quoting the productivity costs/losses they quote.

 

[Dolphin]

Living situation b:
Living alone, no
Married or living together
Living apart together
Living with parents

I don't know what "living apart together" means

 

[Dolphin]

In patients who are chronically ill, treatments like MRT often focus on improving autonomy and the patient's participation in society. Neither of these domains is not included in the EQ-5D-3L. Future studies should assess the extent to which differences in the EQ-5D-3L following treatment reconcile with improvements in disease- specific measurements for patients with CFS after treatment

Their excuse for MRT not getting a good result on QALY (though maybe it is true)

In addition, as van Leeuwen et al. stated in their study in 2015 [40], the Adult Social Care Outcomes Toolkit and the ICEpop CAPability might also be valuable outcome measures in economic evaluations of care interventions because they are at least as reliable as the EQ-5D-3L and are associated with aspects of quality of life broader than health, for example occupation, dignity, control over daily life and the ability to `do' and `be' the things that are important in life [40].

This may well be true.

 

[Dolphin]

For further research, it is recommended that improvement be evaluated based on domains that are important for the individual patient and also to obtain insight into what society is willing to pay for an improved patient with CFS in order to facilitate cost-effectiveness analysis of treatments.

I reckon there's a good chance patients might concentrate more on the quantity of activity they can do i.e. as measured by an actometer rather than fatigue.

 

[Dolphin]

The scarcity of effective treatments for patients with CFS and patient preferences are relevant issues when making healthcare decisions. At this moment there is a scarcity of effective treatments for patients with CFS [41], which might stimulate the implementation of MRT. Preferences of the patient should also be taken into account when making a healthcare decision. In this trial significantly more patients from the MRT group would recommend the treatment to others in comparison with patients from the CBT group [14], which might give an impression of the preferences of treatment for patients with CFS. Further research is needed on this topic

Normally you don't hear the CBT/GET/rehab school of thought mentioning patient preferences with regard to CFS. Of course here, it suits them.

 

[Dolphin]

Another point which should be taken into account is the fact that costs for the MRT were probably overestimated since treatment was new. Costs for MRT might decrease as this treatment is executed more routinely and therapists are better skilled at treating patients more effectively. In a post-hoc analysis the first patients in the MRT group had significantly more contact hours compared to the patients who were included later in the trial. In CBT such development was not found.

I'll post this for completeness.

Additionally, costs of both interventions might become lower when therapists are able to decrease the number of sessions needed to achieve a patient's personal goal or when specific interventions are not needed to achieve a patient's goal. In clinical practice this is already the case, but due to the treatment protocols in this trial, in which a minimum number of hours of treatment were prescribed, this was not an option.

Except CBT and I presume MRT are supposed to bring about recovery. But the evidence from the PACE Trial is that this doesn't occur. So I'm not sure one would see many patients having fewer therapy sessions, unless they were giving up on the therapy.

 

[JohnCB]

I don't know what "living apart together" means

Regarding themselves as being a couple, in a relationship, but maintaining separate households. I think it is more common in middle aged couples who are already economically independent and choosing to keep that while being committed to each other in other respects.

 

[Dolphin]

However, data used in our analyses were derived from a single RCT, presenting a potential limitation to the generalizability of our findings. Furthermore, as only patients who were specifically referred for a treatment in secondary care were included, makes the results highly generalizable to daily care of patients with CFS. On the other hand, as 37 patients did not meet the CDC-94 criteria of CFS and were excluded before randomization, 54 patients were unwilling to participate in the trial, and the data of only 109 patient was used in the analysis should be taken into account when generalizing the results to the total population of patients with fatigue as a main complaint who are referred to secondary healthcare. In clinical practice CDC-94 criteria are not always used in deciding to treat patients in a rehabilitation centre. Furthermore, some patients were unwilling to participate in the trial, which can be seen as selection bias.

In most CBT and GET studies for CFS, they don't mention this issue of some people not being willing to undertake the interventions.

 

[Dolphin]

However, there are some other limitations: First, we relied on self-reported information regarding healthcare, productivity losses and patient-family costs. There may be issues of accuracy with this approach, but it was largely unavoidable, given the impossibility of registering otherwise. Moreover, as these measurements were similar in both groups, these issues did not affect comparability

This limitation is generally not mentioned in CFS studies in my experience.

 

[Dolphin]

Other studies have shown that the method used is acceptable [43,44]. Second, the loss of productivity while being at work was not taken into account. Future studies should include loss of productivity while at work by using the TiC-P with an extra instruction to the patient on how and when to fill in this part of the questionnaire

I'm guessing "productivity" is being used in a different way here i.e. somebody works the same amount of hours somebody else but is not as productive for the employer.

This could be important as if you are less productive you might be more likely to be sacked or have less chance of promotion. Or if one was self-employed, or had a share in the company, the yield from the work might be lower. Again this is something I haven't seen being mentioned in CBT and GET studies in the CFS field

 

[Dolphin]

Finally, the costs and effects were measured only during a period of 52 weeks. It is possible the costs and effects change after 52 weeks.

Seems reasonable.