Cost-utility of home-based fatigue self-management versus usual care for the treatment of CFS

[Dolphin]

FATIGUE: BIOMEDICINE, HEALTH & BEHAVIOR, 2017
https://doi.org/10.1080/21641846.2017.1343171

Cost-utility of home-based fatigue self-management versus usual care for the treatment of chronic fatigue syndrome

Hongdao Menga and Fred Friedbergb

aSchool of Aging Studies, University of South Florida, Tampa, FL, USA;
bDepartment of Psychiatry, Stony Brook University Medical Center, Stony Brook, NY, USA

ABSTRACT

Background:

Chronic fatigue syndrome (CFS) 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 selfmanagement (FSM) intervention as compared to usual care among primary care patients with severe 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 costutility ratios (ICURs) and net monetary benefit (NMB) 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 postintervention, 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.

 

[Wonko]

So delivering CBT over the internet is the cheaper way to deliver a treatment that has no long term benefit so it has a higher efficiency per quid? Even tho CBT has no long term effect?

Seems blindly obvious really - how much did this cost to determine?

edit....and surely it's the only way to deliver CBT to people with severe ME? As people with severe ME tend not to go out much/ at all. So how did they manage to do the comparison?

 

[Dolphin]

In terms of the raw costs, the treatment as usual group resulted in a bigger saving:

Table 2 presents the average costs by resource use categories pre- and post-treatment for TAU and FSM groups. The total cost of the FSM packet is estimated at $79 per patient (personnel: $27, patient information booklet: $10, CD-ROMs: $15, and overhead: $27). Overall, both groups experienced reduction in total average costs of about 10%, with similar costs of pre- and post-interventions. The FSM group had a 6.5% reduction in costs during the post period ($8712–$8143) and the TAU group had a 9.7% reduction in costs during the same period ($8928–$8064).

So $569 vs $864.
TAU $295 less.

Take away: $79 and costs still went down $216 more in the treatment as usual group than the fatigue symptom management group.

This figure includes costs of informal care and missed work.
----
However with the adjusted figures, the fatigue self-management group did better:

At 1-year follow-up, the FSM group had a small positive impact on QALY (0.014, 95% CI: −0.008, 0.036) at lower costs ($64, 95% CI: −208, 77) as compared to TAU, resulting in an ICUR of −4442 (FSM dominated). This means that each additional QALY gained in the FSM were associated with potential saving of $4442 from a societal perspective when compared to TAU. The complete-cases-only analysis showed a lower amount of potential savings at $1455 (95% CI: −18,130, 6602), but this is accompanied by a significant improvement in QALY (as indicated by the 95% CI that does not include zero). In both cases, the bootstrapped 95% confidence intervals for these ICURs suggest that there is considerable uncertainty around the point estimates due in part to the modest sample size.

 

[Dolphin]

Appendix. Unit prices used to value different types of goods/services for the analysis (in 2013 $)

Child/personal care hour $ 11
Hourly wage hour $ 23

Table 2. Costs and changes in costs for TAU and FSM, by category and period.
Pre-intervention Post-intervention
Variables

n (%) users
# of contacts ± SDa
Cost ($)

n (%) users
# of contacts ± SDa
Cost ($)

Changes in costs ($)

Treatment as usual (TAU, n = 48)
9. Informal care, hours 26 (54) 26 ± 32.6 159 38 (79) 17 ± 24.2 157 −2
10. Missed work, hours 38 (79) 10 ± 6.3 185 48 (100) 6 ± 6.3 142 −43

Home-based FSM, n = 89)
9. Informal care, hours 50 (56) 26 ± 23.7 166 73 (82) 20 ± 23.6 194 28
10. Missed work, hours 70 (79) 11 ± 10.1 210 82 (92) 6 ± 5.1 134 −76

The changes in percentages affected are I think due to a three-month period being used before treatment versus 12-month follow-up, though the costs relate to monthly costs.

 

[Dolphin]

Table 1. Baseline characteristics by intervention group
Currently working, % 81.3 86.5

As an aside I thought it was interesting how many worked. My guess is in many other countries such as in Europe the percentages at the same level might be lower, that there is more pressure to work in the US.

Variables
TAU n = 48
FSM n = 89
Fatigue severity scale, mean (SD) 6.6 (0.4) 6.5 (0.5)
SF-36 physical function, mean (SD) 38.9 (22.1) 37.4 (19.8)

 

[Dolphin]

The main target for the treatment was to reduce the negative influences of: affective distress, absence of pleasant affect and experiences, and maladaptive activity patterns.

From what I have read, I find Friedberg's approach less objectionable than normal Dutch and UK CBT. The latter is focused on graded activity and related issues while Friedberg's is more flexible and includes pacing.

 

[Dolphin]

All patients were asked to provide a note from their physicians confirming a diagnosis of CFS.

 

[Dolphin]

Outcome measures

QALYs were generated from the SF-36 questionnaire (version 2) from baseline and 12 months after randomization. The SF-36 questionnaire measures the multi-dimensional concept of health status related to physical, psychological, and social well-being among the general adult population. Because SF-36 scoring assumes equal importance among the items and it is not based on preferences, we used a published algorithm to convert SF-36 data to utility scores on the scale of 0–1 (0 is an anchoring point for death and 1 for perfect health) [29].

These are the only results we are given i.e. we are not given results in the form of SF-36 results:

At 1-year follow-up, the FSM group had a small positive impact on QALY (0.014, 95% CI: −0.008, 0.036)

complete-cases-only analysis:

0.025 (0.001, 0.049)

i.e. there is a statistically significant difference

 

[Dolphin]

Finally, as CBT interventions tend to generate improvement at three to six months post intervention, the one-year time horizon used this analysis may not capture this initial gain and subsequent tapering off.

Dutch and UK CBT CFS studies don't tend to mention this tapering off.

 

[Kati]

Yes of course, managing at home is more economical, but we are still sick. Just like self-service at a gas station is more economical than full serve. Self-management is simply a modern way to get rid of patients.