Fibromyalgia Cost-utility of CBT vs. FDA recommended drugs

[Ecoclimber]

Arthritis Res Ther. 2014 Oct 1;16(5):451. [Epub ahead of print]
Cost-utility of cognitive behavioural therapy versus U.S. food and drug administration recommended drugs and usual care in the treatment of patients with fibromyalgia: an economic evaluation alongside a 6-month randomised controlled trial.
Luciano JV, D Amico F, Cerdà-Lafont M, Peñarrubia-María MT, Knapp M, Cuesta-Vargas AI, Serrano-Blanco A, García-Campay

Abstract
IntroductionCognitive behavioural therapy (CBT) and U.S. Food and Drug Administration (FDA) recommended pharmacological treatments (RPT; pregabalin, duloxetine, and milnacipran) are effective treatment options for fibromyalgia (FM) syndrome and are currently recommended by clinical guidelines.

We compared the cost-utility from the healthcare and societal perspectives of CBT versus RPT (combination of pregabalin¿+¿duloxetine) and usual care (TAU) groups in the treatment of FM.Methods

The economic evaluation was conducted alongside a 6-month, multicentre, randomised, blinded, parallel group, controlled trial. A total of 168 FM patients from 41 general practices in Zaragoza (Spain) were randomised to CBT (n¿=¿57), RPT (n¿=¿56) or TAU (n¿=¿55).

The main outcome measures were Quality-Adjusted Life Years (QALYs, assessed using the EuroQoL-5D questionnaire) and improvements in health-related quality of life (HRQoL, assessed using EuroQoL-5D visual analogue scale, EQ-VAS).

The costs of healthcare utilisation were estimated from patient self-reports (Client Service Receipt Inventory). Cost-utility was assessed using the net-benefit approach and cost-effectiveness acceptability curves (CEACs).ResultsOn average, the total costs per patient in the CBT group (1,847¿) were significantly lower than patients receiving RPT (3,664¿) or TAU (3,124¿).

Patients receiving CBT reported a higher quality of life (QALYs and EQ-VAS scores); the differences between groups were significant only for EQ-VAS. From a complete case analysis approach (base case), the point estimates of the cost-effectiveness ratios resulted in dominance for the CBT group in all of the comparisons performed, using both QALYs and EQ-VAS as outcomes.

These findings were confirmed by bootstrap analyses, net-benefit curves and CEACs. Two additional sensitivity analyses (intention-to-treat analysis and per protocol analysis) indicated that the results were robust.

The comparison of RPT versus TAU yielded no clear preference for either treatment when using QALYs, although RPT was determined to be more cost-effective than TAU when evaluating EQ-VAS.ConclusionsDue to lower costs, CBT is the most cost-effective treatment for adult FM patients.

Implementation in routine medical care would require policymakers to develop more widespread public access to trained and experienced therapists in group-based forms of CBT.
Trial registrationCurrent Controlled Trials ISRCTN10804772. Registered 29 September 2008.

 

[Snow Leopard]

The problem is not so much that CBT is great and wonderful, but rather the current drugs for Fibro are expensive and don't work very well.

 

[chipmunk1]

i have an even better solution for them: provide no healthcare whatsoever this should reduce spending to zero.

 

[JAM]

I HATE that cost is even an issue of study. Stupid capitalist system. Grrrrr. CBT is great for a lot of things, including dealing with the PTSD associated with living with a chronic illness, but can we please move away from this disguised "The Secret" "Law of Attraction" victim blaming? Our pain isn't psychosomatic. Let's move on docs!

 

[*GG*]

I HATE that cost is even an issue of study. Stupid capitalist system. Grrrrr. CBT is great for a lot of things, including dealing with the PTSD associated with living with a chronic illness, but can we please move away from this disguised "The Secret" "Law of Attraction" victim blaming? Our pain isn't psychosomatic. Let's move on docs!

@JAM Really, stupid capitalist system? You think people with our illness in China (Communists) and UK (Socialists) get better treatment than we do in the US?

GG

PS Why not consider cost? Isn't that what we do when we decide to do something that is going to negatively impact our PHYSICAL health, but perhaps we need to do it for out MENTAL health! We still need to live a little, in whatever form that may take, otherwise we would probably be in a bad depression all the time, right?

 

[JAM]

@JAM Really, stupid capitalist system? You think people with our illness in China (Communists) and UK (Socialists) get better treatment than we do in the US?

GG

PS Why not consider cost? Isn't that what we do when we decide to do something that is going to negatively impact our PHYSICAL health, but perhaps we need to do it for out MENTAL health! We still need to live a little, in whatever form that may take, otherwise we would probably be in a bad depression all the time, right?

IMO, we should have a system that promotes what works for both our mental and physical health without having to worry about the financial cost. My dream is a system like many European countries, Denmark, Norway, etc.

 

[alex3619]

Let us discuss quality of life data. Compare psychotherapy, which changes attitudes, to other treatments which change symptoms? Quality of life data might use flawed instruments. Where are the objective measures? Working hours? Time spent recovering (you can use an actometer for this)? I have not read this paper, maybe they do use measures like number of doctors appointments? This is not entirely a bad measure, but its not enough. As a stakeholder I would want to know what the objective measures are.

Cost is one objective measure though. However given its calculated based on a subjective measure, and the best response is to attitude changing treatment, is this good evidence? I doubt it. Comparing QALYs from psychopsych studies with biopsych studies might not be valid. I would want cross comparison with really objective measures. Has this been done? Its something I hope to look into, but don't have time for it right now.

 

[JAM]

Let us discuss quality of life data. Compare psychotherapy, which changes attitudes, to other treatments which change symptoms? Quality of life data might use flawed instruments. Where are the objective measures? Working hours? Time spent recovering (you can use an actometer for this)? I have not read this paper, maybe they do use measures like number of doctors appointments? This is not entirely a bad measure, but its not enough. As a stakeholder I would want to know what the objective measures are.

Cost is one objective measure though. However given its calculated based on a subjective measure, and the best response is to attitude changing treatment, is this good evidence? I doubt it. Comparing QALYs from psychopsych studies with biopsych studies might not be valid. I would want cross comparison with really objective measures. Has this been done? Its something I hope to look into, but don't have time for it right now.

I agree that it is very hard to quantify QOL, but I would rather it be looked at in a somewhat "mushy" manner, than not at all. Most real science starts out with broad observation, which is rarely quantifiable in the real world, and then refined as research progresses. We have to start somewhere, and I think QOL is very important.

 

[alex3619]

I agree that it is very hard to quantify QOL, but I would rather it be looked at in a somewhat "mushy" manner, than not at all. Most real science starts out with broad observation, which is rarely quantifiable in the real world, and then refined as research progresses. We have to start somewhere, and I think QOL is very important.

I don't think QOL is unimportant at all. I think that its sometimes being used in ways that are not scientifically justifiable. Such analysis comes at high risk of bias, and researchers need to be aware of that, state the risks, and qualify their conclusions. Rigorous studies in "soft science" exist, as do rigorous methodologies, but so does waffle. Waffle is predominant in my view.

Or to put it another way, QOLYs are heuristic indicators. They are guides. They are not definitive.

 

[JAM]

I don't think QOL is unimportant at all. I think that its sometimes being used in ways that are not scientifically justifiable. Such analysis comes at high risk of bias, and researchers need to be aware of that, state the risks, and qualify their conclusions. Rigorous studies in "soft science" exist, as do rigorous methodologies, but so does waffle. Waffle is predominant in my view.

Or to put it another way, QOLYs are heuristic indicators. They are guides. They are not definitive.

I see.