What Is Known About the Cost- Effectiveness of Nonpharmacological and Nonsurgical Treatments for Pain?

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Kristina McLaughlin
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1 What Is Known About the Cost- Effectiveness of Nonpharmacological and Nonsurgical Treatments for Pain? Role of Nonpharmacologic Approaches to Pain Management: A National Academies Workshop HEALTH Patricia M. Herman, ND, PhD RAND Health

2 Overview Basics of cost-effectiveness analysis, including the tricky bits What the studies of individual interventions for different types of pain show What we can learn from modeling Summary and next steps

3 Cost-Effectiveness Decision Matrix Increased Costs Definitely Reject Alternative (Usual Care Dominates) Decision: Are benefits worth the costs? Cost Savings Decision: Is health loss worth the savings? Definitely Adopt Alternative (Alternative Dominates) Worse Health Improved Health

4 Quality-Adjusted Life-Years (QALYs)

5 Components of Healthcare Costs Upfront Intervention Costs Lower Ongoing Healthcare Costs

salary of provider, facility space, equipment

6 Perspective: Costs to Whom? Individual or Patient: what the patient pays out of pocket Third-party payer: reimbursed healthcare costs Hospital or provider group: salary of provider, facility space, equipment Employer: productivity loss Society: all costs, no matter who pays

7 Transferability Economic outcomes are NOT generalizable across settings Cannot do a meta-analysis and make broad statements about cost-effectiveness Human physiology and psychology more consistent and replicable across settings than are organizational structures and relative prices Goal of transferability: provide enough information that study results can be adapted to other settings usually through modeling

8 Results of a Systematic Review First Author Brown Musculoskel physician Pain Condition Intervention Perspective Results Time Outpatient orthopedic CUA-H Cost saving 1 yr Ratcliffe Acupuncture Low back pain CUA-S Cost saving 2 yrs Korthols de Bos Herman Herman Manual therapy Naturopathic care Naturopathic care Back pain CUA-S Cost saving 1 yr Chronic low back pain CUA-S Cost saving 6mo Chronic low back pain CUA-E Cost saving 6mo Kim Acupuncture Acute low back pain 60y CUA-S $3k/QALY 5 yrs Witt Acupuncture Dysmenorrhea CUA-S $5k/QALY 3mo UK BEAM + exercise Back pain CUA-P $8k/QALY 1 yr Perspective: E=Employer; H=Hospital; P=Payer; S=Societal; CUA=Cost-Utility Analysis; QALY = Quality-Adjusted Life-Year. Herman et al. BMJ Open

9 Results of a Systematic Review First Author Pain Condition Results Time Ratcliffe Acupuncture Low back pain CUA-P $9k/QALY 2 yrs Williams Osteopathy Subacute back pain CUA-P $9k/QALY 6mo UK BEAM Intervention Perspective Hollinghurst Hollinghurst Hollinghurst Back pain CUA-P $11k/QALY 1 yr + Exercise Alexander technique Alexander + Exercise Chronic or recurrent back pain Chronic or recurrent back pain Chronic or recurrent back pain CUA-P $12k/QALY 1 yr CUA-P $12k/QALY 1 yr CUA-P $13k/QALY 1 yr Witt Acupuncture Chronic low back pain CUA-S $16k/QALY 3mo Witt Acupuncture Headache CUA-S $18k/QALY 3mo Perspective: E=Employer; H=Hospital; P=Payer; S=Societal; CUA=Cost-Utility Analysis; QALY = Quality-Adjusted Life-Year. Herman et al. BMJ Open

10 Results of a Systematic Review First Author UK BEAM Pain Condition Results Time Exercise Back pain CUA-P $19k/QALY 1 yr Witt Acupuncture Chronic neck pain CUA-S $19k/QALY 3mo Vickers Acupuncture Chronic headache CUA-S $20k/QALY 1 yr Vickers Acupuncture Chronic headache CUA-P $21k/QALY 1 yr Reinhold Acupuncture Chronic hip or knee OA CUA-S $28k/QALY 3mo Black Glucosamine Knee osteoarthritis CUA-P $59k/QALY 23yr Haas* Chiropractic Acute low back pain CEA-P $21/pain mm Haas* Chiropractic Chronic low back pain CEA-P $1/pain mm 1 yr Intervention Perspective Hollinghurst Chronic or recurrent back pain 1 yr CUA-P Dominated 1 yr Perspective: E=Employer; H=Hospital; P=Payer; S=Societal; CUA=Cost-Utility Analysis; QALY = Quality-Adjusted Life-Year. Herman et al. BMJ Open *US-based.

11 Results of a Systematic Review First Author UK BEAM Pain Condition Results Time Exercise Back pain CUA-P $19k/QALY 1 yr Witt Acupuncture Chronic neck pain CUA-S $19k/QALY 3mo Vickers Acupuncture Chronic headache CUA-S $20k/QALY 1 yr Vickers Acupuncture Chronic headache CUA-P $21k/QALY 1 yr Reinhold Acupuncture Chronic hip or knee OA CUA-S $28k/QALY 3mo Black Glucosamine Knee osteoarthritis CUA-P $59k/QALY 23yr Haas* Chiropractic Acute low back pain CEA-P $21/pain mm Haas* Chiropractic Chronic low back pain CEA-P $1/pain mm 1 yr Intervention Perspective Hollinghurst Chronic or recurrent back pain 1 yr CUA-P Dominated 1 yr Perspective: E=Employer; H=Hospital; P=Payer; S=Societal; CUA=Cost-Utility Analysis; QALY = Quality-Adjusted Life-Year. Herman et al. BMJ Open *US-based.

12 What We Can Learn From These Studies Nonpharmacologic interventions can be costeffective or even cost saving for pain Most lowest cost interventions used the societal perspective i.e., included reductions in productivity loss Some studies costs would be lower if healthcare cost reductions captured over a longer period Only one US-based study (2 results)

13 Additional Studies Found First Author Pain Condition Results Aboagye Medical yoga Low back pain CUA-S Cost saving 1 yr Aboagye Exercise Low back pain CUA-S Cost saving 1 yr Chuang Yoga Chronic low back pain CUA-S Cost saving 1 yr Herman * MBSR Chronic low back pain CUA-S Cost saving 1 yr Korthals de Bos Lewis Intervention Perspective Richardson Manual therapy Manual therapy Time Neck pain CUA-S Cost saving 1 yr Neck pain CUA-S Cost saving 1 yr Exercise class Knee osteoarthritis CUA-S Cost saving 1.5yr Aboagye Medical yoga Low back pain CUA-P Cost saving 1 yr Aboagye Exercise Low back pain CUA-P Cost saving 1 yr Perspective: E=Employer; H=Hospital; P=Payer; S=Societal; CUA=Cost-Utility Analysis; QALY = Quality-Adjusted Life-Year.; MBSR = Mindfulness-based stress reduction. *US-based.

14 Additional Studies Found First Author Pain Condition Intervention Perspective Results Cochrane Water therapy Knee osteoarthritis CUA-P Cost saving 23y Time Critchley Pain mangmt Chronic low back pain CUA-P Cost saving 1.5yr Herman * MBSR Chronic low back pain CUA-P Cost saving 1 yr Herman * Any CIH Chronic musculoskeletal pain (VA) CUA-P Cost saving 1 yr Jessep Exercise vs PT Chronic knee pain CUA-P Cost saving 1 yr Mahrer * Integrative Pediatric pain clinic Costs-H Cost saving 1 yr Mahrer * Integrative Pediatric pain clinic Costs-P Cost saving 1 yr Herman * Group CBT-P Chronic low back pain CUA-S $3k/QALY 1 yr Korthals de Bos PT + Exercise Neck pain CUA-S $4k/QALY 1 yr Lamb Group CBT-P Subacute/chronic LBP CUA-P $4k/QALY 1 yr Perspective: E=Employer; H=Hospital; P=Payer; S=Societal; CUA=Cost-Utility Analysis; QALY = Quality-Adjusted Life-Year.; CIH = Complementary and integrative health. *US-based.

15 Additional Studies Found First Author Lewis Perspective Whitehurst Manual therapy Pain Condition Intervention Results Time Neck pain CUA-P $6k/QALY 6mo Acupuncture Knee osteoarthritis CUA-P $10k/QALY 1 yr Stamuli Acupuncture Severe irritable bowel CUA-P $11k/QALY 1 yr Johnson Exercise+CBT Chronic low back pain CUA-P $12k/QALY 1.3yr Herman * Group CBT-P Chronic low back pain CUA-P $12k/QALY 1 yr Lewis Diathermy Neck pain CUA-S $14k/QALY 6mo Chuang Yoga Chronic low back pain CUA-P $29k/QALY 1 yr Lewis Diathermy Neck pain CUA-P $33k/QALY 6mo Stamuli Acupuncture Irritable bowel CUA-P $106k/ QALY Perspective: E=Employer; H=Hospital; P=Payer; S=Societal; CUA=Cost-Utility Analysis; QALY = Quality-Adjusted Life-Year.; CBT-P = Cognitive behavioral therapy for pain. *US-based. 1 yr

16 What We Can Learn From These Studies Nonpharmacologic interventions can be costeffective and even more are cost saving for pain Many lowest cost interventions used the societal perspective i.e., included reductions in productivity loss Only three US-based studies (7 results) Can t generalize beyond these broad statements Can say more with modeling

17 Results from Two Models Built for Chronic Low Back Pain

18 Institute for Clinical and Economic Review Cognitive and Mind-Body Therapies for CLBP Markov model (6-month cycles over 5 years) Health states = Chronic pain & Pain improved Perspective of the healthcare system Results Incr. Costs Incr. QALY $/QALY Decisions Acupuncture $ $53,933 Intermediate value* CBT $ $93,799 Intermediate value* MBSR $ $19,975 High-value* Yoga $ $3,929 High-value* Tai chi $ $36,759 Not enough evidence * [S]trength of evidence appears adequate to support coverage 2016US$

19 Markov Model for Chronic Low-Back Pain Low-Impact Chronic Pain Cycle length = 6 weeks Model duration = 1 year No Pain (No/Low Disability) High-Impact Chronic Pain Mod-Impact Chronic Pain For each health state: Healthcare cost Productivity cost Health-related QoL value

20 Cost and Utility Estimates per 6-week cycle by health state, M (SE) Health states Back-related healthcare costs Productivity loss (absenteeism) Utilities (health-related quality of life) No pain (No/low disability) Low-impact chronic pain Moderate-impact chronic pain High-impact chronic pain $ -- $3 ($3) (0.004) $265 ($38) $31 ($10) (0.003) $496 ($56) $48 ($6) (0.006) $690 ($54) $291 ($34) (0.007)

21 Relative Cost-Effectiveness (Typical Chronic Low Back Pain Population; Societal Costs) $1,000 $500 $0 Chiropractic Care -$500 -$1,000 CBT Educational Program Exercise Physical Therapy Multidisciplinary -$1,500 Program -$2,000 TCM Acupuncture Exercise + $50,000/QALY Standardized Acupuncture Spinal Therapeutic Relaxation Structural Individualized Acupuncture Active Trunk Exercise Flexion Distraction Yoga Quality-adjusted life-year (QALYs)

22 Relative Cost-Effectiveness (Typical Chronic Low Back Pain Population; Societal Costs) $1,000 $500 $0 $50,000/QALY 58% of points cost saving 77% are <=$50,000/QALY -$500 -$1,000 -$1,500 -$2, Quality-adjusted life-year (QALYs)

23 Relative Cost-Effectiveness (Typical Chronic Low Back Pain Population; Societal Costs) $1,000 $500 $0 Chiropractic Care -$500 -$1,000 CBT Educational Program Exercise Physical Therapy Multidisciplinary -$1,500 Program -$2,000 TCM Acupuncture Exercise + $50,000/QALY Standardized Acupuncture Spinal Therapeutic Relaxation Structural Individualized Acupuncture Active Trunk Exercise Flexion Distraction Yoga Quality-adjusted life-year (QALYs)

24 Relative Cost-Effectiveness (Typical Chronic Low Back Pain Population; Payer Costs) $1,000 $500 $0 Chiropractic Care -$500 CBT Educational Program -$1,000 -$1,500 TCM Acupuncture Exercise Physical Therapy Exercise + Multidisciplinary Program $50,000/QALY Standardized Acupuncture Spinal Therapeutic Structural Relaxation Individualized Acupuncture Active Trunk Exercise Flexion Distraction Yoga -$2, Quality-adjusted life-year (QALYs)

25 Relative Cost-Effectiveness (Typical Chronic Low Back Pain Population; Societal Costs) $1,000 $500 $0 Chiropractic Care -$500 -$1,000 CBT Educational Program Exercise Physical Therapy Multidisciplinary -$1,500 Program -$2,000 TCM Acupuncture Exercise + $50,000/QALY Standardized Acupuncture Spinal Therapeutic Relaxation Structural Individualized Acupuncture Active Trunk Exercise Flexion Distraction Yoga Quality-adjusted life-year (QALYs)

26 Relative Cost-Effectiveness (Typical Chronic Low Back Pain Population; Societal Costs) $50,000/QALY $1,000 TCM Acupuncture Exercise + Spinal $500 Therapeutic Structural $0 Chiropractic Care Relaxation -$500 CBT Educational Active Trunk -$1,000 Program Standardized Exercise Exercise Acupuncture Flexion -$1,500 Distraction Physical Therapy Individualized Yoga -$2,000 Multidisciplinary Acupuncture Program -$2,500 -$3,000 -$3,500 -$4, Quality-adjusted life-year (QALYs)

27 Relative Cost-Effectiveness (High-Impact Chronic Low Back Pain Population; Societal) $1,000 TCM Acupuncture $500 Chiropractic $0 Exercise care -$500 -$1,000 -$1,500 -$2,000 -$2,500 -$3,000 -$3,500 -$4,000 CBT Educational Program $50,000/QALY Structural Multidisciplinary Program Standardized Acupuncture Exercise + Relaxation Therapeutic Individualized Acupuncture Physical therapy Spinal Active Trunk Exercise Flexion Distraction Yoga Quality-Adjusted Life-Years (QALYs)

28 Summary Individual studies show therapies can be costeffective and even cost saving in specific settings Modeling has shown that nonpharmacologic therapies are likely cost-effective and even cost saving in the US, especially: From the societal perspective Over a year For those with high-impact chronic pain Effectiveness and cost-effectiveness of many nonpharmacologic interventions are similar Modeling can help us understand cost-effectiveness of interventions and to target future studies

29 Thank you! We d like to acknowledge those who generously shared their data: Dr. J. David Cassidy; Dr. Jerilyn Cambron; Dr. Ram Gudavalli; Dr. Mitch Haas at the University of Western States; Dr. Eric Hurwitz; Dr. Wolf E. Mehling; Drs. Daniel Cherkin, Karen Sherman, James E. Moore, and Michael Von Korff of Kaiser Permanente Washington Research Institute (formerly Group Health Research Institute); and the University of Warwick. The RAND model presented here was supported by the National Center for Complementary and Integrative Health of the National Institutes of Health under award number: U19AT The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Cost-Effectiveness of Non-Invasive and Non-Pharmacological Interventions for Low Back Pain: a Systematic Literature Review

Appl Health Econ Health Policy DOI 10.1007/s40258-016-0268-8 SYSTEMATIC REVIEW Cost-Effectiveness of Non-Invasive and Non-Pharmacological Interventions for Low Back Pain: a Systematic Literature Review