Category: Economics

Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome

Sir,

In their economic evaluations of treatments for chronic fatigue syndrome (CFS), Severens et al. compared the cost-effectiveness of cognitive behaviour therapy (CBT) with those of other interventions, and found that the percentage of CFS patients who improved with CBT performed for 8 months was 31% vs. 9% and 12% for other treatments. Considering that, in one study, 28% of CFS patients treated with low-dose hydrocortisone over just one month virtually recovered,  Severens et al. also should have compared the cost-effectiveness of CBT with that of low-dose hydrocortisone.

Treatment with low-dose hydrocortisone for CFS, besides being intuitively far less costly than CBT, is also better-founded clinically than any psychological therapy, because hydrocortisone corrects the hypocortisolism that characterizes at least some CFS patients. Given that ‘frank hypocortisolism’, rather surprisingly, was one of the exclusion criteria for enrolment in the trial of Cleare et al., the percentage of CFS patients who can be effectively treated with low-dose hydrocortisone in day-to-day health care is likely to be higher than the 28% found in that trial.

You can read the rest of this comment here: http://qjmed.oxfordjournals.org/content/97/6/378.long

Comment on: Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. [QJM. 2004]

 

Source: Baschetti R. Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. QJM. 2004 Jun;97(6):378-9. http://qjmed.oxfordjournals.org/content/97/6/378.long (Full article)

 

Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome

Abstract:

BACKGROUND: There is some evidence that cognitive behaviour therapy (CBT) is efficacious in chronic fatigue syndrome (CFS), but little data on its cost-effectiveness.

DESIGN: Prospective economic analysis alongside a randomized clinical trial.

METHODS: CFS patients were randomly assigned to CBT, guided support groups (SG), or the ‘natural course’ (NC, no protocol-based interventions). Patients were treated for 8 months and followed-up for another 6 months. Costs per patient showing clinically significant improvement, based on the CIS fatigue scale, and costs per quality-adjusted life year, were determined for a time period of 14 months.

RESULTS: Data were available for 171 patients at 8 months and for 128 at 14 months. At 8 and 14 months, the percentages of improved patients were 31% and 27% for CBT, 9% and 11% for SG, and 12% and 20% for NC. Mean QALYs gained at 14 months were, for CBT, SG and NC, respectively, 0.0737, -0.0018 and 0.0458. CBT and SG mean treatment costs were euro1490 and euro424. Other medical costs for CBT, SG, and NC, respectively, were euro324, euro623 and euro412 for the first period, and euro232, euro561 and euro378 for the second period. Non-medical costs for these periods for CBT, SG and NC were euro262, euro550, euro427 and euro226, euro439, euro287, respectively. Productivity costs were considerable, but not significantly different between groups.

DISCUSSION: CBT was less costly and more effective than SG. Compared to NC, the baseline incremental cost-effectiveness of CBT was euro20 516 per CFS patient showing clinically significant improvement, and euro21 375 per QALY. The bootstrap ratios showed considerable uncertainty regarding the results. Future research should focus on productivity costs, and follow patients prospectively over a longer period.

Comment in:

Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. [QJM. 2004]

Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. [QJM. 2004]

 

Source: Severens JL, Prins JB, van der Wilt GJ, van der Meer JW, Bleijenberg G. Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. QJM. 2004 Mar;97(3):153-61. http://qjmed.oxfordjournals.org/content/97/3/153.long (Full article)

 

Financial, occupational, and personal consequences of disability in patients with chronic fatigue syndrome and fibromyalgia compared to other fatiguing conditions

Abstract:

OBJECTIVE: To examine the nature and degree of self-reported disability in patients with chronic fatigue syndrome (CFS) and its associated conditions, fibromyalgia (FM) and subsyndromal fatigue (CF), compared with a chronically fatiguing but unrelated medical condition (MED).

METHODS: Six hundred and thirty patients evaluated at the University of Washington Chronic Fatigue Clinic were sent questionnaires asking them to identify the financial, occupational, and personal consequences of their fatiguing illness. Thorough medical evaluations had previously applied accepted criteria for defining CFS, FM, and CF.

RESULTS: The FM groups (those with and without CFS) were among the least employed. Likewise, the FM and CFS groups, more frequently than the other groups, endorsed loss of material possessions (such as car), loss of job, and loss of support by friends and family, as well as recreational activities as a result of their fatiguing illness. There were no reliable differences between groups in use of disability benefits.

CONCLUSION: There is substantial illness-related disability among those evaluated at a specialized chronic fatigue clinic. Those reporting the most pervasive disability met criteria for FM either alone or in conjunction with CFS. Employers and personal relations of patients with chronic fatigue should make a greater effort to accommodate the illness-related limitations of these conditions, especially for those with FM and CFS.

 

Source: Assefi NP, Coy TV, Uslan D, Smith WR, Buchwald D. Financial, occupational, and personal consequences of disability in patients with chronic fatigue syndrome and fibromyalgia compared to other fatiguing conditions. J Rheumatol. 2003 Apr;30(4):804-8. http://www.ncbi.nlm.nih.gov/pubmed/12672203

 

The economic cost of chronic fatigue and chronic fatigue syndrome in UK primary care

Abstract:

BACKGROUND: Chronic fatigue and chronic fatigue syndrome are most often encountered in primary care settings. Given the disabling nature of chronic fatigue it may have a substantial impact on service use and costs as well as on employment. This study estimates this impact.

METHOD: Patients presenting to general practitioners with unexplained chronic fatigue were recruited to the study. Service use over a 3 month period was measured and lost employment recorded. These data were used to estimate economic costs. Patients with chronic fatigue syndrome were compared to patients with only chronic fatigue using a multiple regression model with sample differences controlled.

RESULTS: The mean total cost of services and lost employment across the sample was Pound Sterling1906 for the 3-month period with formal services accounting for 9.3% of this figure. Service use was higher for patients with chronic fatigue syndrome compared to those with chronic fatigue alone. Total 3-month costs were on average higher for chronic fatigue syndrome (Pound Sterling3515 v. Pound Sterling1176) but when sample differences were taken account of the mean difference was reduced to Pound Sterling1406 (P = 0.086). Over 90% of the cost was accounted for by care provided by friends and family members and by lost employment. Patients with dependants had significantly higher costs than those with none and costs were also significantly higher for greater levels of functional impairment.

CONCLUSION: Chronic fatigue imposes substantial economic costs on society, mainly in the form of informal care and lost employment. Treatments need to be developed which recognize these impacts.

Comment in: Costs, correlates and consequences of fatigue in children and adults. [Psychol Med. 2003]

 

Source: McCrone P, Darbishire L, Ridsdale L, Seed P. The economic cost of chronic fatigue and chronic fatigue syndrome in UK primary care. Psychol Med. 2003 Feb;33(2):253-61. http://www.ncbi.nlm.nih.gov/pubmed/12622304

 

Predictors of a medical-offset effect among patients receiving antidepressant therapy

Abstract:

OBJECTIVE: Characteristics of patients receiving antidepressant therapy were examined to identify factors that may be associated with a medical-offset effect.

METHOD: In a retrospective study, the authors analyzed claims data from a large health insurer in New England. The study subjects included 1,661 persons initiating treatment for depression with selective serotonin reuptake inhibitors or tricyclic antidepressants between July 1991 and June 1993.

RESULTS: Patients with anxiety disorders, coronary heart disease, cancer, and chronic fatigue syndrome and those remaining on their initial regimens of antidepressant therapy for at least 6 months were more likely to experience significant reductions in the costs of medical care services. The number of visits to mental health providers had no effect on the costs of medical services.

CONCLUSIONS: Specific comorbid conditions and sustained use of antidepressant drugs may be associated with a medical-offset effect for patients receiving treatment for depression.

 

Source: Thompson D, Hylan TR, McMullen W, Romeis ME, Buesching D, Oster G. Predictors of a medical-offset effect among patients receiving antidepressant therapy. Am J Psychiatry. 1998 Jun;155(6):824-7. http://www.ncbi.nlm.nih.gov/pubmed/9619157

 

Chronic fatigue syndrome and occupational health

Abstract:

Chronic fatigue syndrome (CFS) is a controversial condition that many occupational physicians find difficult to advise on. In this article we review the nature and definition of CFS, the principal aetiologic hypotheses and the evidence concerning prognosis. We also outline a practical approach to patient assessment, diagnosis and management. The conclusions of this review are then applied to the disability discrimination field. The implications of the new UK occupational health legislation are also examined. Despite continuing controversy about the status, aetiology and optimum management of CFS, we argue that much can be done to improve the outcome for patients with this condition. The most urgent needs are for improved education and rehabilitation, especially in regard to employment. Occupational physicians are well placed to play an important and unique role in meeting these needs.

 

Source: Mounstephen A, Sharpe M. Chronic fatigue syndrome and occupational health. Occup Med (Lond). 1997 May;47(4):217-27. http://occmed.oxfordjournals.org/content/47/4/217.long (Full article)

 

Chronic fatigue, chronic fatigue syndrome, and fibromyalgia. Disability and health-care use

Abstract:

OBJECTIVES: Disabling chronic fatigue that does not meet criteria for chronic fatigue syndrome (CFS) or fibromyalgia (FM) is a condition thought to be associated with substantial disability and an apparently high use of health-care services. The authors compare patients who have chronic fatigue, CFS, FM, or CFS and FM together (CFS+FM) on employment status, self-reported disability, number of medical care visits, type of services obtained, and other diagnoses received.

METHODS: The authors studied 402 patients from a university-based chronic fatigue clinic. All patients underwent an initial structured diagnostic assessment. One hundred forty-seven patients met case criteria for CFS, 28 for FM, 61 for CFS+FM, and 166 fell in the residual chronic fatigue group. Of these patients, 388 completed a follow-up questionnaire an average of 1.7 years later. Chi-squared tests and analysis of variance were used to compare groups on follow-up measures of health-care use and disability.

RESULTS: Patients with chronic fatigue, CFS, FM, and CFS+FM were similar in terms of disability and health-care use, though those with CFS+FM were significantly more likely to be unemployed and to use more chiropractic and “other” provider services. Rates of unemployment ranged from 26% (chronic fatigue) to 51% (CFS+FM). Overall, patients reported a mean of 21 visits to a wide variety health-care providers during the previous year, with no significant differences between groups.

CONCLUSIONS: Chronic fatigue, CFS, and FM are associated with considerable personal and occupational disability and low rates of employment. The potentially large economic burden of these disorders underscores the need for accurate estimates of direct and indirect costs, the relative contribution of individual factors to disability, and the need to develop targeted rehabilitation programs.

 

Source: Bombardier CH, Buchwald D. Chronic fatigue, chronic fatigue syndrome, and fibromyalgia. Disability and health-care use. Med Care. 1996 Sep;34(9):924-30. http://www.ncbi.nlm.nih.gov/pubmed/8792781

 

Chronic fatigue syndrome–also an insurance medicine problem

Abstract:

Not everybody who is chronically tired has a chronic fatigue syndrome. The diagnosis of the chronic fatigue syndrome is still a problem, and is becoming a problem in health insurance medicine too. There is a lack of knowledge concerning the causes, the diagnosis and the therapy of the chronic fatigue syndrome. And there is still the question if the chronic fatigue syndrome is an entity of its own. For these reasons we should apply the few facts we really know about the chronic fatigue syndrome. This is the working case definition of Kaplan et al. from 1988. Otherwise there will be done hundreds of expensive laboratory tests, which are useless for the patient and very costly for the health insurance companies.

 

Source: Hakimi R. Chronic fatigue syndrome–also an insurance medicine problem. Versicherungsmedizin. 1996 Apr 1;48(2):59-61. [Article in German] http://www.ncbi.nlm.nih.gov/pubmed/8659056

 

The economic impact of chronic fatigue syndrome

Abstract:

OBJECTIVE: To estimate the economic impact of chronic fatigue syndrome (CFS) on the individual, the government, and the community.

DESIGN: The financial burden produced by CFS was studied by calculating the direct and indirect costs arising from the disorder. Data regarding use of health resources, income and employment were obtained by questionnaire from patients with CFS. In addition, aggregate Medicare data on the incidence and fees charged for each Schedule item for these patients was obtained.

SETTING: The Richmond Valley, New South Wales.

PARTICIPANTS: Forty-two patients with CFS identified in our population-based prevalence study.

RESULTS: The conservative estimate of the per annum costs of CFS in the Richmond Valley, with a prevalence of 37.1 cases per 100,000, was $396,000. If extrapolated to the Australian population, we estimate CFS would generate an annual cost of at least $59 million.

CONCLUSION: This disorder constitutes a large but neglected area of health resource utilisation and economic burden.

Comment in: The economic impact of chronic fatigue syndrome. [Med J Aust. 1993]

 

Source: Lloyd AR, Pender H. The economic impact of chronic fatigue syndrome. Med J Aust. 1992 Nov 2;157(9):599-601. http://www.ncbi.nlm.nih.gov/pubmed/1406420