Chronic pain is a major health concern, which increases in prevalence and impact with age. This is important as chronic pain can result in a significant decrease in function and quality of life along with an increase in use of health and social care. Self-management is a potentially inexpensive form of pain management and it has possible additional benefits of empowering patients to take control of their condition and improve quality of life. These advantages of self-management in chronic pain however, are not established in the literature.

The Musculoskeletal Elves were very interested therefore when they found a recently published systematic review by Boyers et al (2012) on the cost-effectiveness of self-management methods for the treatment of chronic pain in an aging adult population. This review might help to answer some of these unresolved questions.

Here’s what they did

The authors searched a range of electronic databases from inception to December 2010 using search terms including “self-management”, “self-efficacy” and words relating to specific therapies judged to be self-management.

They found only randomised controlled trials that reported cost-effectiveness, cost minimisation or cost-benefit analyses and that compared self-management to usual or another active form of care were included.  The mean age of participants had to be at least 60 years and the interventions had to focus on chronic pain and studies needed to have a follow-up period of more than 6-months at home.

The author’s defined self-management as “a single approach or combination of approaches that can be initially taught by any health professional or learned by an individual to enable them to minimise the impact their chronic pain can have on everyday life”. The authors decided to excluded self-purchased pain-relieving medication and invasive procedures.

Here’s what they found

• 

  No RCT studies reported cost-effectiveness of self-management exclusively in the over 65 age group.

• Ten RCTs reported participants with an average age of 60 years or over and all of these studies measured cost-effectiveness as cost per improvement in primary outcome, 7 of them using the Western Ontario and McMaster Universities Osteoarthritis Index score, of which 6 reported the pain dimension.
• Six studies reported cost per quality-adjusted life year (QALY)-gained information, with a further 1 reporting EQ-5D. In 7 studies, relative to usual care, self-management was effective, and in the remaining 3 studies, there was no significant difference.
• Among those reporting cost per QALY-gained results, self-management did not lead
  to statistically significant QALY gains relative to usual care (with only one exception).
• Eight studies suggested that the cost of developing and delivering self-management interventions may be partly offset by savings from reduced subsequent health care resource use.

The authors concluded

“Self-management is effective among an aging adult population with chronic pain and may be cost effective when outcomes are measured using the Western Ontario and McMaster Universities Osteoarthritis Index pain score. Cost effectiveness is less certain when measured using the QALY metric. Uncertainty over conclusions exists partly due to lack of information regarding societal willingness to pay for pain improvement.”

 

The Musculoskeletal Elf’s view

In this review, self-management intervention for chronic pain in older people were found to be effective in reducing pain and saving costs compared to normal care. The question of whether self-management is cost-effective is not so definitively answered due to limited studies employing generic quality of life measures to evaluate their outcomes.

The authors contribute valuable knowledge through a well-constructed and explained review that addresses an important question. This type of analysis and synthesis of research data is essential in the current climate where every elf must prove that what they do is cost-effective.

So what is a QALY? It is a universal measure of disease burden and combines quality of life with the length of life lived. QALYs are used in health economic analyses to examine whether intervention improve quality of life and, or length of life compared to no intervention. QALY scores can range form 0 to 1, where 0 represents a patient who has died and 1 represents one year of life in full health.

The MSK Elf would be interested to see more of these types of reviews for other population subgroups and interventions.

•  What type of self-management strategies do you employ with your patients with pain?
• How do you measure the effectiveness of these interventions?
• What do you think are the key core components of a successful self-management intervention for chronic pain?

Send us your views on this blog and become part of the ever expanding Musculoskeletal Elf community.

Links

• Boyers D, McNamee P Clarke A, Jones D, Martin D, Schofield P, Smith BH 2012. Cost-effectiveness of Self-management Methods for the Treatment of Chronic Pain in an Aging Adult Population: A Systematic Review of the Literature. Clin J Pain. Published ahead of print. http://www.ncbi.nlm.nih.gov/pubmed/23042472
• Measuring effectiveness and cost effectiveness: the QALY NICE 2012

The Musculoskeletal Elf would like to give special thanks to Chris Seenan who prepared the first draft of this blog.