Table 4 Cost-effectiveness Outcomes: Pain

De Boer et al. 2014 [45*]

CEA/CUA (SF-36 - RAND)

ICER (per every additional PCS point improvement):

No ICER provided for seven week end of treatment period. PCS was five points lower (better) in internet group, giving an ICER based of 40 (CI = − 228 to 56) meaning that for every additional point improvement on the PCS, 40 Euros is saved. Internet treatment is dominant.

Bootstrapping (Y/N;

iterations):

Bootstrapping (5000 replications)

Internet course was cost-effective compared to the group course.

Conclusions:

We conclude that the Internet-based cognitive-behavioural intervention was at least as effective as the face-to-face group intervention and, on some outcome measures appeared to be even more effective (unclear - poorly reported particularly sensitivity analysis details).

F test (Group by time interaction) at 7 weeks and 15 weeks

2.891 (p = 0.096) at 7 weeks,

5.546 (p = 0.023) at 15 weeks

Goossens et al. 2015 [46]

CUA

ICER (cost per QALY gained):

Intervention is dominant

Bootstrapping (Y/N; iterations):

Y; 5000 replications.

Seems to be cost-effective but clinical study underpowered

Intervention costs

Intervention: €2166.84

Control: €1969.39

QALYs gained at 15 months

Intervention: 0.83 (0.13);

Control: 0.82 (0.12);

Difference: 0.01 (−0.6 to 0.07). Not significant.

WTP Threshold(s)

€0 to €80,000

Probability cost-effective at WTP threshold(s):

At €16,000 WTP for a QALY, the probability of EXP treatment being cost-effective is 81%.

At €80,000, the probability diminishes slightly, to 76%.

Kemani et al. 2015 [62*]

CEA (collects SF-6D but not used to derive QALYs)

ICER (cost per PDI change):

ACT was dominant at post-treatment, post assessment and at 3 month FU. At 6 month FU they report no significant differences in costs or effectiveness between the two conditions.

Bootstrapping (Y/N; iterations):

Y; 5000 replications.

ACT was more cost-effective than AR at post and 3-month follow-up assessment, but not at 6-month follow-up

Intervention costs per participant

Intervention costs per participant were estimated to $2177 for ACT. Intervention costs $2148 for AR.

Intervention: 5/24, 4/23, 4/19;

Control: 0/19, 5/18, 2/18

Norton 2015 (but some data taken from Lamb 2010) [83, 84]

CUA (Markov Model with 1 and 10 year time horizons) EQ-5D

EQ-5D data

Intervention: 59% improved at 1 year;

Control: 31% improved at 1 year.

ICER (cost per QALY gained):

$7197 per QALY gained at one year;

$5855 per QALY gained at ten years which is considered cost-effective.

Parameters varied:

Various scenario analyses exploring impact of changing relapse rate, utility values, volume of health services received, insurance plan, worst case

Cognitive Behavioural Therapy is cost-effective LBP care from the US commercial payer perspective

Bootstrapping (Y/N; iterations):

Unclear (poorly reported), either bootstrapping or probabilistic sensitivity analysis; 5000 iterations.

Intervention costs per participant

Intervention (CBT plus AM): £187 (SE = 0.266).

Control: £14.05

WTP Threshold(s)

$50,000 and $100,000 have been cited as benchmarks in the United States

Herman (2017) [49]

CUA (SF-12/ SF-6D)

QALY gains at 1 year follow up compared to baseline 1 year before intervention

CBT: 0.765;

MBSR 0.753;

UC 0.728 CBV vs UC: + 0.041 (+ 0.015, + 0.067);

MBSR vs UC: + 0.034 (+ 0.008, + 0.060).

ICER (cost per QALY gained):

CBT vs UC: $3049.

MBSR dominated UC (lower cost, higher number of QALYs gained).

Bootstrapping (Y/N; iterations):

Bootstrapped ICERs(1000 replications) produced a cost-effectiveness plane.

In this setting CBT and MBSR have high probabilities of being cost-effective, and MBSR may be cost saving, as compared to UC for adults with CLBP. These findings suggest that MBSR, and to a lesser extent CBT, may provide cost-effective treatment for CLBP for payers and society

WTP Threshold(s)

$50,000/QALY

Probability cost-effective at WTP threshold(s):

MBSR has a 90% probability of being cost-effective and CBT has an 81% probability.

Bennell et al., 2016 [35*]

CUA (AQoL)

Treatment costs per participant

PCST & exercise: AU$1065 Exercise: AU$439; PCST: AU$730.

ICER (cost per QALY gained):

Trial showed a cost savings from combined treatment but a smaller gain in QALYs. Mean net benefit of $2600 Australian was not statistically significant

Combined psychological and exercise intervention was significantly more efficacious for improving physical function, but not pain, than either treatment alone; cost effectiveness was not demonstrated (net benefit approach).

Hedman-Lagerlof et al. 2019 [17*]

CEA/CUA

ICER (per additional responder as measured by reliable change in FIQ):

For societal perspective, intervention dominant using FIQ. Healthcare only perspective ICER per 1 additional responder (reliable change in FIQ) was $2211.

Bootstrapping (Y/N; iterations):

Y; 5000 replications.

Study indicates that this treatment may be highly cost-effective.

ICER (cost per QALY gained):

For a societal perspective the intervention was dominant per QALY gained.

Healthcare only perspective the ICER per QALY gained was $726/0.07 = $9734.

Probability cost-effective at WTP threshold(s):

Societal perspective:

At $0 WTP, iExp had 100% probability of being cost-effective for FIQ and QALY outcomes.

Health care perspective: The iExp had an 80% probability of being cost-effective given a WTP value of $2600 for FIQ and $21,500 for QALYs.

Luciano et al. 2014 [71*]

CEA (EQ-5D VAS)/CUA (EQ-5D)

ICER (cost per change in EQ-5D VAS):

For societal perspective: CBT: Dominant against both TAU and RPT. RPT vs TAU: €53 per EQ-5D (VAS) change against TAU (ITT analysis).

For healthcare perspective: CBT: Dominant against both TAU and RPT. RPT vs TAU: €63 per EQ-5D (VAS) change against TAU (ITT analysis).

Parameters varied:

Completers, ITT and per-protocol analyses at the 6-month follow-up for both healthcare and societal perspectives comparing CBT with RPT and TAU.

CBT is cost effective

Bootstrapping (Y/N; iterations):

Y; 1000 replications

QALY gain at follow up

Intervention 1: 0.25 (0.12);

Intervention 2: 0.23 (0.12);

Control: 0.24 (0.13).

The bootstrap analysis suggested that the increment effects of CBT compared to TAU on QALYs was not significant (i.e. the CI crossed zero) in the ITT sample. And that was the same for CBT compared to RPT.

ICER (cost per change in EQ-5D VAS):

For societal perspective: CBT: Dominant against both TAU and RPT. RPT vs TAU: €79,071 per EQ-5D (VAS) change against TAU (ITT analysis). For healthcare perspective: CBT: Dominant against both TAU and RPT. RPT vs TAU: €98,434 per EQ-5D

(VAS) change against TAU (ITT analysis).

WTP Threshold(s)

€0 to €100,000

Probability cost-effective at WTP threshold(s):

For the societal perspective NMB and 95% CIs for the CBT intervention are greater than zero at all hypothetical levels of WTP included. At a WTP of €40,000, RPT has a probability of only approximately 30% to be more cost-effective than TAU. For the healthcare perspective NMB CBT was dominant. For RPT in the ITT analysis ICERs were set to approximately €100,000, which is well above established cost-effectiveness thresholds.

Luciano et al. 2017 [72]

CUA (EQ-5D)

Utility score (EQ-5D) at baseline and follow up

Intervention 1 (GACT): 0.58 (0.17) to 0.8 (0.11);

Intervention 2 (RPT): 0.57 (0.16) to 0.75 (0.15);

Control: 0.54 (0.15) to 0.57 (0.16).

At follow up the between group differences were overall significant (P < .05). With the exception of the comparison of GACT versus RPT, the other between group differences were statistically significant.

ICER (cost per change in EQ-5D VAS):

ACT was marginally more expensive than RPT but marginally more effective. Both ACT and RPT were superior (dominant) to WL control in all the plots they performed so ICERs not reported.

Parameters varied:

Three different samples analysed - completers, Intention to Treat sample, and a Per Protocol Analysis

Acceptance and commitment therapy appears to be a cost-effective treatment compared with RPT in patients with FM (but notes small sample sizes).

ICER (cost per QALY gained):

Conclusions the same as for EQ-5D (VAS) i.e. both ACT and RPT are dominant against WL but ACT also dominant against RPT.

Bootstrapping (Y/N; iterations):

Y; 1000 replications.

Luciano et al. 2013 [69*]

CUA

ICER (cost per QALY gained):

Psychoeducation dominated usual care

Parameters varied:

Completers, ITT and per-protocol analyses

A nonpharmacological intervention based on group psychoeducation is cost-effective compared with usual care alone in the context of primary care (Unclear as difference in costs was not significant).

QALYs gained

Difference between groups = 0.12 (CI 0.06 to 0.19);

Statistically significant

Bootstrapping (Y/N; iterations):

Y; 1000 replications.

Probability cost-effective at WTP threshold(s):

At €0 WTP, probabilities of 85 and 74% of the psychoeducation intervention being cost-effective from the health care and societal perspective, respectively.

At €3000, probabilities of 98 and 95% of the psychoeducation being more cost effective than usual care from the health care and societal perspective, respectively.