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Brief courses of palliative radiotherapy for metastatic bone pain: a pilot cost-minimization comparison with narcotic analgesics |
Macklis R M, Cornelli H, Lasher J |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology The use of palliative radiotherapy for metastatic bone pain. The study did not include a clearly defined comparator. The outcomes were measured before and after the treatment. The costs were compared with the published costs for narcotic pain regimens.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised people with metastatic cancer who required symptomatic pain relief. The study sample comprised 66 outpatients with metastatic cancer, which was treated by palliative radiotherapy to individual bone sites. The inclusion criteria were a willingness to participate in a longitudinal pain reduction survey, and a life expectancy of at least 6 months. The exclusion criteria were severe co-morbid conditions, and a Karnofsky performance score below 70.
Twenty-five patients (38%) were treated for breast cancer, 17 (26%) for prostate cancer, and the remaining 24 for a variety of other malignancies. Sixty per cent of the patients were women and 40% were men. The median age of the patients was 67 years. There were 131 sites treated:
48% were in spinal vertebral bodies;
7% were in the shoulder and arm;
43% were in the hip, pelvis and leg; and
2% were in other sites.
Setting The setting was tertiary care. The economic study was carried out in the USA.
Dates to which data relate The effectiveness evidence was collected from 1995 to 1996. The date for the resources and prices used was 1998.
Source of effectiveness data The effectiveness data were derived from a single study.
Link between effectiveness and cost data The costing was undertaken retrospectively, on a different sample of patients from that used in the effectiveness study.
Study sample No power calculations were performed to determine the sample size. The patients enrolled in the study were chosen for their willingness to participate in a longitudinal pain reduction survey. The authors reported that the patients were representative of the study population, but did not report the rationale for this. A total of 66 outpatients with 131 metastatic sites were included and assessed before and after palliative radiotherapy. The authors did not report the number or details of those patients excluded from the study.
Study design This was a before-and-after study in one group of patients treated at a single centre. The patients were followed for up to 41 weeks. The authors did not report any loss to follow-up.
Analysis of effectiveness The analysis was conducted on an intention to treat basis. The primary outcome was the pain score. This was rated on a scale of 1 to 10, where 10 was defined as "the worst pain you can imagine", and 1 was defined as "a minor irritation with negligible impact on your lifestyle". The patients rated pain levels for rest and movement separately.
Effectiveness results Before treatment.
The mean pain scores (+/- 1 standard deviation) were 5.58 (+/-3.28) at rest and 7.32 (+/-2.72) during movement.
The proportion of patients reporting pain as minimal was 24% at rest and 8% during movement.
After treatment.
At the first follow-up session, the mean pain scores were 1.55 (+/-1.8) at rest and 1.94 (+/-2.07) during movement, (p<0.05).
The changes in pain score were 4.03 for at rest, and 5.38 for during movement.
At the end of the follow-up, the proportion of patients reporting pain as minimal was 76% at rest and 69% during movement.
Clinical conclusions The authors concluded that a brief course of radiotherapy significantly reduced the bone pain caused by metastatic disease from various tumour types.
Measure of benefits used in the economic analysis The outcomes were reported in a disaggregated way. The study should therefore be considered as a cost-consequences analysis.
Direct costs The quantities and costs were not reported separately. The costs to the hospital that were allowable for reimbursement by Medicare (a third party payer) were included in the analysis. The direct costs were for office consultation, treatment planning, simulation, dosimetry calculation, treatment devices, continuing medical radiation physics, treatment delivery, port films, and weekly management. The costs and quantities were estimated from the Medicare allowable charges. The source of the cost was the Medicare locality fee schedule (see Other Publications of Related Interest). The study reported average costs. The costs were not discounted since they were incurred over less than 2 years.
Statistical analysis of costs The authors did not report any statistical analysis of costs.
Indirect Costs The indirect costs were not included in the study as they were not appropriate to the implicit perspective of the study.
Currency US dollars ($). No currency conversion was reported.
Sensitivity analysis The authors did not carry out a sensitivity analysis.
Estimated benefits used in the economic analysis The authors did not calculate the incremental benefits due to the cost-consequences approach adopted. See the 'Effectiveness Results' section.
Cost results The cost of a 1- or 2-week course of palliative radiotherapy was estimated to be $1,500 to $2,500 per patient. From published estimates, the cost of 9 months of narcotic pain relief was estimated as $9,000 to $36,000.
Synthesis of costs and benefits The estimated costs were not combined with the benefits.
Authors' conclusions A brief course of radiotherapy reduced pain and appeared to be cost-effective when compared with narcotic analgesia.
CRD COMMENTARY - Selection of comparators The authors indicated that the use of radiotherapy to treat bone pain is perceived to be high cost, compared with other therapies that might also be less invasive. The effectiveness of radiotherapy was evaluated by assessing the pain before and after the treatment. It was unclear whether the comparator for this analysis was 'no treatment' or other standard care. The authors reported that the patients used narcotic pain relief as required, throughout the evaluation. The cost of radiotherapy was compared with narcotic pain relief, which was expected, but not demonstrated, to produce similar levels of pain relief. You should assess whether the comparators are relevant or widely used in your own setting.
Validity of estimate of measure of effectiveness The authors used a before-and-after study design to compare pain with and without radiotherapy. This may have biased the evaluation, since factors other than the treatment may have affected the pain levels. These factors included disease progression, changes in health care provision or the use of additional non health care services. There was insufficient detail provided about the study design to enable the validity of the effectiveness results to be assessed. For example, the authors did not report the power to detect statistically significant differences and the reasons for loss to follow-up,
Metastatic bone disease causes pain, which can only be measured subjectively. Therefore, the measure of effectiveness seems to have been appropriate. However, the authors used their own scale for assessing pain in cancer, rather than validated standardised scales, which may have been more appropriate. The side effects of palliative radiotherapy and narcotic analgesia were not considered in the study. The study only considered pain relief, and patients were not asked about other issues concerning narcotic analgesia and radiotherapy. The study compared narcotic analgesia with radiotherapy to narcotic analgesia alone. When patients received narcotic analgesia in addition to radiotherapy, the authors stated that no active attempt was made to reduce the dosage of analgesia during the study. The authors noted that most patients could have reduced their use of narcotic pain relief by up to 50%. The costs and outcomes of this reduction would need to be evaluated in further research.
It should be noted that this was a pilot study to provide information with which to design a full cost-minimisation analysis. However, it was unclear whether this study provided sufficient data to demonstrate equivalence between the alternative methods of pain relief.
Validity of estimate of measure of benefit No summary measure of benefit was used in this cost-consequences analysis.
Validity of estimate of costs The costs used were allowable reimbursement charges for hospital-based care. These did not represent the actual cost of treating the patients in the study. In addition, the costs of non-hospital health and social care, and the costs to the patients and informal carers, were excluded. Although this was a pilot study, it might have been useful to have assessed the extent to which these categories of cost may vary between the types of intervention, and the need to include them in a full economic evaluation.
Other issues The authors compared their results with those from published studies, and noted that the results were comparable. The authors did not assess the generalisability of the data to other settings or populations.
Implications of the study The authors concluded that the results of this pilot study warrant a full economic evaluation of palliative radiotherapy for metastatic bone disease.
Bibliographic details Macklis R M, Cornelli H, Lasher J. Brief courses of palliative radiotherapy for metastatic bone pain: a pilot cost-minimization comparison with narcotic analgesics. American Journal of Occupational Therapy 1998; 21(6): 617-622 Other publications of related interest Nationwide Medicare. Ohio Medicare carrier FY 1998 locality fee schedule. Columbus: Nationwide Medicare; 1998.
Indexing Status Subject indexing assigned by NLM MeSH Aged; Analgesics, Opioid /economics /therapeutic use; Bone Neoplasms /complications /radiotherapy /secondary; Comparative Study; Costs and Cost Analysis; Female; Humans; Male; Middle Aged; Pain, Intractable /drug therapy /etiology /economics /radiotherapy; Palliative Care /economics; Pilot Projects; Radiotherapy /economics; United States AccessionNumber 21999000090 Date bibliographic record published 31/05/2002 Date abstract record published 31/05/2002 |
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