The study evaluated the economic implications of shifting the locus of care for patients with neuropathic pain from specialists to general practitioners (GPs). The analysis showed that shifting the locus of care to GPs led to cost-savings to the Norwegian health care system. On the whole, the economic analysis was well conducted but the effectiveness side of the study was weak, owing to the use of authors’ opinions to define the efficacy of the two strategies.

Cost-effectiveness analysis

The objective of the study was to determine the economic implications of a shift in the locus of care for adult patients with painful neuropathic disorders from specialists to general practitioners (GPs). The analysis focused on the economic aspects of this change in treatment patterns.

The current scenario in which most patients are immediately referred for treatment to specialists and pain clinics was compared with a hypothetical scenario in which GPs undergo a formal education programme focusing on the recognition and treatment of neuropathic pain, and treat most patients, thus precluding the need for referral.

Norway.  Primary/secondary care.

Analytical approach: A decision analytic model was developed in order to examine the costs associated with the treatment of painful neuropathies. The clinical data were mainly based on authors’ assumptions, while the economic analysis relied on two surveys of Norwegian physicians. The time horizon of the analysis appears to have been short, although it was not explicitly stated. The authors stated that the perspective of the health care system was adopted.

Effectiveness data: Since a hypothetical scenario was considered, the authors arbitrarily defined clinical data. The key clinical input was the proportion of patients achieving adequate pain control by setting of care. In particular, it was assumed that the educational programme would increase the proportion of patients achieving pain control when treated by GPs.

Monetary benefit and utility valuations: None.

Measure of benefit: The percentage of patients achieving pain control was considered as the benefit measure, although it was not combined with the costs. In effect, a cost-consequences analysis was performed.

Cost data: The categories of costs included in the analysis were visits to health care professionals (GPs, specialists or pain clinics), diagnostic tests (e.g. computed tomography scan, ultrasound, electromyography) and other services (e.g. acupuncture, transcutaneous electrical nerve stimulation). The cost of the training programme for GPs was also included. Information on resource consumption was based on two surveys of Norwegian physicians (GPs and specialists). The costs were derived from the Norwegian Medical Association and were augmented by some authors' assumptions that were supported by experts. The price year was 2004 and the currency was Norwegian kroner (NOK).

Analysis of uncertainty: The issue of uncertainty was addressed by means of a one-way sensitivity analysis in which several estimates in the model were varied by +/- 25%. Extreme scenarios for referral rates and probability of pain control were also considered.

With regard to the clinical side of the analysis, in the hypothetical scenario the percentages of patients achieving adequate pain control increased in all settings (GPs, specialists and pain clinics) when compared with the current scenario.

Using 2004 data on patients in Norway, a total of 34,951 individuals would seek care for neuropathic pain. The switch from specialists to GPs would result in cost-savings of NOK 74,121,846 to the Norwegian health care system. The increase in costs due to the higher number of visits by GPs was more than offset by the reduction in specialists’ visits and visits to pain clinics.

The results of the sensitivity analysis showed that the cost-savings were particularly sensitive to variations in unit costs, use of tests or services at each visit, the proportion of patients achieving pain control and the proportion of patients receiving pharmacotherapy. However, the shift from specialists to GPs remained less costly in all scenarios.

The authors concluded that shifting the locus of care from specialists to GPs for the management of patients with painful neuropathies led to cost-savings to the Norwegian health care system.

Interventions: The selection of the interventions was appropriate because the current standard of care in the authors’ setting was compared against a scenario hypothesised by the authors. The two alternatives were well described.

Effectiveness/benefits: The authors made some key assumptions about the effectiveness of the two interventions. In particular, clinical estimates for the current scenario were based on expert opinion, as opposed to published estimates, probably in order to reflect the authors’ context. Given the use of arbitrarily defined data, wide ranges of these values were considered in the sensitivity analysis.

Costs: The categories of costs included in the analysis were those relevant to the perspective of the study. A breakdown of cost items was provided and details of the unit costs were presented. This enhances the possibility of replicating the analysis in other settings. The sources of the costs were reported. Some costs were not available and were therefore based on expert opinion. Sensitivity analyses were carried out to determine the impact of variations in these costs. Estimates of resource use were based on a survey of Norwegian health care providers.

Analysis and results: The costs and benefits were not synthesised as a cost-consequences analysis was performed. The use of a summary benefit measure would have been more appropriate. The issue of uncertainty was addressed in the sensitivity analysis. Extreme scenarios were considered, which make the results of the analysis more robust. The level of reporting was good and the authors presented the results of the analysis in detail.

Concluding remarks: Overall, the analysis was carried out in a transparent fashion, especially on the economic side of the study. However, the use of assumptions to determine the effectiveness of the two strategies represents a weakness of the analysis.

Pfizer.

Weiner DK, Hanlon JT. Pain in nursing home residents: management strategies. Drug Aging 2001;18:13-29. 

Oster G, Harding G, Dukes E, et al. Pain, medication use, and health-related quality of life in older persons with postherpetic neuralgia: results from a population-based survey. J Pain 2005;6:356-63.

This record was compiled by CRD commissioned reviewers according to a set of guidelines developed in collaboration with a group of leading health economists.