Cost-effectiveness of pharmaceutical management for osteoarthritis pain: a systematic review of the literature and recommendations for future economic evaluation

Cost Effectiveness of Pharmacological Management for Osteoarthritis: A Systematic Review

BACKGROUND AND OBJECTIVE

Osteoarthritis (OA) is a highly prevalent, disabling disease requiring chronic management that is associated with an enormous individual and societal burden. This systematic review provides a global cost-effectiveness evaluation of pharmacological therapy for the management of OA.

METHODS

Following Center for Reviews and Dissemination (CRD) guidance, a literature search strategy was undertaken using PubMed, EMBASE, Cochrane Library, Health Technology Assessment (HTA) database, and National Health Service Economic Evaluation database (NHS EED) to identify original articles containing cost-effectiveness evaluation of OA pharmacological treatment published before 4 November 2021. Risk of bias was assessed by two independent reviewers using the Joanna Briggs Institute (JBI) critical appraisal checklist for economic evaluations. The Quality of Health Economic Studies (QHES) instrument was used to assess the reporting quality of included articles.

RESULTS

Database searches identified 43 cost-effectiveness analysis studies (CEAs) on pharmacological management of OA that were conducted in 18 countries and four continents, with one study containing multiple continents. A total of four classes of drugs were assessed, including non-steroidal anti-inflammatory drugs (NSAIDs), opioid analgesics, symptomatic slow-acting drugs for osteoarthritis (SYSADOAs), and intra-articular (IA) injections. The methodological approaches of these studies showed substantial heterogeneity. The incremental cost-effectiveness ratios (ICERs) per quality-adjusted life-year (QALY) were (in 2021 US dollars) US$44.40 to US$307,013.56 for NSAIDS, US$11,984.84 to US$128,028.74 for opioids, US$10,930.17 to US$27,799.73 for SYSADOAs, and US$258.36 to US$58,447.97 for IA injections in different continents. The key drivers of cost effectiveness included medical resources, productivity, relative risks, and selected comparators.

CONCLUSION

This review showed substantial heterogeneity among studies, ranging from a finding of dominance to very high ICERs, but most studies found interventions to be cost effective based on specific ICER thresholds. Important challenges in the analysis were related to the standardization and methodological quality of studies, as well as the presentation of results.

Cost-effectiveness of Multidisciplinary Interventions for Chronic Low Back Pain: A Narrative Review

OBJECTIVE

Chronic musculoskeletal pain in adults is a global health and economic problem. The aim of this paper was to systematically review and determine what proportion of multidisciplinary approaches to managing chronic musculoskeletal pain are cost-effective.

MATERIALS AND METHODS

The EconLit, Embase, and PubMed electronic databases were searched for randomized and nonrandomized economic evaluation studies of nonpharmaceutical multidisciplinary chronic pain management interventions published from inception through to August 2019.

RESULTS

Seven studies comprising 2095 patients were included. All studies involved diverse multidisciplinary teams in one or more of the study arms. All studies involved chronic (both chronic and subacute) low back pain and were economic evaluations from either a societal or health care perspective. Two of the 3 studies that reported on a multidisciplinary pain intervention compared with nonmultidisciplinary intervention concluded favorable cost-effectiveness based on cost per quality adjusted life years gained, 1 study was not found to be cost-effective. Cost-effectiveness of the multidisciplinary intervention of interest was also not established by another 3-arm study. Two studies compared 2 multidisciplinary interventions; neither of these could definitively declare cost-effectiveness. The remaining study indicated the intervention by a multidisciplinary team was more effective but at a higher cost. None of the included studies used decision models to estimate long-term health outcomes and cost-effectiveness of multidisciplinary programs.

DISCUSSION

There are few studies on the cost-effectiveness of multidisciplinary chronic pain management interventions. This study encourages additional rigorous economic evaluations of multidisciplinary models for chronic pain management. Economic evaluations that enable extrapolating costs and effects of multidisciplinary programs beyond the time horizon of clinical trials may be more informative for clinicians and health administrators.

Utilization of Healthcare Resources in Osteoarthritis: A Cost of Illness Analysis Based on Real-World Data in Italy

Purpose

Understand the demographics and clinical features of patients with osteoarthritis (OA), quantify healthcare resource utilization by OA patients, and estimate the annual direct medical costs per OA patient from a National Health Service (NHS) perspective in Italy.

Patients and Methods

Retrospective observational cohort analysis using data from electronic medical records captured by the Italian IQVIA Longitudinal Patient Database (LPD). Only direct medical costs reimbursed by the NHS were considered. Patients were included if they received at least one diagnosis of OA during the period from January 1 to December 31, 2018. Each patient was observed for 3 years: a 24-month baseline period preceding the index date, and a 12-month follow-up period starting at the index date.

Results

A total of 71,467 patients met inclusion criteria: 43.98% had not been prescribed NSAIDs/opioids, 40.76% had been prescribed NSAIDs, and 15.26% an opioid. Mean age was 71.36 years, and 68.2% of the patients were women. At least one comorbidity was present in 91.34% of the patients; 38.05% were newly diagnosed with OA. During 1-year of follow-up, 173,884 prescriptions with an associated diagnosis of OA were found: 47.36% had been prescribed an NSAID, 9.11% diclofenac, 8.30% codeine+paracetamol, and 7.32% ketoprofen. Nearly 15% of the patients had at least 1 request for a specialist visit and 23.82% had at least 1 request for exams. Orthopedic visits accounted for 60% of all specialist visits. Yearly mean costs per patient were €622, for approximately €2.5 billion per year in direct costs, considering 3.9 million patients with OA in Italy. Protheses were a major driver in annual costs: €143.45 in patients without a prosthesis and €10,090.91 in those with a joint prosthesis.

Conclusion

This real-world analysis of direct costs of care of patients with OA in Italy confirms the substantial economic burden. Direct costs dramatically increased when joint replacement was needed.

Are education, exercise and diet interventions a cost-effective treatment to manage hip and knee osteoarthritis? A systematic review

OBJECTIVE

To identify research gaps and inform implementation we systematically reviewed the literature evaluating cost-effectiveness of recommended treatments (education, exercise and diet) for the management of hip and/or knee OA.

METHODS

We searched Medline, Embase, Cochrane Central Register of Controlled Trials, National Health Services Economic Evaluation Database, and EconLit from inception to November 2019 for trial-based economic evaluations investigating hip and/or knee OA core treatments. Two investigators screened relevant publications, extracted data and synthesized results. Risk of bias was assessed using the Consensus on Health Economic Criteria list.

RESULTS

Two cost-minimization, five cost-effectiveness and 16 cost-utility analyses evaluated core treatments in six health systems. Exercise therapy with and without education or diet was cost-effective or cost-saving compared to education or physician-delivered usual care at conventional willingness to pay (WTP) thresholds in 15 out of 16 publications. Exercise interventions were cost-effective compared to physiotherapist-delivered usual care in three studies at conventional WTP thresholds. Education interventions were not cost-effective compared to usual care or placebo at conventional WTP thresholds in three out of four publications.

CONCLUSIONS

Structured core treatment programs were clinically effective and cost-effective, compared to physician-delivered usual care, in five health care systems. Providing education about core treatments was not consistently cost-effective. Implementing structured core treatment programs into funded clinical pathways would likely be an efficient use of health system resources and enhance physician-delivered usual primary care.

Exosome-Encapsulated microRNA-127-3p Released from Bone Marrow-Derived Mesenchymal Stem Cells Alleviates Osteoarthritis Through Regulating CDH11-Mediated Wnt/β-Catenin Pathway

Objective

Exosome-encapsulated microRNAs (miRNAs) are being considered as either diagnostic or predictive markers in different types of diseases. Here, we discussed the effects of exosome-encapsulated miR-127-3p from bone marrow-derived mesenchymal stem cells (BM-MSCs) on osteoarthritis (OA).

Methods

BM-MSCs and primary chondrocytes were isolated from Sprague Dawley rats. IL-1β was utilized to treat chondrocytes to mimic an OA in vitro model, and exosomes extracted from BM-MSCs were utilized to treat chondrocytes so as to verify their protective effects on OA. Through online website prediction and experiments confirmation, we found the most significantly enriched miRNA in exosomes and elucidated the effect of this miRNA on the therapeutic effect of exosomes by interfering with its expression. Also, the genes targeted by the miRNA and the involved pathway were also found through bioinformatics analysis and experimental research, thereby probing into the protective mechanism of exosomes on chondrocytes.

Results

Exosomes derived from BM-MSCs restricted the IL-1β-induced chondrocytes damage. miR-127-3p was found to be enriched in exosomes, and the protective effect of exosomes was reversed by miR-127-3p inhibition. miR-127-3p targeted CDH11, and overexpressed CDH11 in chondrocytes weakened the therapeutic effect of exosomes. IL-1β treatment resulted in the activation of the Wnt/β-catenin pathway in chondrocytes. Exosomes treatment could inhibit the activation of this pathway, and overexpressed CDH11 reversed the inhibitory effect of exosomes on this pathway.

Conclusion

This study suggests that exosomal miR-127-3p derived from BM-MSCs inhibits CDH11 in chondrocytes, thereby blocking the Wnt/β-catenin pathway activation and relieving chondrocyte damage in OA.

Identifying Musculoskeletal Pain Generators Using Clinical PET

Identifying the source of a person's pain is a significant clinical challenge because the physical sensation of pain is believed to be subjective and difficult to quantify. The experience of pain is not only modulated by the individual's threshold to painful stimuli but also a product of the person's affective contributions, such as fear, anxiety, and previous experiences. Perhaps then to quantify pain is to examine the degree of nociception and pro-nociceptive inflammation, that is, the extent of cellular, chemical, and molecular changes that occur in pain-generating processes. Measuring changes in the local density of receptors, ion channels, mediators, and inflammatory/immune cells that are involved in the painful phenotype using targeted, highly sensitive, and specific positron emission tomography (PET) radiotracers is therefore a promising approach toward objectively identifying peripheral pain generators. Although several preclinical radiotracer candidates are being developed, a growing number of ongoing clinical PET imaging approaches can measure the degree of target concentration and thus serve as a readout for sites of pain generation. Further, when PET is combined with the spatial and contrast resolution afforded by magnetic resonance imaging, nuclear medicine physicians and radiologists can potentially identify pain drivers with greater accuracy and confidence. Clinical PET imaging approaches with fluorine-18 fluorodeoxyglucose, fluorine-18 sodium fluoride, and sigma-1 receptor PET radioligand and translocator protein radioligands to isolate the source of pain are described here.

Methodological and Reporting Quality of Systematic Reviews Published in the Highest Ranking Journals in the Field of Pain

BACKGROUND

Systematic reviews (SRs) are important for making clinical recommendations and guidelines. We analyzed methodological and reporting quality of pain-related SRs published in the top-ranking anesthesiology journals.

METHODS

This was a cross-sectional meta-epidemiological study. SRs published from 2005 to 2015 in the first quartile journals within the Journal Citation Reports category Anesthesiology were analyzed based on the Journal Citation Reports impact factor for year 2014. Each SR was assessed by 2 independent authors using Assessment of Multiple Systematic Reviews (AMSTAR) and Preferred Reporting Items of Systematic reviews and Meta-Analyses (PRISMA) tools. Total score (median and interquartile range, IQR) on checklists, temporal trends in total score, correlation in total scores between the 2 checklists, and variability of those results between journals were analyzed.

RESULTS

A total of 446 SRs were included. Median total score of AMSTAR was 6/11 (IQR: 4-7) and of PRISMA 18.5/27 (IQR: 15-22). High compliance (reported in over 90% SRs) was found in only 1 of 11 AMSTAR and 5 of 27 PRISMA items. Low compliance was found for the majority of AMSTAR and PRISMA individual items. Linear regression indicated that there was no improvement in the methodological and reporting quality of SRs before and after the publication of the 2 checklists (AMSTAR: F(1,8) = 0.22; P = .65, PRISMA: F(1,7) = 0.22; P = .47). Total scores of AMSTAR and PRISMA had positive association (R = 0.71; P < .0001).

CONCLUSIONS

Endorsement of PRISMA in instructions for authors was not a guarantee of compliance. Methodological and reporting quality of pain-related SRs should be improved using relevant checklists. This can be remedied by a joint effort of authors, editors, and peer reviewers.

Cost-effectiveness of surgical interventions for the management of osteoarthritis: a systematic review of the literature

Background

The primary purpose of this study is to assess the existing evidence on the cost-effectiveness of surgical interventions for the management of knee and hip osteoarthritis by systematically reviewing published economic evaluation studies.

Methods

A systematic review was conducted for the period 2004 to 2016. Electronic databases were searched to identify both trial and model based economic evaluation studies that evaluated surgical interventions for knee and hip osteoarthritis.

Results

A total of 23 studies met the inclusion criteria and an assessment of these studies showed that total knee arthroplasty (TKA), and total hip arthroplasty (THA) showed evidence of cost-effectiveness and improvement in quality of life of the patients when compared to non-operative and non-surgical procedures. On the other hand, even though delaying TKA and THA may lead to some cost savings in the short-run, the results from the study showed that this was not a cost-effective option.

Conclusions

TKA and THA are cost-effective and should be recommended for the management of patients with end stage/severe knee and hip OA. However, there needs to be additional studies to assess the cost-effectiveness of other surgical interventions in order for definite conclusions to be reached.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1540-2) contains supplementary material, which is available to authorized users.