I've just read two recent papers that have me musing: LAKEMEIER S, Lind M, Schultz W, Fuchs-Winkelmann S, et al. (2013) paper looks at a comparison between steroid injections and radiofrequency denervations for people with low back pain. The conclusion suggests that both procedures "...appear to be a managing option for chronic function-limiting low back pain of facet origin with favorable short- and midterm results..."; and ANDREW MOORE R. (2013) "What Works for Whom" suggesting that statistical significance is less useful than a patient-centric view of effectiveness.
My question is - if chronic back pain is a condition likely to persist, what are the effects in terms of beliefs about pain, quality of life, interference in "living well despite pain" when a person needs to keep attending clinics to have invasive treatments?
I say this after seeing people who have attended self management programmes, with the same pre-treatment pain intensity, distress, disability as those reported in Lakemeier's paper, remain well with reduced distress and disability - and more importantly from a systems perspective - less need to rely on healthcare.
How can this be measured? Has anyone carried out a head-to-head economic study of self management vs ongoing procedures? Or am I simply showing my self-management bias?
The two references:
LAKEMEIER S, Lind M, Schultz W, Fuchs-Winkelmann S, et al.
A Comparison of Intraarticular Lumbar Facet Joint Steroid Injections and Lumbar
Facet Joint Radiofrequency Denervation in the Treatment of Low Back Pain: A
Randomized, Controlled, Double-Blind Trial.
Anesth Analg. 2013.
PubMed:http://www.ncbi.nlm.nih.gov/pubmed/23632051
ANDREW MOORE R.
What works for whom? Determining the efficacy and harm of treatments for pain.
Pain. 2013 Mar 15. pii: S0304-3959(13)00119-X. doi: 10.1016/j.pain.2013.
PubMed:http://www.ncbi.nlm.nih.gov/pubmed/23622761
This is a difficult question to answer. As I'm sure you know, most economic models for the management of any chronic illness vary considerably in depth and breadth and I have personally struggled quite a bit to incorporate models of direct and indirect cost into my own chronic pain research. I'm aware of a few manuscripts that describe the general cost of chronic pain management programs (see Gatchel & Okifuji, 2006 for an example), but I am unaware of any prospective comparative trials with a strong economic endpoint. Most seem to agree that information about healthcare utilization patterns before and after an intervention can serve as a reasonable surrogate for more refined cost models, but I have yet to see any studies advance this line of research beyond basic measures of disability and absenteeism (missed work time). I personally believe that studies of work presenteeism (present at work, but less productive) are sorely needed. For a few of my manuscripts I have actually counted the # of appointments attended in general and specialty clinics to represent healthcare utilization, but this method is only as reliable as the medical records reviewed for the count. This count revealed a significant decrease in healthcare utilization after self-management intervention (but I did not compare head-to-head with other interventions). It may also be good enough to ask patients to recall the number of visits for care to study utilization, though I don't know how reliable these data would be compared to medical record review. I suspect that more detailed cost estimates would support your suspicion that self-management offers significant long-term cost benefits.
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