The cost-effectiveness of an indicated blended care intervention [...] in patients with moderate persistent somatic symptoms 2023 Toonders et al

Full title: The cost-effectiveness of an indicated blended care intervention in primary care compared to usual care in patients with moderate persistent somatic symptoms

Highlights

• This is the first cost-effectiveness study on treating patients with moderate PSS.
  
  
• Overall, the intervention is not found to be cost-effective compared to usual care.
  
  
• Specific outcome measures do show lower average costs and higher effectiveness.
  

Abstract

Introduction
Appropriate treatment for people with an increased risk for developing chronic Persistent Somatic Symptoms (PSS) is of great importance at an early stage to improve quality of life and prevent high costs for society.

Objective
To evaluate the cost-effectiveness of an integrated blended care intervention compared to usual care for QALYs, subjective symptom impact and physical and mental health status in patients with moderate PSS.

Methods
This economic evaluation was conducted alongside a 12-month prospective, multicenter cluster randomized controlled trial in Dutch primary care. 80 participants received the intervention and 80 participants received usual care. Seemingly unrelated regression analyzes were performed to estimate cost and effect differences. Missing data were imputed using multiple imputation. Bootstrapping techniques were used to estimate uncertainty.

Results
We found no significant difference in total societal costs. Intervention, primary and secondary healthcare and absenteeism costs were higher for the intervention group. The ICER for QALYs demonstrated the intervention was on average less costly and less effective compared to usual care. For the subjective symptom impact and physical health, the ICER indicated that the intervention group was on average less costly and more effective. For mental health, the intervention was on average more costly and less effective.

Conclusion
We didn't find an integrated blended primary care intervention to be cost-effective compared to usual care. However, when looking on relevant, but specific outcome measures (subjective symptom impact and physical health) for this population, average costs are found to be lower and the effectiveness found to be higher.

Open access, https://www.sciencedirect.com/science/article/pii/S0022399923002441

 

"Persistent Somatic Symptoms (PSS) are defined as pain, fatigue, and/or dizziness or a combination of these which last at least several weeks and for which no sufficient explanation can be found after proper medical examination [[1], [2], [3]]. PSS are very common, especially in primary care. Around 25–50% of the complaints that patients present to their general practitioner (GP) can be classified as PSS [4]. Based on severity and disease impact, PSS can be classified as mild, moderate or chronic [5]. In mild symptoms, symptoms recover generally within 3 months [5]. Patients with moderate PSS experience severe unexplained symptoms, with psychological and physical distress, but without a diagnosis of a functional somatic syndrome (FSS), or a somatic symptom disorder (SSD) according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition [6,7]. Patients with chronic PSS experience severe physical symptoms and a high level of psychological distress with a major impact on daily functioning and quality of life [[8], [9], [10]]."

 

A good way to explain how absurd these attempts to treat unexpained somtic symptoms really are is this:

If I told you that I have a drug that can treat almost every unexplained disease, you would not believe it and instead think that there is something wrong with my judgement.

But if someone claims to have a therapy that can treat almost every unexplained disease, this is apparently credible and deserving of funding.

The magical element that makes the second claim credible to some seems to be this idea that unexplained symptoms are psychosomatic, and that all psychosomatic illnesses have similar causes and mechanisms. But as far as I know this has never been demonstrated. It's merely a belief.

 

So far we have no evidence that this intervention approach has any impact on the condition or the symptoms other than a short term up lift in questionnaire scores, so it is likely that it has no real life benefits, certainly we have no evidence for any. Consequently it is hardly surprising there are no cost benefits arising from the intervention.

Personally I would rather see research into the costs of a functional disorder attribution resulting in serious biomedical conditions being missed. We know anecdotally that serious life threatening biomedical diagnoses are overlooked or their diagnosis significantly delayed because of functional disorder misdiagnoses, but we have no idea of the scale of this problem. The costs of misdiagnoses may include: delayed treatment onset increasing the cost of medical intervention required, delayed treatment resulting in avoidable disability or even avoidable deaths, wasted months or years that the terminally could have used very differently had they known they were terminally ill, etc. Unfortunately many current practitioners can not be relied on to recognise their own fallibility as we often see a persistent attachment to the initial misdiagnosis, even when an underlying biomedical condition has been identified, by asserting the unevidenced concept of a functional overlay.

 

Undoubtedly, there are recognized steps required or at least suggested, that are involved in a "proper medical examination", as the authors put it. These are presumably taught in medical school. Or, is this a naive assumption?

The term "proper medical examination", appears to be elastic. Experience has shown it can range from no testing whatsoever for very serious physical conditions dismissed as psychsomatic, to extensive investigations.

Along the way, from one practitioner to the next, it seems to be assumed that thorough evaluation of the condition has been done. However, in some instances snap judgements have wrongly placed the problem in the psychological realm.

Mental health workers, assuming "proper medical examinations" have been done may be taking on clients whose physical condition has been ignored.

I don't know what liability concerns this causes for counselors, but it certainly causes problems for the person suffering from the physical condition.

ETA: fixed typo