AP is cost effective in headache: Implications for British NHS

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Hi All,

 

Re discussion of AP within the British NHS, see (at the end of this

mail) excerpts from Anon MIGRAINE TREATMENTS NOW AND IN

THE FUTURE. Headache. 2004 Sep;44(8):846-850.

 

Abstract (2) says that the AP was given by " appropriately trained

physiotherapists " .

 

It is unclear from the abstract if the physios had been trained in

quickie " Cookbook-type " courses, or in formal in-depth TCM

courses that included TCM Pattern Diferentiation.

 

Note that the mean cost of AP Tx was somewhat higher than that

of " usual treatment " (£stg 403 v 217, respectively).

 

Would the AP costs have changed much had the therapists been

expert in TCM Pattern Diferentiation, etc (i.e. trained to Master or

Doctorate Status in TCM), and therefore needed less that the " up

to 12 " sessions over the 3-months of treatment?

 

Do highly competent therapists expect higher fees? I would have

thought so - if only on the basis of the Law of Supply & Demand.

 

The Medline URL is: http://tinyurl.com/58n8a

 

Best regards,

Phil

 

PS: Herbalists, do you know of any randomised comparative

survey of the cost-benefits of CHM as compared with WM?

 

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(1) Vickers AJ, Rees RW, Zollman CE, McCarney R, Smith CM,

Ellis N, Fisher P, Van Haselen R. AP for chronic headache in

primary care: Large, pragmatic, randomised trial. BMJ.

2004;328:744-750. Objective: To determine the effects of a policy of

" use AP " on headache, health status, days off sick, and use of

resources in patients with chronic headache compared with a

policy of " avoid AP. " Design: Randomized, controlled trial. Setting:

General practices in England and Wales. Participants: 401

patients with chronic headache, predominantly migraine.

Interventions: Patients were randomly allocated to receive up to 12

AP treatments over 3 months or to a control intervention offering

usual care. Main outcome measures: Headache score, SF-36

health status, and use of medication were assessed at baseline, 3,

and 12 months. Use of resources was assessed every 3 months.

Results: Headache score at 12 months, the primary endpoint, was

lower in the AP group (16.2; SD 13.7; n = 161; 34% reduction from

baseline) than in controls (22.3; SD 17.0; n = 140; 16% reduction

from baseline). The adjusted difference between means is 4.6 (95%

CI: 2.2 to 7.0; P=.0002). This result is robust to sensitivity analysis

incorporating imputation for missing data. Patients in the AP group

experienced the equivalent of 22 (8-38) fewer days of

headache/year. SF-36 data favored AP, although differences

reached significance only for physical role functioning, energy, and

change in health. Compared with controls, patients randomized to

AP used 15% less medication (P=.02), made 25% fewer visits to

general practitioners (P=.10), and took 15% fewer days off sick

(P=.2). Conclusions: AP leads to persisting, clinically relevant

benefits for primary care patients with chronic headache,

particularly migraine. Expansion of National Health Service AP

services should be considered.

 

(2) Wonderling D, Vickers AJ, Grieve R, MCarney R. Cost

effectiveness analysis of a randomised trial of AP for chronic

headache in primary care. BMJ 2004; 328:747, doi:

10.1136/bmj.38033.896505.EB (published 15 March 2004).

Objective: To evaluate the cost effectiveness of AP in the

management of chronic headache. Design: Cost effectiveness

analysis of a randomized, controlled trial. Setting: General

practices in England and Wales. Participants: 401 patients with

chronic headache, predominantly migraine. Interventions: Patients

were randomly allocated to receive up to 12 AP treatments over 3

months from appropriately trained physiotherapists, or to usual

care alone. Main outcome measure: Incremental cost per quality-

adjusted life year (QALY) gained. Results: Because of the AP

practitioners' costs, total costs during the 1-year period of the

study were on average higher for the AP group (£stg 403; $768;

euro598) than for controls (£stg 217). The mean health gain from

AP during 1 year of the trial was 0.021 quality-adjusted life years

(QALYs), leading to a base case estimate of £stg 9,180 per QALY

gained. This result was robust to sensitivity analysis. Cost per

QALY dropped substantially when the analysis incorporated likely

QALY differences for the years after the trial. Conclusions: AP for

chronic headache improves health-related quality of life at a small

additional cost; it is relatively cost effective compared with a

number of other interventions provided by the National Health

Service.

 

(3) Comments: An abstract under Pathophysiology by Wager et al

is an important article, which provides a physiological basis for

placebo analgesia. This FMRI methodology may help to explain the

basis for pain and symptom relief with technique such as AP as

cost effective treatment for migraine. The two recent articles above

in the British Medical Journal (BMJ) have examined the efficacy

and cost effectiveness of AP treatments in IHS diagnosed migraine

and tension-type headache using a randomized prareatments in

IHS diagnosed migraine and tension-type headache using a

randomized pragmatic comparison of treatment allocation. It is

difficult, although not impossible to “double blind” AP, either by

using a sham AP needle, sham stimulation, or simulation of a

“nonAP” site. Nevertheless, the BMJ articles provide convincing

evidence of cost effectiveness of around £stg 9,000 per QALY,

leading the authors to recommend acceptance by the U.K. health

services. These two studies stimulated much debate and criticism

about the lack of blinding and of controls, which suggested that the

AP effects were due to placebo. Trial Results are summarized in

Figure 2. For more discussion, see Rapid Responses at the

BMJ.com website. It strikes me that FMRI technology and

appropriate use of sham AP techniques could be utilized to

address these critical issues.

 

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Best regards,

 

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