Cost-of-illness and Economic Evaluation of Interventions in Children and Adolescents With Chronic Pain: A Systematic Review.

OBJECTIVES: Chronic pain in children and adolescents (CPCA) is widespread with an increasing prevalence. It is associated with a decreased quality of life and an increased parental work loss. Accordingly, CPCA may pose a substantial economic burden for patients, health care payers, and society. Therefore, this systematic review aimed to synthesize (1) the results of existing cost-of-illness studies (COIs) for CPCA and (2) the evidence of economic evaluations (EEs) of interventions for CPCA. METHODS: The systematic literature search was conducted in EMBASE, MEDLINE, PsycINFO, NHS EED, and HTA Database until February 2023. Title, abstract, and full-text screening were conducted by 2 researchers. Original articles reporting costs related to CPCA published in English or German were included. Study characteristics, cost components, and costs were extracted. The quality of studies was assessed using standardized tools. All costs were adjusted to 2020 purchasing power parity US dollars (PPP-USD). RESULTS: Fifteen COIs and 10 EEs were included. The mean annual direct costs of CPCA ranged from PPP-USD 603 to PPP-USD 16,271, with outpatient services accounting for the largest share. The mean annual indirect costs ranged from PPP-USD 92 to PPP-USD 12,721. All EEs reported a decrease in overall costs in treated patients. DISCUSSION: The methodology across studies was heterogeneous limiting the comparability. However, it is concluded that CPCA is associated with high overall costs, which were reduced in all EEs. From a health-economic perspective, efforts should address the prevention and early detection of CPCA followed by specialized pain treatment.

Economic long-term effects of intensive interdisciplinary pain treatment in paediatric patients with severe chronic pain: Analysis of claims data.

OBJECTIVE: Chronic pain in children and adolescents gives rise to high healthcare costs. Successful treatment is supposed to reduce the economic burden. The objective of this study was to determine the changes in healthcare utilization and expenditures from 1 year before (Pre) intensive interdisciplinary pain treatment (IIPT) to the first (Post 1) and second (Post 2) years after discharge in a sample of paediatric chronic pain patients. METHODS: Claims data from one statutory health insurance company were analysed for 119 children and adolescents (mean age = 15.3, 68.9% female) who sought IIPT at the German Paediatric Pain Centre. Costs incurred for inpatient treatment, outpatient treatment, medication, remedies and aids were compared before treatment and 2 years after discharge. Healthcare utilization was compared using Wilcoxon signed-rank test, and expenditures using trimmed means and the Yuen's t-test. RESULTS: Overall costs were significantly lower in the 2 years after IIPT compared to before IIPT (Pre: 3,543€, Post 1:2,681€, Post 2:1937€ (trimmed means)). Healthcare utilization changed significantly; hospitalizations decreased in the years after discharge, while psychotherapies stayed stable in the year after discharge but lessened in the second year. CONCLUSION: The results of this study support prior findings on the high economic burden of paediatric chronic pain. IIPT may contribute to a transition in healthcare utilization from somatic-focused treatments to more psychological treatments. Overall costs were reduced as soon as the first year after discharge and decreased even further in the second year. SIGNIFICANCE: This study analyses original claims data from paediatric chronic pain patients in the year before and up to 2 years after intensive interdisciplinary pain treatment in a specialized paediatric pain centre. The analysis of long-term data reveals a continuous cost reduction after intensive interdisciplinary pain treatment and a change in the subsequent outpatient treatment.

Long-term outcomes of children with severe chronic pain: Comparison of former patients with a community sample.

BACKGROUND: Findings on the short- and long-term effectiveness of intensive interdisciplinary pain treatment (IIPT) for children with severe chronic functional pain are promising. However, a definitive appraisal of long-term effectiveness cannot be made due to a lack of comparison groups. The aim of the present study was to compare the health status of former patients with the health status of an age- and sex-matched comparison group from the community. METHODS: Data from two samples, a clinical sample of former patients (n = 162; aged 14 to 26) and an age- and sex-matched community sample (n = 162), were analysed. Former patients provided data 7 years after IIPT. Pain characteristics, physical and mental health status, autonomy, coping and health care utilisation were compared between the two samples. RESULTS: Seven years after treatment, the majority (58%) of the clinical sample were completely pain-free. Compared to the community sample, the clinical sample demonstrated worse physical and mental health and continued to seek more frequent health care, irrespective of whether or not they experienced ongoing chronic pain. However, the clinical sample reported better coping strategies and a comparable level of autonomy. CONCLUSION: Patients experiencing severe chronic pain in childhood who engage in IIPT are likely to have recovered from their pain in early adulthood. Long-term treatment effects may manifest in better coping strategies. However, reduced mental and physical health status may indicate a negative long-term effect of early chronic pain experiences or a general vulnerability in people developing a chronic pain condition in childhood. SIGNIFICANCE: The majority of severely impaired paediatric chronic pain patients no longer suffer from chronic pain seven years after intensive interdisciplinary pain treatment. However, former patients have worse physical and mental health status than a community sample, and continue to seek out more frequent health care utilisation, irrespective of whether or not they continue to experience chronic pain. Therefore, potential negative long-term effects of childhood chronic pain experiences need specific attention early on.

[Chronic pain in children and adolescents: an economic perspective]. / Chronischer Schmerz bei Kindern und Jugendlichen: eine ökonomische Betrachtung.

BACKGROUND: Chronic pain is a frequent and disabling health problem in children and adolescents and is associated with high health care utilization and costs. OBJECTIVE: The aim of this study was to analyze the direct and indirect costs of chronic pain in children and adolescents in monetary terms before and after multimodal pain therapy from a societal perspective. MATERIALS AND METHODS: Health care costs 12 months before and after multimodal pain therapy include direct costs from statutory health insurances and parents as well as indirect costs due to working days lost. RESULTS: Direct median costs before multimodal treatment were 5619 € (min-max: 377-35,509 €) per year. In the year after pain therapy, costs decreased to a median of 3262 € (min-max: 142-42,910 €) (p = 0.001). In all, 55% of patients showed a significant cost reduction, while 18% had a cost increase. CONCLUSIONS: An effective multimodal pain therapy may reduce health care costs in children and adolescents. Further economic studies are needed to evaluate long-term effects of pain therapy for children and adolescents with chronic pain in a controlled design.

Clinical and Economic Long-Term Treatment Outcome of Children and Adolescents with Disabling Chronic Pain.

Objective: Disabling pediatric chronic pain is accompanied by a significant burden to those affected and by high societal costs. Furthermore, it bears the risk of aggravation into adulthood. Studies have shown intensive interdisciplinary pain treatment to result in short-term positive effects on pain-related and psychological outcomes. In this study, we aimed to prove the stability of the long-term effects of intensive interdisciplinary pain treatment four years after treatment. Methods: This longitudinal observational study followed adolescents who had received intensive interdisciplinary pain treatment over four years. We defined a combined end point, overall improvement (pain intensity, pain-related disability, and school/work absence), and investigated three additional psychological outcome domains (anxiety, depression, pain catastrophizing). We also examined changes to economic parameters (health care utilization, subjective financial burden) and their relationship to patient improvement. Results: Similar patterns were observed for pain-related and psychological outcome domains, with data showing statistically and clinically significant reductions from admission to four-year follow-up. These positive effects were stable from one- to four-year follow-up. Approximately 60% of the adolescents showed an overall long-term improvement. Older age was found to be a risk factor for treatment failure. Economic parameters decreased statistically significantly, particularly for those with an overall improvement of the chronic pain disorder. Conclusions: The results of this study support the long-term effectiveness of intensive interdisciplinary pain treatment and indicate that it can interrupt pain chronification. Future research is warranted to investigate why some of the adolescents did not show improvement and to allow for a more individualized treatment.

Health Care Utilization and Cost in Children and Adolescents With Chronic Pain: Analysis of Health Care Claims Data 1 Year Before and After Intensive Interdisciplinary Pain Treatment.

OBJECTIVES: The aim of this study was to analyze changes in health care utilization and cost among a sample of highly impaired children and adolescents who sought a 3-week intensive interdisciplinary pain treatment (IIPT). MATERIALS AND METHODS: Claims data from 7 statutory health insurance companies were analyzed for 65 children and adolescents who sought IIPT at the German Paediatric Pain Centre. The annual health care utilization and cost were determined for the following 4 areas: outpatient care, inpatient care, medications, and remedies and aids. We analyzed the changes in resource utilization in the year before (pre_1 y) IIPT and in the subsequent year (post_1 y). RESULTS: Within the first year after IIPT, overall health care costs did not decrease significantly. However, the pattern of health care utilization changed. First, significantly more children and adolescents started outpatient psychotherapy (P=0.001). Second, the number of hospitalized children decreased significantly from 1-year pre to 1-year post (P=0.001). Accordingly, there were significantly fewer hospitalizations for primary chronic pain disorders at 1-year post (P<0.001). The prescription of nonopioids, co-analgesics and opioids was significantly reduced from 1-year pre to 1-year post (all P<0.013). DISCUSSION: The present results indicate that the health care costs of children and adolescents with severe chronic pain disorders do not significantly decrease 1 year after IIPT; however, the treatment becomes more goal-focused. Differential diagnosis measures and nonindicated therapeutic interventions decreased, and more indicated interventions, such as psychotherapy, were used. Future research is needed to investigate the economic long-term changes after IIPT.

Household income determines access to specialized pediatric chronic pain treatment in Germany.

BACKGROUND: Families with lower socioeconomic status (SES) often face problems with gaining access to health care services. Information is scarce on the relationship between SES and health care delivery for children suffering from chronic pain. METHODS: Families presenting to a specialized pain center (N = 1,001) provided information on 'household income, 'parental education' and 'occupation' to aid the evaluation of their SES. To assess whether the SES of the clinical sample is representative of the general population, it was compared to data from a community sample (N = 14,558). For the clinical sample, travel distance to the clinic was described in relation to the 75% catchment area. Multiple logistic regression was used to analyze the association between SES and the journey from outside the catchment area. RESULTS: The SES was significantly higher in the clinical sample than in the community sample. Within the clinical sample, the distance traveled to the pain center increased with increasing SES. The 75% catchment area was 143 miles for families with the highest SES and 78 miles for the lowest SES. 'Household income' predicted travel distance (OR 1.32 (1.12-1.56)). Education and occupational status were not significant predictors of travel from outside the catchment area. CONCLUSIONS: In Germany, specialized care for children with chronic pain is subject to disparities in access. Future activities should focus on identifying barriers to access and seeking to prevent inequalities in specialized pediatric health care delivery. Increasing the number of specialized treatment facilities could improve access to specialized pediatric pain treatment, regardless of socioeconomic determinants.

Inpatient-based intensive interdisciplinary pain treatment for highly impaired children with severe chronic pain: randomized controlled trial of efficacy and economic effects.

Pediatric chronic pain, which can result in deleterious effects for the child, bears the risk of aggravation into adulthood. Intensive interdisciplinary pain treatment (IIPT) might be an effective treatment, given the advantage of consulting with multiple professionals on a daily basis. Evidence for the effectiveness of IIPT is scarce. We investigated the efficacy of an IIPT within a randomized controlled trial by comparing an intervention group (IG) (n=52) to a waiting-list control group (WCG) (n=52). We made assessments before treatment (PRE), immediately after treatment (POST), as well as at short-term (POST6MONTHS) and long-term (POST12MONTHS) follow-up. We determined a combined endpoint, improvement (pain intensity, disability, school absence), and investigated 3 additional outcome domains (anxiety, depression, catastrophizing). We also investigated changes in economic parameters (health care use, parental work absenteeism, subjective financial burden) and their relationship to the child's improvement. Results at POST showed that significantly more children in the IG than in the WCG were assigned to improvement (55% compared to 14%; Fisher P<.001; 95% confidence interval for incidence difference: 0.21% to 0.60%). Although immediate effects were achieved for disability, school absence, depression, and catastrophizing, pain intensity and anxiety did not change until short-term follow-up. More than 60% of the children in both groups were improved long-term. The parents reported significant reductions in all economic parameters. The results from the present study support the efficacy of the IIPT. Future research is warranted to investigate differences in treatment response and to understand the changes in economic parameters in nonimproved children.