Cost-effectiveness of interventions for medically unexplained symptoms: A systematic review

Background
In primary and secondary care medically unexplained symptoms (MUS) or functional somatic syndromes (FSS) constitute a major burden for patients and society with high healthcare costs and societal costs. Objectives were to provide an overview of the evidence regarding the cost-effectiveness of interventions for MUS or FSS, and to assess the quality of these studies.
Methods
We searched the databases PubMed, PsycINFO, the National Health Service Economic Evaluation Database (NHS-EED) and the CEA registry to conduct a systematic review. Articles with full economic evaluations on interventions focusing on adult patients with undifferentiated MUS or fibromyalgia (FM), irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS), with no restrictions on comparators, published until 15 June 2018, were included. We excluded preventive interventions. Two reviewers independently extracted study characteristics and cost-effectiveness data and used the Consensus on Health Economic Criteria Checklist to appraise the methodological quality.
Results
A total of 39 studies out of 1,613 articles met the inclusion criteria. Twenty-two studies reported costs per quality-adjusted life year (QALY) gained and cost-utility analyses (CUAs). In 13 CUAs the intervention conditions dominated the control conditions or had an incremental cost-effectiveness ratio below the willingness-to-pay threshold of € 50,000 per QALY, meaning that the interventions were (on average) cost-effective in comparison with the control condition. Group interventions focusing on MUS (n = 3) or FM (n = 4) might be more cost-effective than individual interventions. The included studies were heterogeneous with regard to the included patients, interventions, study design, and outcomes.
Conclusion
This review provides an overview of 39 included studies of interventions for patients with MUS and FSS and the methodological quality of these studies. Considering the limited comparability due to the heterogeneity of the studies, group interventions might be more cost-effective than individual interventions.
Registration
Study methods were documented in an international prospective register of systematic reviews (PROSPERO) protocol, registration number: CRD42017060424.

【背景】
在基层医疗与二级医疗场景中，医学无法解释症状（Medically Unexplained Symptoms, MUS）与功能性躯体综合征（Functional Somatic Syndromes, FSS）给患者与社会带来了沉重负担，伴随高昂的医疗成本与社会成本。本研究旨在全面梳理针对MUS或FSS的干预措施的成本效益相关证据，并评估此类研究的方法学质量。

【方法】
我们检索了PubMed、PsycINFO、英国国家卫生服务经济评价数据库（National Health Service Economic Evaluation Database, NHS-EED）以及成本效益分析（Cost-Effectiveness Analysis, CEA）注册库，以开展本系统综述。纳入截至2018年6月15日发表的、针对成年未分化MUS或纤维肌痛（Fibromyalgia, FM）、肠易激综合征（Irritable Bowel Syndrome, IBS）、慢性疲劳综合征（Chronic Fatigue Syndrome, CFS）患者的干预措施的完整经济评价类文章，不限制对照干预类型。本研究排除预防性干预措施。由两名评价员独立提取研究特征与成本效益数据，并采用《卫生经济研究标准共识清单》（Consensus on Health Economic Criteria Checklist）对研究的方法学质量进行评价。

【结果】
本研究从1613篇文献中最终纳入39项符合纳入标准的研究。其中22项研究报告了每获得1个质量调整生命年（Quality-Adjusted Life Year, QALY）所需的成本以及成本效用分析（Cost-Utility Analysis, CUA）结果。在13项CUA研究中，干预组相较于对照组具有绝对成本效益优势，或其增量成本效益比（Incremental Cost-Effectiveness Ratio, ICER）低于50000欧元每QALY的支付意愿阈值，这意味着相较于对照组，此类干预措施（平均而言）具备成本效益。针对MUS（n=3）或FM（n=4）的团体干预措施，或许比个体干预措施更具成本效益。纳入的研究在研究对象、干预措施、研究设计以及结局指标方面均存在异质性。

【结论】
本综述全面梳理了针对MUS与FSS患者的39项相关干预研究，并评估了此类研究的方法学质量。鉴于研究异质性导致研究间可比性有限，团体干预措施或许比个体干预措施更具成本效益。

【注册信息】
本研究方法已在国际系统综述前瞻性注册库（PROSPERO）中完成注册，注册编号为CRD42017060424。