— More evidence needed to distinguish between therapies and to fully understand their effects in chronic neck pain —
Boston, Mass., October 4, 2017– The Institute for Clinical and Economic Review (ICER) has released an Evidence Report assessing the comparative clinical effectiveness of several cognitive and mind-body therapies for treatment of chronic low back and neck pain, including acupuncture, cognitive behavioral therapy (CBT), mindfulness-based stress reduction, yoga, and tai chi. ICER’s review also assessed the value of these therapies for low back pain, but, due to data limitations, did not include value analyses for neck pain.
The report’s findings suggest that these interventions are safe for patients, and likely offer added benefits beyond usual care for those with chronic low back pain. However, evidence is insufficient to distinguish between the interventions. Current evidence is generally inadequate to assess their effects for those with neck pain. The Evidence Report will be subject to public deliberation during the October 19, 2017 public meeting of the California Technology Assessment Forum (CTAF), one of ICER’s three independent evidence appraisal committees. The public meeting will be held in Oakland, CA and will also be available by live webcast.
“In the midst of the opioid crisis our country is facing, it is of critical importance that we consider the merits of non-pharmacologic pain therapies as possible alternatives to opioids,” stated David Rind, MD, ICER’s Chief Medical Officer. “Evidence on therapies such as acupuncture, CBT, mindfulness-based stress reduction, and yoga suggest that they may offer benefit to appropriate patients with chronic back pain. While a portion of the benefit may be attributable to a placebo effect, the therapies pose few risks, and many appear to be reasonably cost-effective when added to usual care. During ICER’s public meeting, patients, payers, and clinicians will have the opportunity to publicly discuss the role of these therapies in patient care, and whether they may be an effective tool in countering the overuse of opioids.”
A draft version of this report was previously open for a four-week public comment period. The updated Evidence Report and Voting Questions reflect changes made based on comments received from patient groups, clinicians, and other stakeholders.
Key Report Findings
For back pain, ICER’s review found that evidence provides moderate certainty that acupuncture, CBT, mindfulness-based stress reduction, and yoga, offer outcomes that are comparable to or better than those observed with usual care alone, defined as pain management education, oral pain medications such as NSAIDs, and/or physical therapy. Evidence on tai chi was promising but inconclusive. Evidence on the clinical effectiveness of the interventions for treatment of neck pain was insufficient for all interventions except acupuncture, for which it was promising but inconclusive.
Due to the data limitations, economic analyses of these interventions were conducted only for treatment of back pain. Each of the nonpharmacologic interventions resulted in increased costs compared to usual care, but most remained below or within the commonly accepted threshold for cost-effectiveness of $100,000-$150,000 per quality adjusted life year (QALY) gained. Value-based price benchmarks, or the prices at which the costs of the intervention would align with the benefits to patients, suggest that while some therapies would require modest discounts of up to 10% to meet the lower threshold, many of the therapies would remain cost-effective even if prices were higher.
ICER’s review also examined the potential budget impact of three interventions that are not commonly covered by insurers: mindfulness-based stress reduction, yoga, and tai chi. Analyses considered the costs of coverage for a hypothetical health insurance plan covering 1 million members. For example, if the plan were to cover mindfulness-based stress reduction, the most expensive of the three interventions, and 50% of eligible patients took part, monthly costs would increase by $0.75 per member. To put that per-member cost in perspective, one large national pharmacy benefits management company spends approximately $4.46 per member per month on medication costs for treatment of pain.
During the October public meeting, the CTAF Panel will vote on key questions raised in the report, and a policy roundtable of experts will discuss recommendations to apply the evidence to policy and practice. During the meeting, pre-registered stakeholders will provide brief oral comments on the report and its findings. Requests to make an oral comment were accepted during the public comment period on the Draft Evidence Report and are now closed.