Productivity costs may not drop dramatically when CFS patients avail
of current services
Tom Kindlon
The authors appear to do a reasonable job, given the limits of the
data available to them, in calculating the productivity costs before
Chronic Fatigue Syndrome (CFS) patients reach the services in the UK.
However, the reader is left with the impression that the productivity
costs will drop dramatically once the patient reaches the services:
"We had no data with which to assess the rate at which people with
CFS/ME recover and return to work, either with or without specialized
treatment. According to a systematic review of the literature, the
proportion of adults in employment increased following interventions
for CFS/ME (individualised rehabilitation, cognitive behavioural
therapy and exercise therapy) and decreased in observational studies
with no intervention [1]. Evidence from a recent evidence trial of
cognitive behavioural therapy and graded exercise therapy indicated a
recovery rate of 30-40% one year after treatment [2]."
However it may not be the case that the therapy offered in UK clinics
(or in similar clinics elsewhere) will reduce the productivity costs
by much if anything. It is interesting to consider what happened in
Belgium where rehabilitation clinics for patients satisfying the same
CFS criteria [3] were treated using cognitive behavioural therapy
(CBT) and graded exercise therapy (GET), the same therapies
recommended for use in the UK [4]. Extensive external audits were
performed there on these (Belgian) clinics. The main reports are in
French and Dutch [5,6]; however, for those who can't understand either
of those languages, a five-page summary is available in English [7].
It says, "Employment status decreased at the end of the therapy, from
an average of 18.3% of a 38h- working week, to 14.9% [...] The
percentage of patients living from a sickness allowance increased
slightly from 54 to 57%."
Collin and colleagues claim, "Evidence from a recent evidence trial of
cognitive behavioural therapy and graded exercise therapy indicated a
recovery rate of 30-40% one year after treatment [9]." However,
although a recovery measure was included in the trial's protocol[8],
the authors have made clear [10] that no recovery rate was reported in
the Lancet paper [9]: "[i]t is important to clarify that our paper did
not report on recovery; we will address this in a future publication."
Collin and colleagues also say, "[a]ccording to a systematic review of
the literature, the proportion of adults in employment increased
following interventions for CFS/ME (individualised rehabilitation,
cognitive behavioural therapy and exercise therapy) and decreased in
observational studies with no intervention [1]." This is indeed
mentioned in the abstract of the review. However, when one reads the
paper, the data on which this is based is very limited: 2 longitudinal
studies reported employment at both times with no
interventions[10,11], 2 rehabilitation programs [12,13], one trial of
GET [14] and one trial of CBT[15]. The figures for the GET study are
for everyone (n=3D66) who was in the trial so include the people who
were in the other arm of the trial ( flexibility exercises and
relaxation therapy) who then chose to do GET. So not those who had GET
alone. This trial used the Oxford criteria [16] to define CFS,
criteria which only requires the symptom of fatigue rather than the
other symptoms required in the Fukuda criteria [3]. A study of those
with fatigue has shown that satisfying the Fukuda CFS criteria [3] was
the most powerful predictor of poor response to either GET or CBT
[17]. So one cannot be extrapolate from such studies that those
satisfying the Fukuda criteria, who are the group that Collin studied
(and the group who used the Belgian clinics), will have the same
improvements in employment measures. Similarly, the trial of CBT [15]
didn't use the Fukuda criteria - patients either satisfied the Oxford
criteria [16] or else criteria for F48.0 (Neurasthenia) [18] i.e. they
didn't all satisfy CFS criteria at all. Employment data was only
available for 51 of the 80 individuals who started CBT (64%). Finally,
in one of the rehabilitation trials quoted [12], only two individuals
took part it (at baseline neither was in employment but at follow-up,
one of the two was).
All in all, the evidence that CBT, GET and similar interventions will
increase productivity is not strong. If governments, and those involve
in providing health services, want to decrease the costs associated
with CFS, throwing more and more money at CBT/GET services may not be
the answer; other methods of treating the condition should be
investigated. As the authors have shown, costs associated with the
condition per individual are substantial, so more expensive
therapeutic strategies can be justified on cost grounds alone.
References:
[1] Ross SD, Estok RP, Frame D, Stone LR, Ludensky V, Levine CB:
Disability and chronic fatigue syndrome: a focus on function. Arch
Intern Med 2004, 164:1098-1107.
[2] White P, Goldsmith K, Johnson A, Potts L, Walwyn R, Decesare J,
Baber H, Burgess M, Clark L, Cox D, et al.: Comparison of adaptive
pacing therapy, cognitive behaviour therapy, graded exercise therapy,
and specialist medical care for chronic fatigue syndrome (PACE): a
randomised trial. Lancet 2011, 377:823-836.
[3] Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A:
The chronic fatigue syndrome: a comprehensive approach to its
definition and study. International Chronic Fatigue Syndrome Study
Group. Ann Intern Med 1994, 121:953-959.
[4] NICE: Chronic fatigue syndrome/Myalgic encephalomyelitis (or
encephalopathy); diagnosis and management. National Institute for
Health and Clinical Excellence (NICE); 2007.
[5] Rapport d=92=E9valuation (2002-2004) portant sur l=92ex=E9cution des
conventions de r=E9=E9ducation entre le Comit=E9 de l=92assurance soins de
sant=E9 (INAMI) et les Centres de r=E9f=E9rence pour le Syndrome de fatigue
chronique (SFC). 2006.
<http://www.inami.fgov.be/care/fr/revalidatie/general-information/studies/s=
tudy-sfc-cvs/pdf/rapport.pdf>
. Accessed September 16, 2011 (French language edition)
[6] Evaluatierapport (2002-2004) met betrekking tot de uitvoering van
de revalidatieovereenkomsten tussen het Comit=E9 van de verzekering voor
geneeskundige verzorging (ingesteld bij het Rijksinstituut voor
Ziekte- en invaliditeitsverzekering) en de Referentiecentra voor het
Chronisch vermoeidheidssyndroom (CVS). 2006. Available online:
<http://www.inami.fgov.be/care/nl/revalidatie/general-information/studies/s=
tudy-sfc-cvs/pdf/rapport.pdf>
Accessed September 16, 2011 (Dutch language version)
[7] Stordeur S, Thiry N, Eyssen M. Chronisch Vermoeidheidssyndroom:
diagnose, behandeling en zorgorganisatie. Health Services Research
(HSR). Brussel: Federaal Kenniscentrum voor de Gezondheidszorg (KCE);
2008. KCE reports 88A (D/2008/10.273/58) [The main link seems to
(temporarily?) not to work on the Belgium government website; it can
be seen combined with another file at: http://bit.ly/t6GxcN ;
alternatively it is on its own at:
http://sacfs.asn.au/download/ReportCFS-NL.pdf ]
[8] White PD, Sharpe MC, Chalder T, DeCesare JC, Walwyn R; PACE trial
group. Protocol for the PACE trial: a randomised controlled trial of
adaptive pacing, cognitive behaviour therapy, and graded exercise, as
supplements to standardised specialist medical care versus
standardised specialist medical care alone for patients with the
chronic fatigue syndrome/myalgic encephalomyelitis or encephalopathy.
BMC Neurol. 2007 Mar 8;7:6.
[9] White PD, Goldsmith KA, Johnson AL, Walwyn R, Baber HL, Chalder T,
Sharpe M, on behalf of the coauthors. The PACE trial in chronic
fatigue syndrome - Authors' reply. The Lancet - 28 May 2011 ( Vol.
377, Issue 9780, Pages 1834-1835 ) DOI: 10.1016/S0140-6736(11)60651-X
[10] Tiersky LA, DeLuca J, Hill N, et al. Longitudinal assessment of
neuropsychological functioning, psychiatric status, functional
disability and employment status in chronic fatigue syndrome. Appl
Neuropsychol. 2001;8:41-50.
[11] Vercoulen JH, Swanink C, Fennis J, Galama JM, van der Meer JW,
Bleijenberg G. Dimensional assessment of chronic fatigue syndrome. J
Psychosom Res. 1994; 38:383-392.
[12] Dyck D, Allen S, Barron J, et al. Management of chronic fatigue
syndrome: case study. AAOHN J. 1996;44:85-92.
[13] Marlin RG, Anchel H, Gibson JC, Goldberg WM, Swinton M. An
evaluation of multidisciplinary intervention for chronic fatigue
syndrome with long-term follow-up, and a comparison with untreated
controls. Am J Med. 1998;105:110S-114S.
[14] Fulcher KY, White PD. Randomised controlled trial of graded
exercise in patients with the chronic fatigue syndrome. BMJ.
1997;314:1647-1652.
[15] Akagi H, Klimes I, Bass C. Cognitive behavioral therapy for
chronic fatigue syndrome in a general hospital: feasible and
effective. Gen Hosp Psychiatry. 2001;23:254-260.
[16] Sharpe MC, Archard LC, Banatvala JE, et al. A report--chronic
fatigue syndrome: guidelines for research. J R Soc Med. 1991
Feb;84(2):118-21.
[17] Darbishire L, Seed P, Ridsdale L. Predictors of outcome following
treatment for chronic fatigue. Br J Psychiatry. 2005 Apr;186:350-1.
[18] ICD-10. The ICD-10 classification of mental, and behavioral
disorders. Geneva, World Health Organization, 1992.
Competing interests
I am the information officer of the Irish ME/CFS Association. All my
work for the Association is voluntary (i.e. unpaid).
------------
Reply to:
The impact of CFS/ME on employment and productivity in the UK: a
cross-sectional study based on the CFS/ME national outcomes database
Simon M Collin, Esther Crawley*, Margaret T May, Jonathan AC Sterne,
William Hollingworth and UK CFS/ME National Outcomes Database
BMC Health Services Research 2011, 11:217
Free full text: http://www.biomedcentral.com/1472-6963/11/217
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