For patients with fibromyalgia, internet-delivered exposure therapy (iExp), a form of cognitive behavioral therapy, proved to be more cost-effective than waitlist control (WLC), which did not involve any treatment during the experimental phase, according to a study published in the Journal of Pain.

Researchers utilized previously reported health economic data to identify 140 patients with fibromyalgia; these patients were then randomly assigned 1:1 to iExp or WLC. Health-economy data were collected before treatment, after treatment, and at 1-year follow-up using the Trimbos and Institute of Medical Technology Assessment Cost Questionnaire for Psychiatry (TIC-P). Patients included in the study were aged ≥18 years, had a confirmed diagnosis of fibromyalgia, and confirmed having access to the internet.

Participants included in the iExp group were provided with internet-delivered treatment with therapist intervention for 10 weeks. Interventions included psychoeducation, exposure to fibromyalgia- and pain-related stimuli, and mindfulness training. Patients were evaluated based on: 1) refraining from avoidance behaviors such as short-term analgesics or heating pads; and 2) approaching uncomfortable situations with positivity, such as participating in social activities without regard to symptoms. Participants in WLC group did not receive any treatment during this phase.

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Participants used the TIC-P to provide their healthcare consumption during the prior month and time spent in informal health-benefiting activities, as well as medication consumption over the previous 2 weeks, days of sick leave, and reduced work capacity. Costs associated with unemployment were not included. Monetary losses associated with sick leave, as well as work- and household cutback due to fibromyalgia were estimated based on the average gross earning in Sweden in accordance with the participants’ level of education. Medical costs were estimated based on Swedish national public health information, and costs for informal health-enhancing activities and products were estimated using national free market prices.

The Fibromyalgia Impact Questionnaire (FIQ) — a tool that comprises 10 questions that assess the patients’ fibromyalgia symptoms in the previous week — was used to measure treatment effectiveness. Scores range from 0 to 100; a total score <39 indicates mild impairment, a score between 39 and 58 indicates moderate impairment, and a score ≥59 indicates severe impairment. Secondary clinical outcome were assessed using the EuroQol questionnaire (ED-5Q), a non-disease-specific questionnaire that measures mobility, self-care, usual activities, pain/discomfort, and anxiety/depression.

Mean score on the FIQ at pre-treatment was 55.02 (SD, 16.78) for the iExp group and 57.86 (SD, 15.76) for the WLC group; corresponding figures following treatment were 36.44 (SD, 25.56) and 57.51 (SD, 21.62), respectively. During follow-up, the average score for the iExp group was 39.95 (SD, 21.77), which resulted in a nonsignificant difference. The iExp group had a significantly higher total cost reduction following treatment (multilevel regression, -5097) compared with the WLC group; this difference were primarily driven by lower indirect nonmedical costs (z= -2.35), more specifically lower costs of work cutback (z= -2.95). Patients who had a decrease of ≥19.67 points on the FIQ (8 participants in the WLC group and 31 participants in the iExp group) had lower net total costs following treatment.

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The researchers estimated a total societal cost saving of $15,295 for 1 additional responder to treatment as measured by change on the FIQ. The iExp was found to have an 80% probability of being cost-effective, given a willingness-to-pay value of $2600.

“Results showed that this treatment can be highly cost-effective as each incremental responder to treatment in comparison to a waitlist control condition generated a societal annual cost reduction of $15,295,” the authors concluded. “Looking at total costs, iExp had a significantly larger cost-reduction than the control condition from pre- to post-treatment.”


Hedman-Lagerlöf M, Hedman-Lagerlöf E, Ljótsson B, Wicksell RK, Flink I, Andersson E. Cost-effectiveness and cost-utility of internet-delivered exposure therapy for fibromyalgia: results from a randomized controlled trial [published online August 11, 2018]. J Pain. doi: 10.1016/j.jpain.2018.07.012