درمان شناختی مبتنی بر ذهن آگاهی برای بیماران مبتلا به علائم پزشکی غیر قابل توضیح: مطالعه هزینه اثربخشی

Objective Our aim was to assess cost-effectiveness of mindfulness-based cognitive therapy (MBCT) compared with enhanced usual care (EUC) in treating patients with persistent medically unexplained symptoms(MUS). Methods A full economic evaluation with a one year time horizon was performed from a societal perspective. Costs were assessed by prospective cost diaries. Health-related Quality of Life was measured using SF-6D. Outcomes were costs per Quality-Adjusted Life Year (QALY). Bootstrap simulations were performed to obtain mean costs, QALY scores and incremental cost-effectiveness ratios (ICERs). Results MBCT participants (n = 55) had lower hospital costs and higher mental health care costs than patients who received EUC (n = 41). Mean bootstrapped costs for MBCT were €6269, and €5617 for EUC (95% uncertainty interval for difference: − €1576; €2955). QALYs were 0.674 for MBCT and 0.663 for EUC. MBCT was on average more effective and more costly than EUC, resulting in an ICER of €56,637 per QALY gained. At a willingness to pay of €80,000 per QALY, the probability that MBCT is cost-effective is 57%. Conclusion Total costs were not statistically significantly different between MBCT and EUC. However, MBCT seemed to cause a shift in the use of health care resources as mental health care costs were higher and hospital care costs lower in the MBCT condition. Due to the higher drop-out in the EUC condition the cost-effectiveness of MBCT might have been underestimated. The shift in health care use might lead to more effective care for patients with persistent MUS. The longer-term impact of MBCT for patients with persistent MUS needs to be further studied.

Medically unexplained symptoms (MUS) are commonly encountered across all healthcare settings. About one in five patients presenting at the general practitioner (GP)'s office has medically unexplained symptoms [1] and [2]. Often, these symptoms resolve spontaneously. However, in 10–16% of primary care patients the symptoms persist and result in functional impairment [1] and [3]. Frequent attendance because of persistent medically unexplained symptoms is seen in 2.5% of primary care patients. This group mainly consists of women with a lower socioeconomic status [4]. Societal costs associated with persistent MUS are substantial [5] and [6], they mainly consist of health care costs and costs of lost productivity. Health care costs of patients with persistent MUS are high due to high consultation rates in both primary and secondary care [7] and [8] and due to often unnecessary medical procedures with the potential for iatrogenic harm [5], [9] and [10]. In the United Kingdom the incremental annual health care cost incurred by patients with MUS was estimated at approximately 10% of the total health care expenditure for the working‐age population [11]. In the United States 16% of the total medical care costs are attributable to the incremental costs of MUS [7]. In addition, disabilities caused by MUS lead to diminished employment participation: patients with persistent MUS are more on sick leave and have higher rates of unemployment [12]. Clearly, effective interventions for MUS are needed in order to diminish functional impairment and societal costs. Mindfulness-based cognitive therapy (MBCT) is a promising treatment in the field of MUS as it appears to be effective [13] and provides us with a new approach: MBCT stimulates acceptance of symptoms [14]. An economic evaluation of MBCT for patients with somatization disorder has been performed within a recent Danish trial. MBCT was compared to a specialized treatment consisting of a two-hour individual consultation by a psychiatrist [15]. Total health care costs did not differ between the conditions, but the percentage of patients on disability pension had decreased significantly more in the MBCT condition. In a recently randomized controlled trial the effectiveness of MBCT was compared to enhanced usual care (EUC) for frequently attending patients with persistent MUS [13]. Both MBCT and EUC succeeded in improving current health status and mental and physical functioning. However, MBCT led to an earlier improvement of mental functioning, especially with regard to vitality and social functioning. In the context of health care budget constraints, an economic evaluation of this effect can inform decisions which health care services to offer to these patients. Therefore, we performed a cost-effectiveness analysis comparing MBCT versus EUC for patients with persistent MUS.