Internet-delivered exposure therapy was cost-effective for increasing treatment response in fibromyalgia

Question In patients with fibromyalgia (FM), is Internet-delivered exposure therapy (iExp) cost-effective? Methods Design Economic analysis of a randomized controlled trial*. Setting Sweden. Patients 140 adults 18 years of age (mean age 50 y, 98% women) who had a confirmed diagnosis of FM and lived in Sweden. Exclusion criteria included late pregnancy (>29 wk gestation), severe physical illness that overrode the concern for FM or that required immediate treatment, severe depression or suicidal ideation, ongoing psychosis or alcohol or substance abuse/dependency, or inability to manage a text-based treatment. Intervention iExp (n =70) or a wait-list control (WLC) group (n =70). iExp was an Internet-delivered, therapist-supported treatment comprising 8 self-help modules (100 pages total) delivered over 10 weeks. The modules focused on psychoeducation, mindfulness training to facilitate exposure, and exposure to FM- and pain-related stimuli. Patients had regular written contact with their online therapist, received written progress feedback, and were reminded and encouraged by their therapist if they were inactive for 4 days. Outcomes Treatment response (19.67-point reduction on the Fibromyalgia Impact Questionnaire), quality-adjusted life-years based on European Quality of Life 5Dimensions (EQ-5D) questionnaire scores, costs in 2016 US$, and incremental cost-effectiveness ratio. Societal costs included health care provider costs (e.g., direct treatment costs, including health care visits and medications), direct nonmedical costs, and indirect nonmedical costs (sick leave, work loss, and domestic loss). Main results The main results are in the Table. Groups did not differ for change in EQ-5D (mean between-group difference 0.08, 95% CI 0.04 to 0.20, P =0.18). Conclusion In patients with fibromyalgia, an Internet-delivered exposure therapy was cost-effective for increasing treatment response compared with a wait-list control group. Internet-delivered exposure therapy (iExp) vs wait-list for treatment response in patients with fibromyalgia Perspective Treatment response rates Difference in costs (US$) Incremental cost per responder gained at 1 y (US$) iExp Wait-list Societal 44% 11% $5025 $15295 Health care provider 44% 11% $726 $2221 Treatment response defined as reduction of 19.67 points from baseline on the Fibromyalgia Impact Questionnaire (score range 0 to 100; higher score indicates greater severity). Between-group difference P <0.001. Commentary Fibromyalgia is a chronic pain condition without a defining cause or cure. Prevalence in the general population is 1.8%, and rates are higher among women (3.8%) and patients with such chronic diseases as rheumatologic disorders (15%) and irritable bowel syndrome (13%) (1). The trial by Hedman-Lagerlf and colleagues showed that the iExp group had a response immediately after treatment and up to 12 months later, whereas the control group did not have a response at the end of the treatment period. Patients assigned to iExp seemed to have lower indirect medical costs, driven by less work loss and reduced direct medical costs through fewer health care visits. The trial represents 1 of the few Internet-based interventions that shows an improvement in quality of life. A recent review found that Internet-based interventions with progressive modules of engagement and layers of targeted approaches (e.g., assignments and self-monitoring for personalized feedback) improved health more than electronically delivered educational materials (2). Should a trial in which only 70 patients received the intervention change how we manage fibromyalgia? For providers and health systems with the resources to invest in similar Internet-based interventions, I suggest exploring that opportunity. If the results can be replicated in other settings with more diverse populations, the trial could support delivering more behavioral interventions through the Internet for patients with fibromyalgia.