Return on investment of internet delivered exposure therapy for irritable bowel syndrome: a randomized controlled trial

Hugo Wallén, Perjohan Lindfors, Erik Andersson, Erik Hedman-Lagerlöf, Hugo Hesser, Nils Lindefors, Cecilia Svanborg, Brjánn Ljótsson, Hugo Wallén, Perjohan Lindfors, Erik Andersson, Erik Hedman-Lagerlöf, Hugo Hesser, Nils Lindefors, Cecilia Svanborg, Brjánn Ljótsson

Abstract

Background: Irritable bowel syndrome (IBS) is a debilitating and costly disorder. Cognitive behavior therapy (CBT) is effective in the treatment of IBS, both when delivered over the internet and in face-to-face settings. CBT consists of different components and little is known about their relative importance. We have in an earlier study showed that inclusion of exposure in the CBT for IBS makes it even more effective. In the present study we wanted to evaluate the economic effects for society of inclusion vs exclusion of exposure in an internet delivered CBT for IBS.

Methods: We used data from a previous study with 309 participants with IBS. Participants were randomized to internet delivered CBT with (ICBT) or without exposure (ICBT-WE). We compared direct and indirect costs at baseline, after treatment, and 6 months after treatment (primary endpoint; 6MFU). Data was also collected on symptom severity and time spent by therapists and participants. The relative Incremental Cost Effectiveness Ratio (ICER) was calculated for the two treatment conditions and the return on investment (ROI).

Results: Results showed that ICBT cost $213.5 (20%) more than ICBT-WE per participant. However, ICBT was associated with larger reductions regarding both costs and symptoms than ICBT-WE at 6MFU. The ICER was - 301.69, meaning that for every point improvement on the Gastrointestinal Symptom Rating Scale-IBS version in ICBT, societal costs would be reduced with approximately $300. At a willingness to pay for a case of clinically significant improvement in IBS symptoms of $0, there was an 84% probability of cost-effectiveness. ROI analysis showed that for every $1 invested in ICBT rather than ICBT-WE, the return would be $5.64 six months after treatment. Analyses of post-treatment data showed a similar pattern although cost-savings were smaller.

Conclusions: Including exposure in Cognitive Behavior Treatment for IBS is more cost-effective from a societal perspective than not including it, even though it may demand more therapist and patient time in the short term.

Trial registration: This study is reported in accordance with the CONSORT statement for non-pharmacological trials [1]. Clinicaltrials.gov registration ID: NCT01529567 (14/02/2013).

Keywords: Cognitive behavior therapy; Cost-effectiveness analysis; Exposure; IBS; Internet; Return on investment.

Conflict of interest statement

B.L. has developed the treatment used in the study and is the owner of the intellectual property. He might in some future sell the rights or economically benefit from the spread of this treatment. No other author in the manuscript has any competing interest.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Cost-effectiveness plane comparing ICBT to ICBT-WE
Fig. 2
Fig. 2
Cost-effectiveness plane comparing ICBT to ICBT-WE for clinical improvement

References

    1. Boutron I, Moher D, Altman D, Schulz K, Ravaud P. Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration. Ann Intern Med. 2008;148(4):295–309. doi: 10.7326/0003-4819-148-4-200802190-00008.
    1. Lovell RM, Ford AC. Global prevalence of and risk factors for irritable bowel syndrome: a meta-analysis. Clin Gastroenterol Hepatol. 2012;10(7):712–721.e714. doi: 10.1016/j.cgh.2012.02.029.
    1. Palsson OS, Whitehead WE, van Tilburg MAL, Chang L, Chey W, Crowell MD, Keefer L, Lembo AJ, Parkman HP, Rao SSC, et al. Development and validation of the Rome IV diagnostic questionnaire for adults. Gastroenterology. 2016;150(6):1481–1491. doi: 10.1053/j.gastro.2016.02.014.
    1. Fadgyas-Stanculete M, Buga A-M, Popa-Wagner A, Dumitrascu DL. The relationship between irritable bowel syndrome and psychiatric disorders: from molecular changes to clinical manifestations. J Mol Psychiatry. 2014;2(1):4. doi: 10.1186/2049-9256-2-4.
    1. Soubieres A, Wilson P, Poullis A, Wilkins J, Rance M. Burden of irritable bowel syndrome in an increasingly cost-aware National Health Service. Front Gastroenterol. 2015;6(4):246–251. doi: 10.1136/flgastro-2014-100542.
    1. De Giorgio R, Barbara G, Stanghellini V, Cremon C, Salvioli B, De Ponti F, Corinaldesi R. Diagnosis and therapy of irritable bowel syndrome. Aliment Pharmacol Ther. 2004;20(Suppl 2):10–22. doi: 10.1111/j.1365-2036.2004.02038.x.
    1. Drossman DA. What does the future hold for irritable bowel syndrome and the functional gastrointestinal disorders? J Clin Gastroenterol. 2005;39(5 Suppl):S251–256. doi: 10.1097/01.mcg.0000156107.13247.69.
    1. Lacy B, Lee R. Irritable bowel syndrome: a syndrome in evolution. J Clin Gastroenterol. 2005;39(4 Suppl 3):S230–242. doi: 10.1097/.
    1. Hillilä MT, Färkkilä NJ, Färkkilä MA. Societal costs for irritable bowel syndrome–a population based study. Scand J Gastroenterol. 2010;45(5):582–591. doi: 10.3109/00365521003637211.
    1. Drossman DA, Camilleri M, Mayer EA, Whitehead WE. AGA technical review on irritable bowel syndrome. Gastroenterology. 2002;123(6):2108–2131. doi: 10.1053/gast.2002.37095.
    1. Laird KT, Tanner-Smith EE, Russell AC, Hollon SD, Walker LS. Comparative efficacy of psychological therapies for improving mental health and daily functioning in irritable bowel syndrome: A systematic review and meta-analysis. Clin Psychol Rev. 2017;51:142–152. doi: 10.1016/j.cpr.2016.11.001.
    1. Labus JS, Mayer EA, Chang L, Bolus R, Naliboff BD. The central role of gastrointestinal-specific anxiety in irritable bowel syndrome: further validation of the visceral sensitivity index. Psychosom Med. 2007;69(1):89–98. doi: 10.1097/PSY.0b013e31802e2f24.
    1. Craske MG, Wolitzky-Taylor KB, Labus JS, Wu S, Frese M, Mayer EA, Naliboff BD. A cognitive-behavioral treatment for irritable bowel syndrome using interoceptive exposure to visceral sensations. Behav Res Ther. 2011;49(6):413–421. doi: 10.1016/j.brat.2011.04.001.
    1. Labus JS, Bolus R, Chang L, Wiklund I, Naesdal J, Mayer EA, Naliboff BD. The Visceral Sensitivity Index: development and validation of a gastrointestinal symptom-specific anxiety scale. Aliment Pharmacol Ther. 2004;20(1):89–97. doi: 10.1111/j.1365-2036.2004.02007.x.
    1. Reme SE, Darnley S, Kennedy T, Chalder T. The development of the irritable bowel syndrome-behavioral responses questionnaire. J Psychosom Res. 2010;69(3):319–325. doi: 10.1016/j.jpsychores.2010.01.025.
    1. Windgassen S, Moss-Morris R, Chilcot J, Sibelli A, Goldsmith K, Chalder T. The journey between brain and gut: a systematic review of psychological mechanisms of treatment effect in irritable bowel syndrome. Br J Health Psychol. 2017;22(4):701–736. doi: 10.1111/bjhp.12250.
    1. Boersma K, Ljótsson B, Edebol-Carlman H, Schrooten M, Linton SJ, Brummer RJ. Exposure-based cognitive behavioral therapy for irritable bowel syndrome. A single-case experimental design across 13 subjects. Cogn Behav Therapy. 2016;45(6):415–430. doi: 10.1080/16506073.2016.1194455.
    1. Ljótsson B, Andréewitch S, Hedman E, Rück C, Andersson G, Lindefors N. Exposure and mindfulness based therapy for irritable bowel syndrome - an open pilot study. J Behav Ther Exp Psychiatry. 2010;41(3):185–190. doi: 10.1016/j.jbtep.2010.01.001.
    1. Ljótsson B, Andersson G, Andersson E, Hedman E, Lindfors P, Andréewitch S, Rück C, Lindefors N. Acceptability, effectiveness, and cost-effectiveness of internet-based exposure treatment for irritable bowel syndrome in a clinical sample: a randomized controlled trial. BMC Gastroenterol. 2011;11(1):110. doi: 10.1186/1471-230X-11-110.
    1. Ljótsson B, Falk L, Vesterlund AW, Hedman E, Lindfors P, Rück C, Hursti T, Andréewitch S, Jansson L, Lindefors N, et al. Internet-delivered exposure and mindfulness based therapy for irritable bowel syndrome - a randomized controlled trial. Behav Res Ther. 2010;48(6):531–539. doi: 10.1016/j.brat.2010.03.003.
    1. Ljótsson B, Hesser H, Andersson E, Lackner JM, El Alaoui S, Falk L, Aspvall K, Fransson J, Hammarlund K, Löfström A, et al. Provoking symptoms to relieve symptoms: a randomized controlled dismantling study of exposure therapy in irritable bowel syndrome. Behav Res Ther. 2014;55C:27–39. doi: 10.1016/j.brat.2014.01.007.
    1. Hesser H, Hedman E, Lindfors P, Andersson E, Ljótsson B. The specific effect of systematic exposure in irritable bowel syndrome: complier average causal effect analysis using growth mixture modeling. Psychol Med. 2017;47(15):2653–2662. doi: 10.1017/S0033291717001167.
    1. Hesser H, Hedman-Lagerlöf E, Andersson E, Lindfors P, Ljótsson B. How does exposure therapy work? A comparison between generic and gastrointestinal anxiety-specific mediators in a dismantling study of exposure therapy for irritable bowel syndrome. J Consult Clin Psychol. 2018;86(3):254–267. doi: 10.1037/ccp0000273.
    1. Howard DH, Conti RM. Are new drugs more expensive than old ones? Trends in the benefit-adjusted launch prices of anticancer drugs, 1995–2013. J Clin Oncol. 2014;32(15):6525–6525. doi: 10.1200/jco.2014.32.15_suppl.6525.
    1. Myhr G, Payne K. Cost-effectiveness of cognitive-behavioural therapy for mental disorders: implications for Public Health Care Funding Policy in Canada. Canad J Psychiatry. 2006;51(10):662–670. doi: 10.1177/070674370605101006.
    1. Hedman E, Ljótsson B, Lindefors N. Cognitive behavior therapy via the Internet: a systematic review of applications, clinical efficacy and cost–effectiveness. Expert Rev Pharmacoecon Outcomes Res. 2012;12(6):745–764. doi: 10.1586/erp.12.67.
    1. Andersson E, Ljótsson B, Smit F, Paxling B, Hedman E, Lindefors N, Andersson G, Rück C. Cost-effectiveness of internet-based cognitive behavior therapy for irritable bowel syndrome: results from a randomized controlled trial. BMC Public Health. 2011;11:215. doi: 10.1186/1471-2458-11-215.
    1. How to calculate return on investment to figure how much money you've made []
    1. Hedman E, Ljótsson B, Rück C, Furmark T, Carlbring P, Lindefors N, Andersson G. Internet administration of self-report measures commonly used in research on social anxiety disorder: A psychometric evaluation. Comput Hum Behav. 2010;26(4):736–740. doi: 10.1016/j.chb.2010.01.010.
    1. Longstreth G, Thompson W, Chey W, Houghton L, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology. 2006;130(5):1480–1491. doi: 10.1053/j.gastro.2005.11.061.
    1. Spiller RC, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, Jones R, Kumar D, Rubin G, Trudgill N, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut. 2007;56(12):1770–1798. doi: 10.1136/gut.2007.119446.
    1. Carlbring P, Andersson G, Cuijpers P, Riper H, Hedman-Lagerlöf E. Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis. Cogn Behav Therapy. 2018;47(1):1–18. doi: 10.1080/16506073.2017.1401115.
    1. Ahmedani BK, Belville-Robertson T, Hirsch A, Jurayj A. An online mental health and wellness intervention supplementing standard care of depression and anxiety. Arch Psychiatr Nurs. 2016;30(6):666–670. doi: 10.1016/j.apnu.2016.03.003.
    1. Abramowitz JS, Deacon BJ, Whiteside SPH. Exposure therapy for anxiety: principles and practice. New York: Guilford Press; 2011.
    1. Wiklund I, Fullerton S, Hawkey C, Jones R, Longstreth G, Mayer EA, Peacock R, Wilson I, Naesdal J. An irritable bowel syndrome-specific symptom questionnaire: development and validation. Scand J Gastroenterol. 2003;38(9):947–954. doi: 10.1080/00365520310004209.
    1. Ljótsson B, Jones M, Talley NJ, Kjellström L, Agréus L, Andreasson A. Discriminant and convergent validity of the GSRS-IBS symptom severity measure for irritable bowel syndrome: a population study. Unit Eur Gastroenterol J. 2020;8:284. doi: 10.1177/2050640619900577.
    1. Bouwmans C, De Jong K, Timman R, Zijlstra-Vlasveld M, Van der Feltz-Cornelis C, Tan SS, Hakkaart-van Roijen L. Feasibility, reliability and validity of a questionnaire on healthcare consumption and productivity loss in patients with a psychiatric disorder (TiC-P) BMC Health Serv Res. 2013;13(1):217. doi: 10.1186/1472-6963-13-217.
    1. Genomsnittlig månadslön efter sektor 1992–2018.
    1. Purchasing power parities (PPP).
    1. Referensvikter för slutenvårds-och öppenvårdsgrupper, NordDRG 2017.
    1. Ersättningssystem i hemtjänst 2019.
    1. Kanters TA, Bouwmans CAM, van der Linden N, Tan SS, Hakkaart-van Roijen L. Update of the Dutch manual for costing studies in health care. PLoS ONE. 2017;12(11):e0187477. doi: 10.1371/journal.pone.0187477.
    1. R Core Team: R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria 2019.
    1. Pinheiro J, Bates D, DebRoy S, Sarkar D: R Core Team. nlme: Linear and Nonlinear Mixed Effects Models. R package version 3.1–137. 2018. In: 2019.
    1. Nieuwenhuis R, te Grotenhuis H, Pelzer B. Influence. ME: tools for detecting influential data in mixed effects models. 2012.
    1. Dear BF, Gandy M, Karin E, Ricciardi T, Langman N, Staples LG, Fogliati VJ, Sharpe L, McLellan LF, Titov N. The Pain Course: exploring predictors of clinical response to an Internet-delivered pain management program. Pain. 2016;157(10):2257–2268. doi: 10.1097/j.pain.0000000000000639.
    1. Guidance for Industry Irritable Bowel Syndrome - Clinical Evaluation of Drugs for Treatment.
    1. Chisholm D, Sweeny K, Sheehan P, Rasmussen B, Smit F, Cuijpers P, Saxena S. Scaling-up treatment of depression and anxiety: a global return on investment analysis. Lancet Psychiatry. 2016;3(5):415–424. doi: 10.1016/S2215-0366(16)30024-4.
    1. Return on Investment (ROI).
    1. Utomlänsprislista år 2017 Region Stockholm – Gotland Prislista övrig öppenvård.
    1. Lane P. Handling drop-out in longitudinal clinical trials: a comparison of the LOCF and MMRM approaches. Pharm Stat. 2008;7(2):93–106. doi: 10.1002/pst.267.
    1. Briggs A. Handling uncertainty in economic evaluation. BMJ. 1999;319(7202):120. doi: 10.1136/bmj.319.7202.120.
    1. Barlow DH. Negative effects from psychological treatments: a perspective. Am Psychol. 2010;65(1):13–20. doi: 10.1037/a0015643.
    1. Crawford MJ, Thana L, Farquharson L, Palmer L, Hancock E, Bassett P, Clarke J, Parry GD. Patient experience of negative effects of psychological treatment: results of a national survey. Br J Psychiatry. 2018;208(3):260–265. doi: 10.1192/bjp.bp.114.162628.
    1. Olatunji BO, Deacon BJ, Abramowitz JS. The cruelest cure? Ethical issues in the implementation of exposure-based treatments. Cogn Behav Pract. 2009;16(2):172–180. doi: 10.1016/j.cbpra.2008.07.003.
    1. Koloski N, Talley NJ, Boyce P. Predictors of health care seeking for irritable bowel syndrome and nonulcer dyspepsia: a critical review of the literature on symptom and psychosocial factors. Am J Gastroenterol. 2001;96(5):1340–1349. doi: 10.1111/j.1572-0241.2001.03789.x.
    1. Demmelmaier I, Åsenlöf P, Lindberg P, Denison E. Biopsychosocial predictors of pain, disability, health care consumption, and sick leave in first-episode and long-term back pain: a longitudinal study in the general population. Int J Behav Med. 2010;17(2):79–89. doi: 10.1007/s12529-009-9055-3.
    1. Briggs A. Economic evaluation and clinical trials: size matters. Need Great Power Cost Anal Poses Ethical Dilemma. 2000;321(7273):1362–1363.

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