Economics of pain and pain management: impact on policy, practice and patients
Submitting Institution
Swansea UniversityUnit of Assessment
Allied Health Professions, Dentistry, Nursing and PharmacySummary Impact Type
HealthResearch Subject Area(s)
Medical and Health Sciences: Clinical Sciences, Public Health and Health Services
Summary of the impact
This case study focuses on impacts that have arisen from research on the
economics of pain and pain management established by Phillips on his
arrival in Swansea in 1997. The impact of the research programme has been
multifaceted, encompassing economic, public awareness, policy and practice
dimensions and a reframing of priorities. It is exemplified by:
- engagement with pharmaceutical companies to introduce new therapeutic
agents for the management of patients with chronic pain;
- re-focusing of patient management to embrace the impact of pain on
whole persons and their communities;
- enhancing the status of pain and its management in the development of
health policy and practice; and
- an increase in the awareness within the UK and EU political community
of the range of consequences associated with pain.
Underpinning research
It is known that around 20% of the population in the UK suffer with
chronic pain — defined as pain that is experienced every day for at least
3 months within a 6-month period.
Phillips had led, and collaborated with colleagues at other universities,
on earlier studies that had assessed the total costs and societal burden
of a number of conditions, including those costs that occurred from
treatment side effects, to derive strategies for patient management. The
underpinning research programme arose from a study to assess the impact of
major side effects from treating pain with non-steroidal inflammatory
drugs (NSAIDs) [R1] and subsequently developed to impact on the four areas
identified in Section 1. The study on the costs associated with treatment
side effects in the management of pain was led by Phillips at Swansea and
Moore at Oxford (Moore holds an Honorary Chair at Swansea) and was based
on the utilisation of evidence, gleaned from systematic reviews in an
economic modelling exercise. This considered the likelihood that patients
prescribed NSAIDs would experience adverse gastrointestinal events that,
in some cases, could lead to death. The costs of treating these events
were derived from published sources and risk factors were obtained from
prior work undertaken by the collaboration. The findings showed that for
every patient prescribed an NSAID the additional cost to the UK NHS in
managing the adverse consequences amounted to £48. The cost of NSAID
prescribing ca. 24 million prescriptions at the time of the study was £220
million. However, when the overall cost associated with these therapies
was estimated, incorporating preventive and treatment costs associated
with adverse events, this was between £400 million and £600 million,
comprising over £35 million in hospitalisations and between £140 million
and £340 million in prescribing protective agents. Further work in
relation to these phenomena was published in 2006 [R2].
The research programme developed through funding from organisations such
the National Institute for Health Research (NIHR), Welsh Government and
pharmaceutical companies. Studies included assessments of the costs of
managing pain [R3-4], evaluations of interventions designed to secure pain
relief and studies that examined the relationship between pain and work.
An example of the latter was a NIHR funded project that explored the
effectiveness and cost-effectiveness of strategies for managing patients
with sciatica [R5] — a condition that has a lifetime prevalence rate of
around 5% for men and 4% for women. The research involved both evidence
synthesis and economic modelling, with the economic modelling undertaken
by Phillips and Fitzsimmons at Swansea, who were also involved with
colleagues in Cardiff on the evidence search and synthesis. The Welsh
Government funded project (2008-09), led by Phillips, assessed the costs
and benefits of a scheme designed to minimise workers' sickness absence by
introduction of early physiotherapy interventions to reduce the adverse
effects of pain and improve work retention and return to work rates [R6].
The research demonstrated that the scheme produced: significant reductions
in sickness absence and improvements in work-related performance; a
substantial reduction in resource utilisation; marked benefits for
employees with musculoskeletal problems and significant improvements in
their quality of life.
References to the research
R1 Moore A, Phillips CJ. Cost of NSAID adverse effects to the UK National
Health Service. Journal of Medical Economics, 1999; 2: 45-55
R2 Moore RA, Derry S, Phillips CJ, et al. Nonsteroidal anti-inflammatory
drugs (NSAIDs), cyxlooxygenase-2 selective inhibitors (coxibs) and
gastrointestinal harm: review of clinical trials and clinical practice.
BMC Musculoskeletal Disorders, 2006; 7:79 doi: 10.1186/1471- 2474-7-79
R3 Phillips CJ. Economic burden of chronic pain. Expert Review of
Pharmacoeconomics & Outcomes Research, 2006; 6: 591-601.
R4 Phillips CJ, Main CJ, Buck R, Aylward M et al. Prioritising pain in
policy making: The need for a whole systems perspective, Health Policy,
2008; 88: 166-75
R5 Lewis R, Williams N, Matar HE, Din, N, Fitzsimmons D, Phillips CJ et
al. The clinical effectiveness and cost-effectiveness of management
strategies for sciatica: systematic review and economic model. Health
Technol Assess 2011;15(39):1-578
R6 Phillips CJ, Phillips R, Main CJ, Watson PJ et al. The cost
effectiveness of UK National Health Service Physiotherapy support for
occupational health services. BMC Musculoskelet Disord. 2012 Feb
23;13(1):29. doi:10.1186/1471-2474-13-29.
Relevant grants
• 2002-03 Main CJ, Phillips CJ. Development of Wales Health Work
Partnership Programme. Funded by Department of Work and Pensions/Welsh
Assembly Government: £15,000
• 2003-04 Phillips CJ. Assessment of quality of life of patients with GI
adverse events. Funded by Merck Inc: £50,000.
• 2005-09 Phillips CJ, Main CJ, Buck R. Well-being in Work Initiative: a
series of projects designed to investigate the relationship between health
and work, to develop and evaluate interventions aimed at improving work
retention and rehabilitation. Phase I, Phase II and Phase III funded by
Wales Centre for Health: £250,000.
• 2008-09 Williams N, Lewis R, Phillips CJ, Fitzsimmons D et al.
Management strategies for sciatica. HIHR HTA Programme: £250,000
• 2008-09 Phillips CJ, Davies S, Noble G, Aylward M et al. Development of
a framework for the evaluation of the Occupational Health Physiotherapy
Pilot Project. Welsh Assembly Government: £95,000
• 2008-10 Siebert S, Brophy S, Lyons R, Gravenor M, Phillips CJ, et al. A
population-based ankylosing spondylitis project. MRC: £240,000.
Details of the impact
Impact 1. Engaging with pharmaceutical companies to introduce new pain
therapeutic agents
Work relating to the first two papers referenced in section 3 [R1, 2] was
instrumental in the development of a new class of therapies that
significantly reduced the extent of gastrointestinal side effects evident
in other therapies for pain relief:
"At the time of the development of the new therapeutic agents — Cox II
inhibitors (coxibs) — for the management of chronic pain by the
pharmaceutical industry, little was known about the scope and health
economic impact of NSAID-related adverse experiences. Dr Phillips' work
studying the clinical impact of these types of AEs (adverse effects) and
quantifying the healthcare resource utilization employed by clinical
practice was very important to help gain an understanding [of] the
economic impact of introducing coxibs to clinical practice. Dr Phillips,
in collaboration with Dr Moore and Merck researchers, was instrumental
in the development of the first health economic analyses of the coxibs."
(Head of Economics and Statistics, Merck Corporation) [C1]
There were some 940,000 prescriptions for coxibs in England, Scotland and
Wales during 2012, which represents over 5% of total analgesic
prescribing. The drugs are of major benefit to patients who previously had
major problems in securing pain relief due to the side effects associated
with the alternative therapies.
Impact 2. Re-focusing patient management
Findings from the research programme on costs associated with chronic
pain [R3-4] led to Phillips contributing to the development of NICE
guidance for employers, NHS and other professionals and managers involved
in the management of long-term sickness absence and incapacity. He has
also contributed to clinical update sessions for medical professionals,
including recent meetings at the Royal College of Anaesthetists and Royal
College of General Practitioners. Further, a Welsh Government commissioned
evaluation of costs and benefits of an early physiotherapy intervention
[R6] which demonstrated significant improvements in clinical and quality
of life measures and sickness absence rates. This work was a key component
in assessing the need for a national occupational health service for
Wales, and in informing the evidence base for Fit for Work pilots — a
major component of the UK government's policy of welfare reform:
"The impact of the Occupational Health and Physiotherapy Pilot
[i.e., R6] was fed in, following Dame Carol Black's Review, to support
the evidence base for the Department of Work and Pensions `Fit for Work'
pilots - 11 pilots were introduced, with 7 being extended." (Head of
Workplace Settings, Welsh Government) [C2]
In addition, the impact of the research has been acknowledged by patient
groups:
"... vouch that his work has greatly impacted on elevating the status
of pain management within the UK and further afield from the patient
perspective. Professor Phillips' work on the impact of pain is
recognised and valued within the EU pain community and has served to
increase awareness of pain at a political level to support the patients'
voice in getting a higher priority for the management of pain"
(Patient representative) [C2]
Impact 3. Enhancing the status of pain and its management in the
development of health policy and practice
Research findings (R3-4) have also been widely used to influence policy
developments in UK and overseas. For example, findings were used to inform
a chapter in the Chief Medical Officer of Health Annual Report 2008 -
entitled "Pain: breaking through the barrier."
"The research findings [i.e., R3] were influential in framing
the chapter on pain in the CMO Report and the data his work has produced
on costs and burden of pain provided a useful background to the chapter
and the need for concerted action to initiate evidence-based policies
and treatments to grapple with the problem. His direct input discussing
the direction and content for the chapter and offering support and
suggesting refinements was greatly valued at the time. His on-going
involvement in UK-wide discussions about public and health policy to
reduce the burden of ill health from chronic pain remains greatly
appreciated" (Senior Clinical Advisor to Chief Medical Officer,
England) [C3]
The opening section of the chapter — entitled Impact on Lives — was
largely drawn from the data synthesised in references R3 and R4. Further,
the research helped to formulate policy development in Canada:
"We are just beginning discussions here in relation to a provincial
policy strategy for the management of chronic pain.....Your paper on
chronic pain burden [R3] will be very useful....please let us
know if we can share your document" (Head of Pain Management,
Calgary Health Region, Alberta, Canada ) [C3]
and was widely utilised in developing the Welsh Service Directive and
Commissioning Directive (2008) on chronic non-malignant pain — a key
strategic document in establishing and developing pain services in Welsh
hospitals. Thus Phillips'
".....contribution was invaluable in helping to ensure that we were
able to outline an approach for Wales which was evidence based taking
full account of both the clinical and cost effective impacts on
improving the management of this across Wales. This was pioneering work
at the time with Wales the first country in the UK to produce such
policy guidance" [C3]
A written response to an Assembly question given by the Welsh Minister on
9th July 2013 indicated that Health Boards had achieved 87% compliance
with the actions within the above document to establish more robust
community pain services linked with secondary care to support more
effective pain management.
Impact 4. Increasing the awareness within the political community of
the societal burden of pain
Research findings [R1-R6] have also been used to raise political
awareness of pain and its management. Presentations at the Parliamentary
Health Group (House of Commons, 2003 and 2004) were instrumental in the
formation of the Chronic Pain Coalition — a forum established in 2006 to
unite patients, professionals and parliamentarians in a mission to develop
an improved strategy for the prevention, treatment and management of
chronic pain and its associated conditions.
"Through his research into the socio-economic impact of pain and its
treatment modalities, he is acknowledged nationally as the leading
health economist in our speciality area. His detailed research work has
been instrumental in establishing pain as an important long term
condition, with profound impact on patients' quality of life, NHS
workload and costs, as well as wider societal costs through loss of
productivity and benefits/pensions" (Past President, British Pain
Society) [C4].
Phillips also presented sessions at a Europe against Pain Conference
(Brussels 2010) and Societal Impact of Pain Conference (Brussels 2011) -
to increase awareness among politicians and policy makers at a European
level of the impact of pain on society and the need for concerted action
to alleviate the impact on individuals and societies. A testimonial to the
impact of the work from one of the main sponsors of the initiative is
provided below:
"The concept of `Societal Impact of Pain' can be traced to your
analysis, presentations and publications and led me to invite the
European Federation of IASP Chapters board to enter a dialogue in
Brussels with policy makers on the prioritization of pain management in
the health care system. The roadmap for action on pain management that
emerged from the series of meetings in Brussels was inspired by your
publications and you have fuelled the discussion in a far wider sphere
of influence than the UK" (Head of Political Affairs, Grünenthal
GmbH — major pharmaceutical company in pain management) [C4].
The methods developed in assessing the full range of costs and benefits
(including the adverse events) of pain management have been subsequently
applied, with funding from a number of sources, to other conditions and
healthcare interventions, including cancer, dentistry, multiple sclerosis,
public health and wound management, impacting on policy, practice and
therapeutic developments in each of these areas.
Sources to corroborate the impact
C1. Stimulating pharmaceutical companies to develop new pain
therapeutic agents
- Moore RA, Phillips CJ, et al. Economic Evaluation of Etoricoxib versus
Non-Selective NSAIDs in the Treatment of Osteoarthritis and Rheumatoid
Arthritis Patients in the UK. Pharmacoeconomics, 2004; 22: 643-60
- Moore RA, Phillips CJ, Pellissier J, Kong S. Health economic
comparisons of rofecoxib versus conventional nonsteroidal
antiinflammatory drugs for osteoarthritis in the United Kingdom. Journal
of Medical Economics, 2001: 4:1-17.
- quote from Head of Economics and Statistics, Merck Corporation
C2 Re-focusing patient management
C3 Enhancing the status of pain and its management in the
development of health policy and practice
C4 Increasing the awareness within the political community of the
societal burden of pain