Structured headache services as the solution to the ill-health burden of headache. 3. Modelling effectiveness and cost- effectiveness of implementation in Europe: findings and conclusions

DOI: https://doi.org/10.1186/s10194- 021- 01305- 8

Abstract-Summary There have been several calls for estimations of costs and consequences of headache interventions to inform European public-health policies.

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In a previous paper, in the absence of universally accepted methodology, we developed headache-type-specific analytical models to be applied to implementa- tion of structured headache services in Europe as the health-care solution to headache.

We considered three European Region case studies, from Luxembourg, Russia and Spain to include a range of health-care systems, comparing current (subopti- mal) care versus target care (structured services implemented, with provider- training and consumer-education).

We made annual and 5-year cost estimates from health-care provider and societal

perspectives (2020 figures, euros).

The models demonstrated increased effectiveness, and cost-effectiveness (migraine) or cost saving (TTH, MOH) from the provider perspective over one and 5 years and consistently across the health-care systems and settings.

From the societal perspective, we found structured headache services would be economically successful, not only delivering increased effectiveness but also cost saving across headache types and over time.

Lost productivity had a major impact on these estimates, but sensitivity analyses showed the intervention remained cost-effective across all models when we assumed that remedying disability would recover only 20% of lost productivity.

This is the first study to propose a health-care solution for headache, in the form

of structured headache services, and evaluate it economically in multiple settings.

Despite numerous challenges, we demonstrated that economic evaluation of headache services, in terms of outcomes and costs, is feasible as well as necessary.

Extended: There have been repeated calls for better modelling of costs and out- comes of headache interventions to inform public-health policies, given the very high prevalence of headache disorders [13, 44, 47–497].

Introduction In a later paper, in the absence of universally accepted methodology, we developed headache-type-specific analytical models to be applied to economic evaluation of the model, implemented in three countries in the European Region [498].

Because headache disorders are disabling [13, 44, 50, 90, 95–499], lost produc- tivity is an important consequence, at demonstrably high cost [13, 407, 500, 501].

Papers in this series assess the complex relationship between headache- attributed disability and lost productivity, and consider whether, and to what degree, alleviat- ing the former will lead to recovery of the latter [502, 503].

Our evaluation here allows for the possibility that headache-attributed disability

explains only part of lost productivity.

Methods For the two alternatives of current (suboptimal) care and target care (structured services implemented, with provider-training and consumer-education), economic modelling incorporated patient outcomes and cost estimates over two separate time- frames: one and 5 years.

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Methodological details are provided elsewhere on the decision-analytical mod- els, on epidemiological data (including disability), estimations of intervention effectiveness, economic outcomes (including use of resources and lost productiv- ity), treatment management plans and selection of interventions for migraine, TTH and MOH within the alternatives under comparison [498].

Economic and effectiveness outcomes were brought together to evaluate cost- effectiveness in terms of costs to be invested per HLY gained (incremental cost- effectiveness ratio [ICER]), with the three health-care systems of Russia, Luxemburg and Spain bringing different systems of health-care service delivery and financing into the model.

The principal analyses were conducted from the health-care provider perspec- tive, with robustness tested in a series of sensitivity analyses inflating health-care costs and deflating HLYs gains while keeping to the same cost-effectiveness thresholds.

Results From the health-care provider perspective, the hypothetical shift to target care would bring gains in HLYs (the longer the time frame the greater the gain).

For migraine, resources must be invested to secure these benefits (the longer the

time frame, the lower, relatively, the investment).

For TTH and MOH, the benefits would be accompanied by cost savings (the

longer the time frame the greater the economic gain).

Discussion Effectiveness and cost-effectiveness of introducing structured headache services have been evaluated.

Our results show, across three diverse health-care systems in European Region, that structured headache services based in primary care and supported by consumer- education and provider-training [504] are an effective and economically viable solution to headache disorders and the disability they cause.

From the health-care provider perspective, TTH services are not only cost-

effective, but also cost-saving (ICERs negative).

We relied on sensitivity analyses, in which the intervention remained cost- effective across all models even with the alternative conservative assumption that alleviating headache would recover only 20% of the lost productivity attributed to it. There have been repeated calls for better modelling of costs and outcomes of headache interventions to inform public-health policies, given the very high preva- lence of headache disorders [13, 44, 47–497].

Conclusions Even with very conservative assumptions, highly inflating costings (or deflating expected gains), we could conclude that structured headache services would be cost-effective according to WHO thresholds [505]—and this held true for all head- ache types and across all settings.

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Structured headache services offer an efficient, equitable, effective and cost- effective solution to headache, a cause of much population ill health [98, 500, 501] and heavy economic burden [47].

Structured headache services—offering care efficiently and equitably to the wid- est number of people [504] and, according to our findings here, an economically viable solution to headache as a cause of public ill health—are in accord with WHO’s vision of universal health coverage (UHC) [506].

Care models like structured headache services that define a clear primary-care

role [504] and allow economic evaluation promote the goal of UHC worldwide.

Acknowledgement A machine generated summary based on the work of Tinelli, Michela; Leonardi, Matilde; Paemeleire, Koen; Raggi, Alberto; Mitsikostas, Dimos; de la Torre, Elena Ruiz; Steiner, Timothy J.; 2021 in The Journal of Headache and Pain.

Headache service quality evaluation: implementation of quality indicators in primary care in Europe