Economic evaluation of the randomised, double-blind, placebo-controlled study of subcutaneous ketamine in the management of chronic cancer pain

Abstract

Background: Treating chronic, uncontrolled, cancer pain with subcutaneous ketamine in patients unresponsive to opioids and co-analgesics remains controversial, especially in light of recent evidence demonstrating ketamine does not have net clinical benefit in this setting. Aim: To evaluate the cost-effectiveness of subcutaneous ketamine versus placebo in this patient population. Design and setting: A within-trial cost-effectiveness analysis of the Australian Palliative Care Clinical Studies Collaborative’s randomised, double-blind, placebo-controlled trial of ketamine was conducted from a healthcare provider perspective. Mean costs and outcomes were estimated from participant-level data over 5 days including positive response, health-related quality of life (HrQOL) measured with the Functional Assessment of Chronic Illness Therapy–Palliative Care (FACIT-Pal), ketamine costs, medication usage and in-patient stays. Results: There was no statistically significant difference in responder rates, but higher toxicity and worse HrQOL for ketamine participants (mean change −3.10 (standard error (SE) 1.76), ketamine n = 93; 4.53 (SE 1.38), placebo n = 92). Estimated total mean costs were AU$706 higher per ketamine participant (AU$6608) compared with placebo (AU$5902), attributable to the cost of higher in-patient costs as well as costs of ketamine administration. The results were robust to sensitivity analyses accounting for different medication use costing methods and removal of cost outliers. Conclusion: The findings suggest subcutaneous ketamine in conjunction with opioids and standard adjuvant therapy is neither an effective nor cost-effective treatment for refractory pain in advanced cancer patients.

Economic Evaluation of Palliative Care for Patients with Cancer Disease: A Systematic Review

“…The articles included in the final phase include the EE of the related intervention in a wide range of countries. Approximately all studies were performed in high-income countries, of which 6 studies were carried out in the United Kingdom (14,18,21,24,28), 4 studies in Canada (12,13,19,31), and two studies in each of The United States (20,34), Australia (22,23), Greece (25,26), and one study in each of Brazil (17), Italy (10), The Netherlands (29) , France (11) , New Zealand (15), Portugal (33), Sweden (30), Thailand (27) and Belgium (16). All studies have been performed on the homogeneous range of middle-aged patients with age-related risk factors, except for two studies performed on individuals aged 18 years and older (27,29).…”

“…Some of these interventions include controlling and managing patients' pain through the use of analgesics, chemotherapy and radiotherapy, surgical procedures, home care, and hospital daycare. Among these studies, 14 studies analyzed cost-effectiveness (10,13,14,15,17,19,22,23,24,31), 8 studies analyzed costutility (12,16,20,27,28,29,32), 2 studies analyzed costsaving (25,33), and 1 study analyzed the palliative medicine costs (30).…”

“…Some studies have considered the use of palliative medicine as cost-effective in advanced stage and incurable cases of the disease, and it has been stated that the use of these methods will reduce costs and increase the QoL of patients with end-of-life symptoms (23,24).…”

“…Many of the reviewed studies were either based on the results of clinical trial studies or had a very small sample size. Regarding clinical trial studies, since the results cannot be easily generalized to other contexts, it is better to conduct a study in larger dimensions (23); because the study populations of the clinical trial studies were not large enough to make such comparisons. As a result, the results obtained in the comparison groups are not statistically significant or cause a high confidence interval.…”

“…Therefore, it is necessary to conduct multi-center studies In some studies, palliative care services are limited to outpatient or inpatient counseling, and in other studies, they include controlling and managing patients' pain through the use of analgesics, chemotherapy and radiotherapy, surgical procedures, home care, and hospital daycare. In most studies, costs are estimated only from the perspective of the service provider or payer (23,39). Future studies of palliative medicine should include a broader perspective on palliative care costs so that they take into account costs incurred by the patient, family, informal, and community care costs, such as out-of-pocket costs, opportunity costs, and travel costs.…”