Cost-effectiveness of an extended-role [GP] clinic for [PPS]: results from the Multiple Symptoms Study 3 (MSS3)... 2024 Deary, Burton et al

Andy

Andy

Retired committee member
Full title: Cost-effectiveness of an extended-role general practitioner clinic for persistent physical symptoms: results from the Multiple Symptoms Study 3 (MSS3) pragmatic randomised controlled trial

Highlights
  • Persistent physical symptoms is a common problem, impacting patients’ quality of life with substantial costs to health services and society.
  • This is the first economic evaluation to assess the value added by an extended-role GP symptoms clinic (SC) compared to UC in primary care.
  • SC+UC has the potential to be cost-effective compared to UC alone in a 12 month time horizon, yielding increased QALYs at reasonable cost using a threshold £20 000 per QALY gained.
ABSTRACT

Objectives
To evaluate the cost-effectiveness of an extended-role general practitioner (GP) symptoms clinic (SC), added to usual care (UC) for patients with multiple persistent physical symptoms (sometimes known as "medically unexplained symptoms").

Methods
A 52-week within-trial cost-utility analysis of a pragmatic multicentre randomised controlled trial comparing SC+UC (n=178) against UC alone (n=176), conducted from the primary perspective of the UK National Health Service (NHS) and personal and social services (PSS). Base-case quality-adjusted life-years (QALYs) were measured using EQ-5D-5L. Missing data were imputed using multiple imputation (MI). Cost-effectiveness results were presented as incremental cost-effectiveness ratios (ICERs) and incremental net monetary benefits (INMBs). Uncertainty was explored using cost-effectiveness acceptability curves (using 1000 non-parametric bootstrapped samples) and sensitivity analysis (including societal costs, using SF-6D and capability ICECAP-A outcomes to estimate QALYs and years of full capability (YFC) respectively, varying intervention costs, missing data mechanism assumptions).

Results
Multiple imputation analysis showed that, compared to UC alone, SC+UC was more expensive [(adjusted mean cost difference: 704; 95% CI:£605, £807)] and more effective [(adjusted mean QALY difference: 0.0447 (95% CI:0.0067, 0.0826)] yielding an ICER of £15,765/QALY, INMB of £189.22 (95% CI:−£573.62, £948.28) and a 69% probability of the SC+UC intervention arm being cost-effective at a threshold of £20000 per QALY. Results were robust to most sensitivity analyses, but sensitive to missing data assumptions (2 of the 8 scenarios investigated), SF-6D and ICECAP-A quality of life outcomes.

Conclusions
A Symptoms Clinic is likely to be a potentially cost-effective treatment for patients with persistent physical symptoms.

Open access, https://www.sciencedirect.com/science/article/pii/S1098301524066452
 
Likely to potentially...improve quality of life (debatably measured) and somewhat save some money somewhere but not much money and the money that was maybe saved in secondary care (which is all that really matters to NHSE and ICSs) was probably due to chance anyway.
 
The aim of the intervention is to recognise and validate the experience of the patient, work with them to reach an explanation for their persistent physical symptoms which makes sense24-26 and use this to agree actions to manage symptoms or limit their impact.
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So the same old nothing. The idea that this is effective, even cost-effective, is laughable. But almost no one seems bothered by that.
Participants were potentially eligible if they had at least one symptom syndrome code within GP electronic records, 2 or more specialist referrals in the preceding 3 years and multiple physical symptoms (PHQ-15 between 10 and 20). They were excluded, however, if they had diseases likely to cause multiple symptoms or disability
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"Illness without disease". As they explain early on, this is what they perceive as 'somatization'. So, the exact same old nonsense with the same intent and purpose, the same methods and models.

Literally the same old nonsense, basically in the form of a GP consult, but longer, then offering 'explanations' about things they don't understand:
The SC intervention is a sequence of medical consultations which aim to elicit a detailed clinical history, ensure that the patient’s experience is fully heard and validated, to offer rational explanations for symptoms and to assist the patient to develop ways of managing their symptoms. It harnesses GPs’ skills as clinical generalists across biomedical and psychosocial domains and as interpretive practitioners.30 The treatment model can be summarized under four headings: Recognition, Explanation, Action and Learning (REAL): content, teaching and delivery of this are described elsewhere.27 The SC consists of up to four consultations with an erGP over 6-12 weeks. These comprise an initial long consultation (approximately 50 minutes) followed by up to three medium length consultations (15-20 minutes); erGPs had flexibility to increase the gaps between sessions if required. Clinic attenders received a SMS reminder the day before each SC appointment and were offered a further appointment if they missed an appointment. Consultations before March 2020 were delivered face-to-face. Subsequently consultations took place via video consultation or telephone
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And as is tradition, the difference is not statistically significant, but they still think that even though it's more expensive, that it must be cost-effective and recommend it:
Compared with UC alone, a higher unadjusted QALY difference was observed for the SC+UC intervention group (0.0533), but the difference was not statistically significant
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Mathematicians and physicists work with imaginary numbers, but physicians deal with really imaginary numbers. Well, that and lies, damned lies, and statistical analyses of really imaginary numbers.

And what is a clinic, if not a 'symptoms clinic'? Of course they mean symptoms with no physical cause they understand, which they prefer to think of as 'somatization'. Hey, this approach has failed for decades, maybe this time doing it exactly the same old way it will work*.

And of course this is a randomized trial but they call it randomized controlled because why not? It's not as if anyone cares about stuff like this anymore.

(* It won't)
 
rvallee said:
So the same old nothing. The idea that this is effective, even cost-effective, is laughable. But almost no one seems bothered by that.

"Illness without disease". As they explain early on, this is what they perceive as 'somatization'. So, the exact same old nonsense with the same intent and purpose, the same methods and models.

Literally the same old nonsense, basically in the form of a GP consult, but longer, then offering 'explanations' about things they don't understand:

And as is tradition, the difference is not statistically significant, but they still think that even though it's more expensive, that it must be cost-effective and recommend it:

Mathematicians and physicists work with imaginary numbers, but physicians deal with really imaginary numbers. Well, that and lies, damned lies, and statistical analyses of really imaginary numbers.

And what is a clinic, if not a 'symptoms clinic'? Of course they mean symptoms with no physical cause they understand, which they prefer to think of as 'somatization'. Hey, this approach has failed for decades, maybe this time doing it exactly the same old way it will work*.

And of course this is a randomized trial but they call it randomized controlled because why not? It's not as if anyone cares about stuff like this anymore.

(* It won't)
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Indeed

I saw this and thought of the phrase ‘playing the system’

and of course it’s these HCPs who are wanting to profit by knowing where the sales pitches are (not the patients getting immorally screwed over by this)

it never saves money

always makes patients worse and leads to numbers increasing and then the cheek is they use that failure as an excuse to say they need more money to do the same crap ‘because the issue is growing’

someone needs to get wise and regulate this pathway to conning ICBs full of busy people being smarmed and the tick boxes being played in a way reminiscent of the days of drug reps when they were allowed to give gifts or kickbacks or whatever it was

how are these people any different to that other than they are playing the money train from the inside?
 
Abstract said:
SC+UC was more expensive [(adjusted mean cost difference: 704; 95% CI:£605, £807)] and more effective [(adjusted mean QALY difference: 0.0447 (95% CI:0.0067, 0.0826)]
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A QALY is a year of life lived in perfect health. The mean QALY difference was 0.0447. I make that 16 days. It is set up to be a one-off intervention. And, as @rvallee says, actually as the paper says, the difference was not statistically significant. So, a tiny absolute difference that probably is just a statistical blip. No real difference.

Abstract said:
but sensitive to missing data assumptions
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And, on top of that, it sounds as though they had a substantial missing data problem. When your reported benefit is indistinguishable from zero, and you didn't count the participants whose life was probably made worse by your intervention, and the intervention costs money, where is the benefit? Certainly not with the health system or the patients.

Imagine if they actually counted the QALY's of the people who suffered a negative effect from their intervention, people who lost trust in the medical system, people who lost self-esteem maybe even committed suicide out of despair, people who subsequently didn't go to the doctor with a treatable condition, people who made themselves worse by pushing through trying to achieve their agreed goals... These things are not an exaggeration.

The treatment model can be summarized under four headings: Recognition, Explanation, Action and Learning (REAL)
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Ha, REAL, that ironic, given the made up models the GPs were trained to provide and the appalling mis-representation of this trial as some sort of success.
 
Haveyoutriedyoga said:
What a minute, this was done during Covid, and they didn’t factor that into the analysis of subsequent resource use.
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It's mentioned in the text but they mostly shrug it off as "good enough", even though given that those were a small number of assigned GPs I don't think this excuse holds up well (6 GPs were involved, come on) but I doubt it would have changed anything and it's not as if any of this matters, trials like this always write themselves from the conclusion out. They are funded not to provide information but to make evidence up for that conclusion:
Finally, the consequences of the pandemic for access to healthcare premises affected our method of data collection. Our original plan was to extract healthcare resource use from GP records, with participant self-report as a back-up. However this became extremely difficult due to access to GP surgeries during the pandemic and so self-report data has been used in all analyses. This affected our collection of information on prescribed information which was originally intended to be extracted from the GP record system. Thus the medication section of the self-report form was kept fairly brief to minimise participant burden. However medication use was not an important outcome in this study as there are no guideline-indicated medicines recommended for heterogeneous persistent physical symptoms.
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Hutan said:
The mean QALY difference was 0.0447. I make that 16 days.
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I didn't bother calculating what it means but when you put it like that it's not just completely laughable, as you say this is about years/days of perfect health so it's not even valid since those are healthy years equivalent. It literally means nothing. This is at least as completely delusional as homeopathy, probably even more.
 
This seems to be so similar I didn't think it warranted a separate thread.

Multiple Symptoms Study 3 An extended-role general practitioner clinic for patients with persistent physical symptoms: a Randomised Controlled Trial, 2025, Burton et al

Abstract

People with multiple and persistent physical symptoms have impaired quality of life and poor experiences of health care. We aimed to evaluate the effectiveness of a community-based Symptoms Clinic intervention in people with multiple and persistent physical symptoms.Pragmatic multicentre individually randomised parallel group clinical trial.

Participants: Recruitment was between December 2018 and December 2021 in four areas of the UK. Eligibility was based on electronic health records, healthcare use and multiple physical symptoms (PHQ-15 between 10 and 20) which were not due to other medical conditions. Intervention delivery changed from face to face to online in 2020 in response to the pandemic.

Interventions: Participants were randomised to receive the Symptoms Clinic plus usual care (intervention) or usual care alone (control). The Symptoms Clinic is a short-term extended medical consultation-based intervention delivered over approximately 8 weeks. Objective: To test the clinical and cost-effectiveness of an extended-role general practitioner 'Symptoms Clinic' for people with persistent physical symptoms.

Outcome: The primary outcome measure was the PHQ-15 at 52 weeks post randomisation. Randomisation: Participants were randomised 1 : 1 using a centralised web-based system, stratified by study centre with random permuted blocks of varying sizes.

Masking: It was not possible to mask participants to their allocation. Outcome assessors who handled patient-reported questionnaires were masked to allocation.Numbers randomised: 354 participants were randomised into the trial: 176 to the usual care group and 178 to the intervention group. Numbers analysed: 132 participants in the usual care group and 144 participants in the intervention group were included in the analysis representing 77.8% retention.

Outcome: Mean (SD) PHQ-15 at baseline was 14.9 (3.0) in the control group and 15.0 (2.9) in the intervention group. At 52 weeks it was 14.1 (3.7) in the control group and 12.2 (4.5) in the intervention group. The between-group difference, adjusted for age, sex, baseline PHQ-15 and clinician effect was -1.82 (95% CI -2.67 to -0.97; p < 0.001) favouring the intervention.

Harms: There were no significant between-group differences in the proportions of patients experiencing non-serious (-0.03, 95% CI -0.11 to 0.05) or serious (0.02, 95% CI -0.02 to 0.07) adverse events. All serious adverse events were deemed unrelated to trial interventions. Economic evaluation: Cost-effectiveness analysis indicated an incremental cost-effectiveness ratio of £15,751/QALY.

Process evaluation: The intervention was delivered with high fidelity and was acceptable to patients. The intervention appeared to act through the hypothesised mechanism of explanation as a bridge from uncertainty about the cause to actions to manage symptoms.

Limitations and further research: The intervention was delivered by a small number of GPs in long consultations. Further research should examine wider implementation and how to integrate elements of the intervention into shorter consultations.

Conclusions: The Symptoms Clinic delivered by specially trained GPs leads to a clinically meaningful improvement in physical symptoms at 52 weeks and is likely to be a cost-effective addition to current care.

Open access
 
The other similar paper said:
The intervention appeared to act through the hypothesised mechanism of explanation as a bridge from uncertainty about the cause to actions to manage symptoms.
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"Imagine a world"-based medicine isn't even adequate for this tripe, this is just insulting people's intelligence with marketing buzzwords. I have no idea what role journals and reviewers even play if they find this mindless word salad worth publishing.

But, yeah, those are basically identical studies. Damn this grift is too easy.
The paper said:
an extended-role general practitioner 'Symptoms Clinic' for people with persistent physical symptoms
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So, a clinic. This just describes most of what a regular GP clinic does, and the most common thing they see: people with symptoms.
 
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