Economic Evaluations of Educational, Physical, and Psychological Treatments for Fibromyalgia

A Systematic Review With Meta-Analysis

Cristina Maria Nunes Cabral; Gisela Cristiane Miyamoto; Katherinne Ferro Moura Franco; Judith Ekkina Bosmans


Pain. 2021;162(9):2331-2345. 

In This Article

Abstract and Introduction


Nonpharmacological interventions are recommended for the treatment of fibromyalgia, but there is a lack of knowledge about the cost-effectiveness of these interventions. The aim of this study was to systematically review economic evaluations of educational, physical, and psychological interventions for the treatment of fibromyalgia. The search was performed in PUBMED, EMBASE, CINAHL, Cochrane Library, Physiotherapy Evidence Database, PsycINFO, EconLit, National Health Service Economic Evaluation Database, and Health Technology Assessment. Economic evaluations of educational, physical, and psychological interventions for adult patients with fibromyalgia were included. Primary outcomes were healthcare and societal costs, and quality-adjusted life-years, and secondary outcomes were any disease-specific clinical outcome. Costs and effects were pooled in a meta-analysis, when possible. Eleven studies were included, of which 7 compared a psychological intervention with another intervention or usual care/control. Over a 6-month time horizon, healthcare and societal costs of the psychological intervention were significantly lower than usual care (mean difference: $−2087, 95% confidence interval [CI]: −3061 to −1112; mean difference: $−2411, 95% CI: −3582 to −1240, respectively), and healthcare costs were significantly lower for the psychological intervention compared with a pharmacological intervention (mean difference: $−1443, 95% CI: −2165 to −721). Over a 12-month time horizon, healthcare costs for the psychological intervention were significantly lower than for usual care (mean difference: $−538, 95% CI: −917 to −158). Incremental cost-effectiveness ratios for quality-adjusted life-years and impact of fibromyalgia showed that the psychological intervention was cost-effective compared with other interventions and control conditions. There is a need of more economic evaluations conducted alongside randomized controlled trials with interventions recommended for the treatment of fibromyalgia, such as physical exercise.


Fibromyalgia is a chronic widespread pain, often accompanied by physical exhaustion, and sleep and cognitive disturbances.[12] Patients with fibromyalgia report a wide range of comorbid conditions, such as functional somatic syndromes, anxiety and depressive symptoms, and rheumatic diseases.[12] The overall prevalence of fibromyalgia in the general population ranges between 1.8%[15] and 2.7%.[39] Treatment should focus first on nonpharmacological modalities, such as exercise therapy and psychological and multicomponent therapies, including education.[12,29,42] Pharmacological therapy is recommended only if there is a lack of effect of nonpharmacological treatments[29] because pharmacological interventions have several potential adverse effects and unsustainable effects.[5,12]

Fibromyalgia carries a significant economic burden for patients and society.[23] Costs related to fibromyalgia are substantial, with a large share resulting from lost productivity costs.[20] Moreover, healthcare and lost productivity costs of patients with fibromyalgia are higher than those of matched peers and similar to patients with other chronic diseases, such as rheumatoid arthritis.[12] Considering the scarcity of resources available for health care worldwide, policy makers need to make choices about which treatments to reimburse and which ones not, to ensure that treatments provide value for money for patients and society.[12] Such decisions are often made using information from economic evaluations. Economic evaluations compare the differences in costs and effects of 2 or more interventions.[47] Within the field of musculoskeletal and painful disorders, cost-effectiveness (effects are expressed as disease-specific outcomes) and cost-utility (effects are expressed as quality-adjusted life-years [QALYs]), studies are the most commonly encountered types of economic evaluations.[30,46]

There is a lack of knowledge about the cost-effectiveness of educational, physical, and psychological interventions for patients with fibromyalgia,[43] and doubts exist about the methodological quality of existing studies. Recently, a systematic review[53] on the cost-effectiveness of interventions for functional somatic syndromes including fibromyalgia was published. However, only the available information in the included studies was presented without performing a meta-analysis, and no effort was made to calculate incremental cost-effectiveness ratios (ICERs) for studies that did not present ICERs. However, more complete reporting of costs, effects, and ICERs will result in important information for patients, clinicians, and decision makers. Therefore, the aim of this study was to systematically review economic evaluations of educational, physical, and psychological interventions in the treatment of patients with fibromyalgia, while also assessing the quality of the studies and performing a meta-analysis of the results when possible.