Abstract
In addition to its high frequency and relevant individual and social impact, chronic pain (CP) has been shown to be a major contributor to increased healthcare utilisation, reduced labour productivity, and consequently large direct and indirect costs. In the context of a larger nationwide study, we aimed to assess the total annual direct and indirect costs associated with CP in Portugal. A population-based study was conducted in a representative sample of the Portuguese adult population. The 5,094 participants were selected using random digit dialling and contacted by computer-assisted telephone interviews. Questionnaires included the brief pain inventory and pain disability index. Estimates were adequately weighted for the population. From all CP subjects identified, a subsample (n = 562) accepted to participate in this economic study. Mean total annualised costs per CP subject of €1,883.30 were observed, amounting to €4,611.69 million nationally, with 42.7 % direct and 57.3 % indirect costs, and corresponding to 2.71 % of the Portuguese annual GDP in 2010. Only socio-demographic variables were significantly and independently associated with CP costs, and not CP severity, raising the possibility of existing inequalities in the distribution of healthcare in Portugal. The high economic impact of CP in Portugal was comprehensively demonstrated. Given the high indirect costs observed, restricting healthcare services is not a rational response to these high societal costs; instead improving the quality of CP prevention and management is recommended.
Similar content being viewed by others
References
Maniadakis, N., Gray, A.: The economic burden of back pain in the UK. Pain 84(1), 95–103 (2000)
Thomsen, A.B., Sorensen, J., Sjogren, P., Eriksen, J.: Chronic non-malignant pain patients and health economic consequences. Eur J Pain 6(5), 341–352 (2002)
Turk, D.C.: Chronic non-malignant pain patients and health economic consequences. Eur J Pain 6(5), 353–355 (2002). doi:10.1016/S1090-3801(02)00024-1
Goldberg, D.S., McGee, S.J.: Pain as a global public health priority. BMC Public Health 11, 770 (2011). doi:10.1186/1471-2458-11-770
Breivik, H.: A major challenge for a generous welfare system: a heavy socio-economic burden of chronic pain conditions in Sweden–and how to meet this challenge. Eur J Pain 16(2), 167–169 (2012). doi:10.1002/j.1532-2149.2011.00025.x
Juniper, M., Le, T.K., Mladsi, D.: The epidemiology, economic burden, and pharmacological treatment of chronic low back pain in France, Germany, Italy, Spain and the UK: a literature-based review. Expert Opin Pharmacother 10(16), 2581–2592 (2009). doi:10.1517/14656560903304063
Leadley, R.M., Armstrong, N., Lee, Y.C., Allen, A., Kleijnen, J.: Chronic diseases in the European Union: the prevalence and health cost implications of chronic pain. J Pain Palliat care Pharmacother 26(4), 310–325 (2012). doi:10.3109/15360288.2012.736933
Maetzel, A., Li, L.: The economic burden of low back pain: a review of studies published between 1996 and 2001. Best Pract Res Clin Rheumatol 16(1), 23–30 (2002). doi:10.1053/berh.2001.0204
Nachemson, A.: Chronic pain–the end of the welfare state? Qual Life Res 3(Suppl 1), S11–S17 (1994)
Phillips, C.J.: Economic burden of chronic pain. Expert Rev Pharmacoecon Outcomes Res 6(5), 591–601 (2006). doi:10.1586/14737167.6.5.591
Fit for work Europe website: fit for work? Musculoskeletal disorders in the European workforce. Accessed from www.fitforworkeurope.eu last accessed in June 2013. (2009)
Engel, C.C., von Korff, M., Katon, W.J.: Back pain in primary care: predictors of high health-care costs. Pain 65(2–3), 197–204 (1996)
Mehra, M., Hill, K., Nicholl, D., Schadrack, J.: The burden of chronic low back pain with and without a neuropathic component: a healthcare resource use and cost analysis. J Med Econ 15(2), 245–252 (2012). doi:10.3111/13696998.2011.642090
van Tulder, M.W., Koes, B.W., Bouter, L.M.: A cost-of-illness study of back pain in The Netherlands. Pain 62(2), 233–240 (1995)
Depont, F., Hunsche, E., Abouelfath, A., Diatta, T., Addra, I., Grelaud, A., Lagnaoui, R., Molimard, M., Moore, N.: Medical and non-medical direct costs of chronic low back pain in patients consulting primary care physicians in France. Fundam Clin Pharmacol 24(1), 101–108 (2010). doi:10.1111/j.1472-8206.2009.00730.x
Gannon, B., Finn, D.P., O’Gorman, D., Ruane, N., McGuire, B.E.: The cost of chronic pain: an analysis of a regional pain management service in Ireland. Pain Med (2013). doi:10.1111/pme.12202
Garattini, L., Koleva, D., Motterlini, N., Cornago, D.: Medical costs of chronic musculoskeletal pain in Italy. Clin Drug Investig 27(2), 139–148 (2007)
Guerriere, D.N., Choiniere, M., Dion, D., Peng, P., Stafford-Coyte, E., Zagorski, B., Banner, R., Barton, P.M., Boulanger, A., Clark, A.J., Gordon, A.S., Guertin, M.C., Intrater, H.M., Lefort, S.M., Lynch, M.E., Moulin, D.E., Ong-Lam, M., Racine, M., Rashiq, S., Shir, Y., Taenzer, P., Ware, M.: The Canadian STOP-PAIN project—Part 2: what is the cost of pain for patients on waitlists of multidisciplinary pain treatment facilities? Can J Anaesth 57(6), 549–558 (2010). doi:10.1007/s12630-010-9306-4
Kronborg, C., Handberg, G., Axelsen, F.: Health care costs, work productivity and activity impairment in non-malignant chronic pain patients. Eur J Health Econ 10(1), 5–13 (2009). doi:10.1007/s10198-008-0096-3
Hutubessy, R.C., van Tulder, M.W., Vondeling, H., Bouter, L.M.: Indirect costs of back pain in the Netherlands: a comparison of the human capital method with the friction cost method. Pain 80(1–2), 201–207 (1999)
Gouveia, M., Augusto, M.: Custos indirectos da dor crónica em Portugal (Indirect costs of chronic pain). Rev Port Saúde Pública 2(29), 100–107 (2011)
Raftery, M.N., Ryan, P., Normand, C., Murphy, A.W., de la Harpe, D., McGuire, B.E.: The economic cost of chronic noncancer pain in Ireland: results from the PRIME study, part 2. J Pain 13(2), 139–145 (2012). doi:10.1016/j.jpain.2011.10.004
Gustavsson, A., Bjorkman, J., Ljungcrantz, C., Rhodin, A., Rivano-Fischer, M., Sjolund, K.F., Mannheimer, C.: Socio-economic burden of patients with a diagnosis related to chronic pain–register data of 840,000 Swedish patients. Eur J Pain 16(2), 289–299 (2012). doi:10.1016/j.ejpain.2011.07.006
Azevedo, L.F., Costa-Pereira, A., Mendonça, L., Dias, CC., Castro-Lopes, J.M.: Epidemiology of chronic pain: a population-based nationwide study on its prevalence, characteristics and associated disability in Portugal. J. Pain. 13(8):773–783 (2012). doi:10.1016/j.jpain.2012.05.012
Azevedo, L.F., Costa-Pereira, A., Mendonça, L., Dias, CC., Castro-Lopes, J.M.: Chronic pain and health services utilization: is there overuse of diagnostic tests and inequalities in nonpharmacologic treatment methods utilization? Med. Care. 51(10):859–869 (2013). doi:10.1097/MLR.0b013e3182a53e4e
IASP: subcommittee on taxonomy. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Pain. p 226 (1986)
Drummond, M.F., Sculpher, M.J., Torrance, G.W., O’Brien, B.J., Stoddart, G.L.: Methods for the economic evaluation of health care programmes, 3rd edn. Oxford University Press, New York (2005)
Administração Central do Sistema de Saúde (ACSS): Base de Dados dos Elementos Analíticos (BDEA) do Sistema Nacional de Saúde. Accessed from http://www.acss.min-saude.pt/Publicações/SNS/InformaçãodeGestão/tabid/124/language/pt-PT/Default.aspx [last accessed in June 2013] (2010). Accessed June 2010
Ministério da Saúde [Portuguese Health Ministery]: DR série, Portaria no 132/2009 de 30 de Janeiro—Regulamento das tabelas de preços das instituições do SNS. Accessed from http://www.portaldasaude.pt/NR/rdonlyres/7A929657-9E9D-4FCC-85E1-A5DC40E64414/0/Portaria132_2009Regulamentopre%C3%A7osSNS.pdf [last accessed in June 2013]. (2009)
INFARMED: Infomed—Base de dados de medicamentos [Infomed—National Medicines Database]. Accessed from http://www.infarmed.pt/infomed/inicio.php [last accessed in June 2013] (2010). Accessed June 2010
The World Bank—PPP conversion factors. http://data.worldbank.org/indicator/PA.NUS.PPP. Accessed Oct 2014
INE: Quadro - Rendimento médio mensal líquido da população empregada por Profissão, em 2010. Accessed from http://www.ine.pt [last accessed in June 2013] (2010)
Briggs, A.H., O’Brien, B.J., Blackhouse, G.: Thinking outside the box: recent advances in the analysis and presentation of uncertainty in cost-effectiveness studies. Annu Rev Public Health 23, 377–401 (2002)
Briggs, A.H., Wonderling, D.E., Mooney, C.Z.: Pulling cost-effectiveness analysis up by its bootstraps: a non-parametric approach to confidence interval estimation. Health Econ 6(4), 327–340 (1997)
R Foundation for Statistical Computing R: a language and environment for statistical computing [program]. 3.0.1 version. In (2013)
INE: Instituto Nacional de Estatística. Statistics Portugal. Accessed from http://www.ine.pt [last accessed in June 2013]. (2010)
Barber, J., Thompson, S.: Multiple regression of cost data: use of generalised linear models. J Health Serv Res Policy 9(4), 197–204 (2004). doi:10.1258/1355819042250249
Basu, A., Manning, W.G.: Issues for the next generation of health care cost analyses. Med. Care 47(7 Suppl 1), S109–S114 (2009). doi:10.1097/MLR.0b013e31819c94a1
Dodd, S., Bassi, A., Bodger, K., Williamson, P.: A comparison of multivariable regression models to analyse cost data. J Eval Clin Pract 12(1), 76–86 (2006). doi:10.1111/j.1365-2753.2006.00610.x
Tweedie, MCK.: An index which distinguishes between some important exponential families. In: Ghosh, JKRJ., (ed.) Statistics: applications and new directions. In: Proceedings of the Indian Statistical Institute Golden Jubilee International Conference, Calcutta: Indian Statistical Institute (1984) pp. 579–604
von Lengerke, T., John, J., Mielck, A.: Excess direct medical costs of severe obesity by socioeconomic status in German adults. Psychosoc Med 7, (2010). doi:10.3205/psm000063
Buntin, M.B., Zaslavsky, A.M.: Too much ado about two-part models and transformation? Comparing methods of modeling Medicare expenditures. J Health Econ 23(3), 525–542 (2004). doi:10.1016/j.jhealeco.2003.10.005
Burgoyne, D.S.: Prevalence and economic implications of chronic pain. Manag Care 16(2 Suppl 3), 2–4 (2007)
Gatchel, R.J., Okifuji, A.: Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. J Pain 7(11), 779–793 (2006). doi:10.1016/j.jpain.2006.08.005
IOM (Institute of Medicine): Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. The National Academies Press, Washington (2011)
Fishman, P., Von Korff, M., Lozano, P., Hecht, J.: Chronic care costs in managed care. Health Aff (Millwood) 16(3), 239–247 (1997)
Wenig, C.M., Schmidt, C.O., Kohlmann, T., Schweikert, B.: Costs of back pain in Germany. Eur. J. Pain 13(3), 280–286 (2009). doi:10.1016/j.ejpain.2008.04.005
Bolten, W., Kempel-Waibel, A., Pforringer, W.: Analysis of the cost of illness in backache. Med Klin (Munich) 93(6), 388–393 (1998)
Sculpher, M.J., Pang, F.S., Manca, A., Drummond, M.F., Golder, S., Urdahl, H., Davies, L.M., Eastwood, A.: Generalisability in economic evaluation studies in healthcare: a review and case studies. Health technology assessment 8(49), 1–192 (2004)
Zhao, F.L., Xie, F., Hu, H., Li, S.C.: Transferability of indirect cost of chronic disease: a systematic review and meta-analysis. Pharmacoeconomics 31(6), 501–508 (2013). doi:10.1007/s40273-013-0053-6
Andrew, R., Derry, S., Taylor, R.S., Straube, S., Phillips, C.J.: The costs and consequences of adequately managed chronic non-cancer pain and chronic neuropathic pain. Pain Pract 14(1), 79–94 (2014). doi:10.1111/papr.12050
Acknowledgments
We are most grateful to all the people who accepted to participate in this study for their support, time, and patience. We also thank all the interviewers who participated in the data collection process for their commitment and professionalism—Ana Alexandra Fonseca Vilela, Ana Cláudia Monteiro Grijó, Ana Sofia Soares Teixeira, Carla Rolanda Caetano Cid, Cláudia Marisa Neves Valente, Ema Cristina Ribeiro Fernandes Loja, João Tiago Ribeiro Machado Pimentel, Manuela Antónia Alves Marques de Oliveira, Patrícia Rosa Sousa Alves, Renata dos Santos Serra, and Teresa da Felicidade Vieira Quintas Ferreira.
Conflict of interest statements
This work was financially supported by equal unrestricted research grants from the Portuguese local offices of Grünenthal, Pfizer, and Janssen-Cilag and support obtained through a protocol established between the Faculty of Medicine, University of Porto, and the Directorate-General of Health (Direcção Geral de Saúde, DGS) and the Central Administration of the National Health System (Administração Central do Sistema de Saúde, ACSS) of the Portuguese Ministry of Health (Ministério da Saúde) as part of the National Program for Pain Control (Programa Nacional de Controlo da Dor). The sponsors did not participate in the design or conduct of this study; in the collection, management, analysis, or interpretation of data; or in the preparation, review, approval, or decision to submit this manuscript for publication. The authors are fully responsible for the contents of the manuscript and further declare that they have no conflict of interests.
Author information
Authors and Affiliations
Corresponding author
Electronic supplementary material
Below is the link to the electronic supplementary material.
Figure 1S. Flow chart of study subject selection and participation. (Supplementary material).
Rights and permissions
About this article
Cite this article
Azevedo, L.F., Costa-Pereira, A., Mendonça, L. et al. The economic impact of chronic pain: a nationwide population-based cost-of-illness study in Portugal. Eur J Health Econ 17, 87–98 (2016). https://doi.org/10.1007/s10198-014-0659-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10198-014-0659-4