Cost Effectiveness of Treatments for Chronic Constipation: A Systematic Review

Dolly Han, Nicolas Iragorri, Fiona Clement, Diane Lorenzetti, Eldon Spackman

Chronic constipation (CC) has a significant impact on patients' quality of life and imposes an economic burden on individuals and the healthcare system. Treatment options include dietary changes, lifestyle modifications, fibre supplements, stool softeners, and laxatives. We undertook this systematic review to comprehensively evaluate the cost effectiveness of treatments for CC. We searched ten common databases to identify economic evaluations published to 13 June 2017. Abstract and full-text review were completed in duplicate. The quality of the included studies was assessed using the Consensus on Health Economic Criteria. Data extracted included costs and outcomes of treatments for CC and cost-effectiveness methods. A narrative synthesis was completed. From the 4338 unique citations identified, 79 proceeded to full-text review, with 10 studies forming the final dataset. Eight different definitions of CC were used to define the study populations. Study designs used were decision-tree models (4), Markov model (1), and retrospective (1) and prospective (4) studies. Quality-adjusted life-years (QALY) were reported in five studies; other outcomes included, discontinuation of laxative treatment and frequency of bowel movements. The majority of studies stated that their results were from a payer perspective; however, some of these studies only considered treatment costs, a subset of costs included in the payer perspective. Lifestyle advice, dietary treatments and abdominal massage were each compared with current care with laxatives, while polyethylene glycol (PEG) and senna-fibre combination were each compared with lactulose. Two studies compared newer treatments in patients who had not responded to laxatives: prucalopride was compared with continuing laxatives, and linaclotide was compared with lubiprostone. All of the interventions were reported by the study authors to be cost effective, with the exception of abdominal massage. A consistent definition of CC is needed and the QALY should be used to capture the diverse symptoms of CC. Further analysis is needed comparing all available treatments for patients who have not responded to laxatives. Overall, results from economic evaluations appear to align with stepwise practice guidelines.