Efficiency can be defined as the resources required producing the benefits of treatment:

Cost-effectiveness - the financial cost of achieving a specific clinical target, such as return to work or reduction in pain score by 30 percent. Turk16 cautions against simple comparisons between different modalities of treatment because of the "broad differences in the pain syndromes and inclusion criteria used, the drug dosages, comparability of treatments, the definition of 'chronic' used, the outcome criteria selected to determine success, and societal differences between studies.'' It is necessary to have detailed knowledge and understanding of each study that is compared -simple reference to published abstracts is insufficient.

Cost-utility - the financial cost of improving patients' lives - usually more patient-focused outcomes, which are less objective and often cover a broad range of measures. Results from the SF36 questionnaire, may be converted to an abstract measure such the Quality Adjusted Life Year (QALY). One QALY can be demonstrated to cost about $60-70,000 for

Table 14.2 A summary of the differences between clinical trials and clinical practice.

Clinical trial

Clinical practice

Demonstrates drug



Confounding diagnoses



Outcome measures Duration


To demonstrate that the drug works Strictly defined, homogeneous Absent High

Good, assured, low dropout rate Comprehensive

Short, often concluded after enough time for initial improvement


To improve patient's condition Mixed, variable, ill-defined Frequent Often low

Often poor, failure to attend appointments Often vague or nonexistent Indefinite interdisciplinary management of chronic spinal pain17 or $15,000 for acupuncture for chronic neck pain18 (up to $100,000 per QALY is usually considered to be justified). These measures are useful in order to help refine pharmacoeconomic models of managing pain.19 Cost benefit - the ratio of healthcare expenditure to financial benefit (i.e. the sum of treatment cost savings, reduced disability benefits, and wages earned) considered in purely monetary terms.

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