Many clinical trials performed during last fifty years confirmed the effectiveness of acupuncture in the treatment of many diseases, and its unique safety profile making it the safest effective medical intervention known in the world. This is not enough however in present economic situation. Any method looking for integration with modern health care systems, needs to be also economically justified. This article discusses economic evaluation of acupuncture and shows analyses of its cost-effectiveness. In many trials acupuncture proved to be benefit for patients and improve or prolong their life for relatively low price. Acupuncture is also valuable for insurance system reducing number of used drugs (including refunded ones), reducing number of days spent in hospitals, days off the work, and in many cases saving patients from expensive operations because of clinical improvement.
Apart from efficiency, safety and explaining mechanisms of action of a given treatment method, the essential factor influencing the decision on including it to the healthcare system is its cost-effectiveness. Healthcare system managers must know whether specific health-related results may be achieved with lesser financial input. There are numerous indices used for economic analysis of medical interventions, and QUALY- quality-adjusted life year-is one of them.
The amount of researches on the economics of acupuncture is not great when compared to hundreds of trial focusing on effectiveness, safety and mechanisms of action of acupunctureHowever, the issue of cost-effectiveness appears in the descriptions of the aforementioned researches, and economical analyses are included to the designed clinical trials on acupuncture. This is a short review of the status of these researches.
No later than in 1992 the article was published, which underlines the savings resulting from the application of acupuncture in patients awaiting knee surgeries due to the progressing osteoarthritis The authors tried acupuncture treatment on 29 people. 7 of them improved substantially which allowed for cancelling the surgery and savings of 9,000 USD per patient.
One year later another article occurred, and this time it listed savings obtained after application of acupuncture in post-stroke rehabilitation. 79 patients were divided randomly into two groups; one group underwent standard rehabilitation process and the other had acupuncture in addition. Average number of days spent in hospitals or nursing homes was 161 in control group and only 88 days in acupuncture group. Taking into account the costs of maintenance of inpatients, the addition of acupuncture to the standard care resulted in 26,000 USD savings per patient.
Doctor Ballegaard from University Hospital in Copenhagen was interested in the efficiency of acupuncture in patients with advanced angina pectoris. In 1996 the paper was published, presenting effects of using acupuncture, Shiatsu and lifestyle changes in the group of 69 patients suffering from angina pectoris. It is worth mentioning that the time of observation lasted long- two years. In this period of time 7% patients died in the group under trial, much less than in control groups (CABG – 21% and PTCA-15%). 61% of patients gave up the treatment due to the improvement of health state. The amount of days as inpatients was reduced by 91% obtaining 12,000 USD savings per patient. In 1999 Ballegaard and his team published the findings of open, prospective trial involving 105 patients with angina pectoris This time, mainly due to the limited amount of days of hospitalization, the obtained savings equalled 30,000 USD per patient. In 2004 another article was published, concerning the application of integrated rehabilitation (encompassing acupuncture, among others) in 168 patients with cardiological conditions precluding the application of surgical procedures. The savings balanced from 22,000 USD in patients with impossibility to undergo surgery to 36,000 USD in patients qualified for surgical procedures.
Also, in 1999 the work on savings from the application of various nerve stimulations, such as laser-acupuncture, in 31 patients suffering from carpal tunnel syndrome was published. The estimated savings amounted to 11,000 USD per patient.
A year later, an extraordinary paper of Italian researchers appeared, revealing savings from application of acupuncture in patients with migraine. The savings were the aftermath of decreased number of days-off from work 120 patients were divided randomly into two groups. Interestingly enough, the authors made courageous comparison of acupuncture with pharmacological treatment. It turned out that after 12 months of treatment the incidents of migraine in the group with acupuncture decreased from 9,823 to 1,590. In the group undergoing standard treatment the effects were visibly worse (decrease of incidents from 8,405 to 3,084). What is more, the amount of days-off in the researched group was 1120 and in a control group approx. 300 more (1404). It gave the savings of 186,677,000 lira (about 700 Euro) per patient.
Headaches are one of main indications for acupuncture, most frequently reviewed and widely-accepted even in most orthodox medical environments. No wonder this very indication is most commonly researched by authors analysing costs of acupuncture. In 2004 „British Medical Journal” published the findings of the controlled, randomized trial by Vickers and Wonderling with their team. 401 patients were randomly divided into groups, one with acupuncture and the other one- with standard treatment. The groups were observed for the period of one year. After that period it turned out that in the group undergoing acupuncture treatment:
- headaches were less intense,
- headaches occurred less frequently (on average, 22 days more, free from pain, in a year),
- intake of medications was reduced by 15% in this group
- patients went to work more frequently (15% less days-off than in a control group)
- patients visited doctors less often (25% times less consultations than in the control group)
The cost of one QUALY was estimated at the level of 9,180 GBP, for the declared level of cost effectiveness 30,000- 50,000 GBP per QUALY point.
Similar results were found in the research of Witt and co-authors on the group of 3182 patients Due to the costs of remunerating acupuncturists, the group under acupuncture treatment costed more than the treatment of the control group. On average, the cost of obtaining QUALY point amounted to 11,657 Euro which- in comparison with the declared levels of cost-effectiveness – allows for conclusion that acupuncture is economically justified method for headache treatment.
Acupuncture is also the acclaimed and well-reviewed method of treatment of lower back pain. In 2006, the team of Ratcliffe published the results of cost-effectiveness analysis for treatment of the aforementioned disorder using acupuncture. The trial was carried out on 241 patients. Like in the case of headaches, the costs in the research group were slightly higher than in the control group due to remunerating acupuncturists. Nevertheless the cost of obtaining one QUALY point was estimated at the level of 4241 GBP, also lower than the declared cost-efficiency. The interesting thing is that a similar trial was to be performed by Witt and his team on the group of 11,000 patients However, authors were forced to give up the randomization process in a part of patients, who feared they may not be assigned to the group under acupuncture treatment. On the basis of the results of randomized patients exclusively, the improvement of the condition was substantially higher in the group with acupuncture. The cost of obtaining one QUALY point equalled 10,526 Euro – again lower than the declared cost-efficiency threshold.
Jorge Vas made a retrospective analysis of data obtained from almost six thousand patients (5981) treated for non-cancer pain. In case of patients who attended acupuncture treatment the amount of pain killers and anti-inflammatory drugs decreased and that gave average savings of 7.1 Euro per patient per week. In the sub-group of people suffering from headaches these savings were visibly higher and equaled 26.1 Euro per patient per week.
Recently a paper has been published on economic cost-effectiveness of acupuncture for irritable bowel syndrome treatment Whilst general findings failed to indicate the cost-effectiveness of acupuncture for this indication, after the division of patients into sub-groups depending on the severity of illness, acupuncture turned out to be most effective in the group of the most seriously ill.
As seen in the aforementioned list, acupuncture turned out to be cost beneficial in many indications, nonetheless there is a substantial heterogeneity of research methodology and presentation of findings. Hopefully, meta-analyses of works concerning the economic evaluation of acupuncture have been published recently as well.
Ambrozio presents the meta-analysis of trials on acupuncture for treatment of various pain disorders. He compares the results of published trials with the declared levels of acceptable costs, concluding that in case of all indications acupuncture is placed substantially below these thresholds. An interesting analysis is suggested by Kim SY who concludes that all trials prove that acupuncture performed alone as a therapy or as a complementary therapy to the standard one is economically effective in comparison with the waiting list or with standard therapies.
In case of numerous indications acupuncture is the effective and economically justified method leading to either savings or the improvement of patients’ life quality at a lower cost than the one declared as acceptable. Savings resulting from the application of acupuncture include:
- Savings resulting from escaping surgical procedure.
- Reduced amount of drugs intake.
- Reduced number of days-off from work.
- Reduction of necessary medical review appointments.
2 Johansson K et al (1993), “Can sensory stimulation improve the function al outcome in stroke patients?” Neurology 43:2189-2192
3 Ballegaard S, Nørrelund S, Smith DF. “Cost-benefit of combined use of acupuncture, Shiatsu and lifestyle adjustment for treatment of patients with severe angina pectoris” Acupunct Electrother Res. 1996 Jul-Dec;21(3-4):187-97
4 Ballegaard S, Johannessen A, Karpatschof B, Nyboe J. “Addition of Acupuncture and Self-Care Education in the Treatment of Patients with Severe Angina Pectoris May be Cost Beneficial: An Open, Prospective Study” J Altern Complement Med. 1999;5:405-13
5 Ballegaard S, Borg E, Karpatschof B, Nyboe J, Johannessen A. “Long-Term Effects of Integrated Rehabilitation in Patients with advanced angina pectoris: a nonrandomized comparative study.” J Altern Complement Med. 2004;10(5):777-83
6 Branco K, Naeser MA. “Carpal tunnel syndrome: clinical outcome after low-level laser acupuncture, microamps transcutaneous electrical nerve stimulation, and other alternative therapies–an open protocol study”. J Altern Complement Med. 1999;5(1):5-26
7 Liguori A, Petti F, Bangrazi A, et al. “Comparison of pharmacological treatment versus acupuncture treatment for migraine without aura–analysis of socio-medical parameters”. J Tradit Chin Med. 2000;20:231-40
8 Wonderling D, Vickers AJ, Grieve R, McCarney R. “Cost effectiveness analysis of a randomised trial of acupuncture for chronic headache in primary care”. BMJ. 2004;328(7442):747.
9 Witt CM, Reinhold T, Jena S, Brinkhaus B, Willich SN. “Cost-effectiveness of acupuncture treatment in patients with headache.” Cephalalgia. 2008;28(4):334-45
10 Ratcliffe J, Thomas KJ, MacPherson H, Brazier J. “A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis.” BMJ. 2006;333(7569):626.
11 Witt CM, Jena S, Selim D, Brinkhaus B, Reinhold T, Wruck K, et al. “Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain”. Am J Epidemiol. 2006;164(5):487-96.
12 Eugena Stamuli, et al „Cost-effectiveness of acupuncture for irritable bowel syndrome: findings from an economic evaluation conducted alongside a pragmatic randomised controlled trial in primary care” BMC Gastroenterology 2012, 12:149
13 E.M.M. Ambrósio, K. Bloor, H. MacPherson. „Costs and consequences of acupuncture as a treatment for chronic pain: A systematic review of economic evaluations conducted alongside randomised controlled trials” Complementary Therapies in Medicine (2012) 20, 364—374
14 Kim SY, Lee H, Chae Y, Park HJ, Lee H. „A systematic review of cost-effectiveness analyses alongside randomised controlled trials of acupuncture.” Acupunct Med. 2012 Dec;30(4):273-85