Table 5 - uploaded by Kate Thomas
Content may be subject to copyright.
Cost effectiveness of acupuncture care or usual care for treatment of persistent non-specific low back pain
Source publication
To evaluate the cost effectiveness of acupuncture in the management of persistent non-specific low back pain.
Cost effectiveness analysis of a randomised controlled trial.
Three private acupuncture clinics and 18 general practices in York, England.
241 adults aged 18-65 with non-specific low back pain of 4-52 weeks' duration.
Ten individualised acu...
Context in source publication
Context 1
... the incremental cost effectiveness ratio for acupunc- ture in the treatment of low back pain was positive (table 5), with a mean of £4241 at 24 months. The figure shows the probability of the intervention being cost effective using the base case data for a range of cost effectiveness ceilings. ...
Similar publications
This paper examines some of the problems specifically associated with conducting research into acupuncture and how this can lead to further problems with subsequent systematic reviews. Studies for the treatment of chronic neck pain have been used as examples of how presented information can be misleading to an acupuncture-naive reader and how resea...
To assess the cost effectiveness of laparoscopic hysterectomy compared with conventional hysterectomy (abdominal or vaginal).
Cost effectiveness analysis based on two parallel trials: laparoscopic (n = 324) compared with vaginal hysterectomy (n = 163); and laparoscopic (n = 573) compared with abdominal hysterectomy (n = 286).
1346 women requiring a...
Fibromyalgia is a multidimensional disorder for which treatment as yet remains unsatisfactory. Studies of an acupuncture-based approach, despite its broad acceptance among patients and healthcare staff, have not produced sufficient evidence of its effectiveness in treating this syndrome. The present study aims to evaluate the effectiveness of indiv...
Citations
... A high-quality RCT demonstrated that the cost per quality adjusted life year gained from acupuncture was only 4,241 pounds, well below the commonly accepted threshold of 20,000 pounds. Moreover, sensitivity analyses confirmed a greater than 90% probability of cost-effectiveness, highlighting its economic and therapeutic value (7). Previous meta-analyses have shown that acupuncture re-establishes swallowing function and effectively improves quality of life in patients with PSD (8,9). ...
Background
Post-stroke dysphagia (PSD) affects the efficacy and safety of swallowing, causing serious complications. Acupuncture is a promising and cost-effective treatment for PSD; however, as the number of randomized controlled trials increases, scientific analysis of the parameters and acupoint prescription is required. Therefore, this study aimed to explore the effects of acupuncture on parameters related to post-stroke dysphagia (PSD).
Methods
We searched the Cochrane Library, PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang Database, Chinese Biomedical Literature, and Chongqing VIP Database for randomized controlled trials of acupuncture for PSD in the last 15 years and relevant parameters were analyzed using data mining techniques.
Results
In total, 3,205 records were identified, of which 3,507 patients with PSD were included in 39 studies. The comprehensive analysis demonstrated that the closest parameter combinations of acupuncture on PSD were 0.25 mm × 40 mm needle size, 30 min retention time, five treatments per week, and a 4-week total course of treatment. Additionally, the gallbladder and nontraditional meridians, crossing points, and head and neck sites are the most commonly used acupoint parameters. The core acupoints identified were GB20, RN23, EX-HN14, Gongxue, MS6, SJ17, EX-HN12, EX-HN13, and the commonly used combination of EX-HN12, EX-HN13, GB20, and RN23.
Conclusion
This study analyzed the patterns of PSD-related needling and acupoint parameters to provide evidence-based guidelines for clinical acupuncturists in treating PSD, potentially benefitting affected patients.
... Lin et al. 34 noted that GP care was associated with low health care costs, but with higher societal costs than other treatments; thus, most treatments were found to be costeffective compared with GP care. Acupuncture was shown to be cost-effective in a study of chronic LBP by Ratcliffe et al., 39 and our findings on cost-effectiveness for ALBP in the longer term are similar to both that study as well as to trials of chronic LBP reported by Andronis et al. 12 One trial of the use of acupuncture for pelvic pain and LBP in pregnancy also showed that acupuncture is cost-effective, resulting in lower societal costs and better health outcomes; 14 however, in that case, the effect was measured in days with pain numeric rating scale (NRS) ⩽ 4, and not in QALYs, as in our study. ...
Objective
To assess the cost-effectiveness of a single treatment session of acupuncture, when applied in addition to usual care for acute low back pain (ALBP).
Methods
Secondary analysis of a multicentre randomised controlled trial in Norwegian general practice. In total, 171 participants with ALBP ⩽14 days were randomised to a control group (CG) receiving usual care or to an acupuncture group (AG) receiving one additional session of Western medical acupuncture alongside usual care. Primary outcome measures for this cost-effectiveness analysis were quality-adjusted life years (QALYs), health care costs and societal costs at days 28 and 365, the incremental cost-effectiveness ratio (ICER) and net monetary benefit (NMB). The NMB was calculated on the basis of the Norwegian cost-effectiveness threshold of NOK 275,000 (USD 35,628) per QALY gained. Missing data were replaced by multiple chained imputation.
Results
Eighty-six participants in the CG and 81 in the AG were included in the analysis. We found no QALY gain at day 28. At day 365, the incremental QALY of 0.035 was statistically significant. The differences in health care costs and societal costs were not statistically significant. Three out of four calculations led to negative ICERs (cost saving) and positive NMBs. For the health care perspective at day 365, the ICER was USD –568 per QALY and the NMB was USD 1265, with 95.9% probability of acupuncture being cost-effective.
Conclusion
To our knowledge, this is the first cost-effectiveness analysis of acupuncture for ALBP. The findings indicate that acupuncture may be cost-effective from a 1-year perspective, but more studies are needed.
Trial registration number
NCT01439412 (ClinicalTrials.gov).
... To our knowledge, this is the first study in Korea using economic evaluation alongside a clinical trial to compare EA plus UC with UC alone in the treatment of patients with non-acute pain after back surgery. Prior research in the UK demonstrated that additional acupuncture treatment was cost-effective compared with UC alone for treating chronic LBP [38]. Moreover, in Germany, acupuncture was shown to be relatively cost-effective [39]. ...
Electroacupuncture (EA) is used to treat pain after back surgery. Although this treatment is covered by national health insurance in Korea, evidence supporting its cost-effectiveness and contribution to the sustainability of the national health care system has yet to be published. Therefore, an economic evaluation, alongside a clinical trial, was conducted to estimate the cost-effectiveness of EA and usual care (UC) versus UC alone to treat non-acute low back pain (LBP). In total, 108 patients were recruited and randomly assigned to treatment groups; 106 were included in the final cost utility analysis. The incremental cost-effectiveness ratio of EA plus UC was estimated as 7,048,602 Korean Rate Won (KRW) per quality-adjusted life years (QALYs) from the societal perspective (SP). If the national threshold was KRW 30 million per QALY, the cost-effectiveness probability of EA plus UC was an estimated 85.9%; and, if the national threshold was over KRW 42,496,372 per QALY, the cost-effectiveness probability would be over 95% percent statistical significance. Based on these results, EA plus UC combination therapy for patients with non-acute LBP may be cost-effective from a societal perspective in Korea.
... Instead of penetrating the skin, the point of the Streitberger needle retracts up the handle shaft when the acupuncturist presses it against the skin. This sham device has been validated by studies showing that subjects are unable to distinguish between real and sham needling [45][46][47]. ...
Chronic low back pain (cLBP) is a common disorder with unsatisfactory treatment options. Acupuncture has emerged as a promising method for treating cLBP. However, the mechanism underlying acupuncture remains unclear. In this study, we investigated the modulation effects of acupuncture on resting state functional connectivity (rsFC) of the periaqueductal gray (PAG) and ventral tegmental area (VTA) in patients with cLBP. Seventy-nine cLBP patients were recruited and assigned to four weeks of real or sham acupuncture. Resting state functional magnetic resonance imaging data were collected before the first and after the last treatment. Fifty patients completed the study. We found remission of pain bothersomeness in all treatment groups after four weeks, with greater pain relief after real acupuncture compared to sham acupuncture. We also found that real acupuncture can increase VTA/PAG rsFC with the amygdala, and the increased rsFC was associated with decreased pain bothersomeness scores. Baseline PAG-amygdala rsFC could predict four-week treatment response. Our results suggest that acupuncture may simultaneously modulate the rsFC of key regions in the descending pain modulation (PAG) and reward systems (VTA), and the amygdala may be a key node linking the two systems to produce antinociceptive effects. Our findings highlight the potential of acupuncture for chronic low back pain management.
... Grade of Recommendation: ICost Utility Question 7: Is pharmacological management (over-the-counter + prescription medications) for patients with low back pain more or less cost-effective than interventional treatments including physical therapy and injection therapies?A systematic review of the literature yielded no studies to adequately address this question.Cost Utility Question 8: Is spinal manipulative therapy in the management of patients with low back pain more cost effective than other medical/interventional treatments?There is insufficient evidence to make a recommendation for or against the cost utility of spinal manipulative therapy for the treatment of low back pain.[301] Cost Utility Question 9: Is acupuncture-based therapy in the management of patients with low back pain more cost effective than other medical/interventional treatments?Acupuncture-based therapy in the management of patients with low back pain is suggested to be cost effective when compared with other medical/interventional treatments.[302][303][304] Grade of Recommendation: B Cost Utility Question 10: Are over-the-counter medications only without other medical interventions more cost effective in the management of patients with low back pain than other medical/interventional treatments? ...
Background context
The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016.
PURPOSE
The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.
Study design
This is a guideline summary review.
Methods
This guideline is the product of the Low Back Pain Work Group of NASS’ Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.
Results
Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.
Conclusions
The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx
... 15 Despite the evidence in the literature to support use of acupuncture for low back pain, it is not covered by most insurance plans in the United States. 79,80 A study by the State of Washington found that even with a substantial number of people using insurance benefits for nonpharmacologic therapies, including acupuncture, the effect on insurance expenditures was modest. 81 In a followup study of Washington state-insured patients with back pain, fibromyalgia and menopause symptoms, users of nonpharmacologic therapy providers had lower insurance expenditures than those who did not use them. ...
... So far no cost effectiveness study was undertaken to evaluate acupuncture as treatment of low back pain during pregnancy. Previous studies in non-pregnant persons concluded to a modest health benefit for minor extra cost compared with usual care, from the point of view of the health care system [36] or of society at large [37]. A pilot paper argued that trials such as the one we report, would be welcomed by women and clinicians [38]. ...
Objective
To assess the cost-effectiveness of acupuncture for pelvic girdle and low back pain (PGLBP) during pregnancy.
Design
Pragmatic-open-label randomised controlled trial.
Setting
Five maternity hospitals
Population
Pregnant women with PGLBP
Method
1:1 randomization to standard care or standard care plus acupuncture (5 sessions by an acupuncturist midwife).
Main outcome measure
Efficacy: proportion of days with self-assessed pain by numerical rating scale (NRS) ≤ 4/10. Cost effectiveness (societal viewpoint, time horizon: pregnancy): incremental cost per days with NRS ≤ 4/10. Indirect non-healthcare costs included daily compensations for sick leave and productivity loss caused by absenteeism or presenteeism.
Results
96 women were allocated to acupuncture and 103 to standard care (total 199). The proportion of days with NRS ≤ 4/10 was greater in the acupuncture group than in the standard care group (61% vs 48%, p = 0.007). The mean Oswestry disability score was lower in the acupuncture group than with standard care alone (33 versus 38, Δ = 5, 95% CI: 0.8 to 9, p = 0.02). Average total costs were higher in the control group (€2947) than in the acupuncture group (€2635, Δ = —€312, 95% CI: -966 to +325), resulting from the higher indirect costs of absenteeism and presenteeism. Acupuncture was a dominant strategy when both healthcare and non-healthcare costs were included. Costs for the health system (employer and out-of-pocket costs excluded) were slightly higher for acupuncture (€1512 versus €1452, Δ = €60, 95% CI: -272 to +470).
Conclusion
Acupuncture was a dominant strategy when accounting for employer costs. A 100% probability of cost-effectiveness was obtained for a willingness to pay of €100 per days with pain NRS ≤ 4.
... The primary measure of outcome for this analysis will be the incremental cost per unit of improvement in functional outcomes of sleep using the FOSQ [39]. We will also calculate the incremental cost per quality adjusted life year gained as measured by the EQ-5D-5L [55]. See Supplementary Material for further details. ...
Study Objectives
Obstructive sleep apnea (OSA) is a serious and costly public health problem. The main medical treatment, continuous positive airway pressure, is efficacious when used, but poorly tolerated in up to 50% of patients. Upper airway reconstructive surgery is available when medical treatments fail but randomized trial evidence supporting its use is limited. This protocol details a randomized controlled trial designed to assess the clinical effectiveness, safety, and cost-effectiveness of a multilevel upper airway surgical procedure for OSA.
Methods
A prospective, parallel-group, open label, randomized, controlled, multicenter clinical trial in adults with moderate or severe OSA who have failed or refused medical therapies. Six clinical sites in Australia randomly allocated participants in a 1:1 ratio to receive either an upper airway surgical procedure consisting of a modified uvulopalatopharyngoplasty and minimally invasive tongue volume reduction, or to continue with ongoing medical management, and followed them for 6 months.
Results
Primary outcomes: difference between groups in baseline-adjusted 6 month OSA severity (apnea–hypopnea index) and subjective sleepiness (Epworth Sleepiness Scale). Secondary outcomes: other OSA symptoms (e.g. snoring and objective sleepiness), other polysomnography parameters (e.g. arousal index and 4% oxygen desaturation index), quality of life, 24 hr ambulatory blood pressure, adverse events, and adherence to ongoing medical therapies (medical group).
Conclusions
The Sleep Apnea Multilevel Surgery (SAMS) trial is of global public health importance for testing the effectiveness and safety of a multilevel surgical procedure for patients with OSA who have failed medical treatment.
Clinical Trial Registration
Multilevel airway surgery in patients with moderate-severe Obstructive Sleep Apnea (OSA) who have failed medical management to assess change in OSA events and daytime sleepiness. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366019&isReview=true Australian New Zealand Clinical Trials Registry ACTRN12614000338662, prospectively registered on 31 March 2014.
... 14 4. Acupuncture is cost-effective for chronic pain management: In two randomized trials that included >12,000 patients with low back pain, acupuncture treatment was associated with clinically meaningful improvement in quality of life with a modest incremental increase in cost greatly below the $50,000 cost per quality ratio. 15,16 C. Recommendations for inclusion of education requirements for acupuncture providers: There are *37,000 licensed acupuncturists (LAcs) in the United States, who received comprehensive clinical (660 h) and didactic (1245 h) acupuncture training and have an established master's level accredited education and certification process. LAcs are recognized as qualified providers of acupuncture by the Department of Veteran Affairs, 47 states and the District of Columbia, as well as many thirdparty payers throughout the country. ...
... Kim et al. [74] synthesize available evidence and include in a model and find acupuncture in conjunction with other therapy to be cost-effective in Korean setting. Thomas [75] and later Ratcliffe et al. [76] report results from the same randomized controlled trial that show acupuncture to be tolerable, cheap and effective, together making a short course of the treatment to be cost-effective. ...
