BMJ  2006;333:611-612 (23 September), doi:10.1136/bmj.38954.627361.BE

Editorial

Acupuncture in mainstream health care

Is cost effective for chronic non-specific low back pain and migraine

Lower back pain is a common ailment that places a considerable burden on society in terms of reduced quality of life and lost productivity.¹ In this week's BMJ an economic evaluation by Ratcliffe and colleagues shows that acupuncture is relatively cost effective as an adjunct to usual care for patients with persistent non-specific lower back pain.² The study is based on a well conducted pragmatic randomised controlled trial, which is also published this week.³ The trial showed a modest but statistically significant reduction in back pain and increase in health related quality of life compared with usual care.

The addition of acupuncture to usual care for low back pain raised health service costs by £140 (207; $265) per patient, but this increase was small relative to the health gain. At £4000 per quality adjusted life year (QALY) gained, this is well below the lower NHS funding threshold used by the United Kingdom's National Institute for Health and Clinical Excellence (NICE) of £20 000 per QALY gained,⁴ which implies that acupuncture is more cost effective than many treatments provided by the NHS.⁵ Even at the upper 95% confidence interval of £28 000 per QALY gained, it is still below NICE's upper threshold of £30 000 per QALY gained.

The authors followed the methods of NICE,⁴ and did not include (except in a sensitivity analysis) the indirect cost savings associated with participants in the trial returning to work. This is because inclusion would represent double counting of the health gain already captured in the QALYs. Furthermore, the inclusion of these productivity gains would run counter to the equity stance of the NHS, because if generally applied it would prioritise interventions for young, fit adults over those for elderly people and those unable to work. To my knowledge this is only the second rigorous economic evaluation of acupuncture.^{6 7} The first, in which I was an investigator, had a similar design but studied patients with migraine.⁸ We found that acupuncture cost £9000 per QALY gained in patients with migraine. Other economic studies of acupuncture have found substantial cost savings compared with usual care, but they have usually been conducted by advocates of acupuncture and have used questionable methods.^{7 8} For example, studies have claimed cost savings on the basis of hypothetical interventions that would have been deemed necessary by the investigator if acupuncture had not been used. Other studies have used before and after comparisons or non-randomised controls. The two studies based on randomised evidence do not show the dramatic cost savings that have been postulated by advocates, but neither do they show that the health gain is too trivial to be cost effective.

Sceptics will argue that the results of these studies could be entirely due to a placebo response. Recent reviews of data from clinical trials have questioned the existence of a general placebo response across all health outcomes.⁹ But for pain, randomised controlled trials and psychological experiments provide evidence for a placebo response.^{9 10}

It is also plausible that the placebo response would be translated into differences in health related quality of life (as measured by the SF6D instrument in the trial by Thomas and colleagues³). The design of the study (with patients randomised to have new treatment plus usual care versus usual care alone) is suited to evaluation of effectiveness and cost effectiveness, but it is inappropriate for assessing the extent to which the observed outcomes are attributable to the placebo response. For this we should turn to the Cochrane review on acupuncture for patients with chronic low back pain.¹¹

The Cochrane review found evidence from high quality randomised controlled trials that acupuncture reduces pain in the short and intermediate term compared with sham (placebo) acupuncture.¹¹ This implies that treatment has real effects over and above a placebo response. In contrast, a recent randomised controlled trial of acupuncture for tension headache showed that sham acupuncture was almost as effective as acupuncture when compared with no treatment (rates of clinical improvement were 35%, 46%, and 4%, respectively),¹² and the effect could have been mainly or wholly due to a placebo response.

Rigorous economic evaluations of acupuncture are important because acupuncture sometimes has serious side effects,¹³ and if money is spent on acupuncture then that same money will not be available to be spent on other clinically effective treatments for other patients. But commissioners of research should also ensure that the effectiveness of each intervention compared with placebo has been well established, even if placebo controlled trials of complementary medicine are fraught with difficulties. The same issues apply to more orthodox forms of medicine, such as surgery, where placebo controlled trials might be helpful but are rarely conducted.

The new research in this week's BMJ means that acupuncture for persistent lower back pain has been clinically researched more thoroughly than many orthodox medical treatments. Healthcare decision makers should consider acupuncture as an adjunct to usual care for patients with persistent low back pain or migraine: the best evidence shows that the associated health gain represents good value.

National Collaborating Centre for Acute Care, Royal College of Surgeons of England, London WC2A 3PE
(dwonderling{at}rcseng.ac.uk)

---

Competing interests: None declared.

Research pp 623, 626

References

1. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 2000;84: 95-103.[CrossRef][ISI][Medline]
2. Ratcliffe J, Thomas KJ, MacPherson H, Brazier J. A randomised controlled trial of acupuncture care for lower back pain: cost effectiveness analysis. BMJ 2006 doi: 10.1136/bmj.38932.806134.7C.[Abstract/Free Full Text]
3. Thomas KJ, MacPherson H, Thorpe L, Brazier J, Fitter M, Campbell MJ, et al. Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ 2006 doi: 10.1136/bmj.38878.907361.7C.[Abstract/Free Full Text]
4. National Institute for Health and Clinical Excellence. Guide to the methods of technology appraisal. London: NICE, 2004. www.nice.org.uk/page.aspx?o=201973 (last accessed 31 Aug 2006).
5. Raftery J. NICE: faster access to modern treatments? Analysis of guidance on health technologies. BMJ 2001;323: 1300-3.[Free Full Text]
6. Canter PH, Thompson Coon J, Ernst E. Cost-effectiveness of complementary treatments in the United Kingdom: systematic review. BMJ 2005;331: 880-1.[Free Full Text]
7. White AR, Ernst E. Economic analysis of complementary medicine: a systematic review. Complement Ther Med 2000; 8:; 111-8.[CrossRef][ISI][Medline]
8. Wonderling D, Vickers AJ, Grieve R, McCartney R. Cost effectiveness analysis of a randomised trial of acupuncture for chronic headache in primary care. BMJ 2004;328: 747-52.[Abstract/Free Full Text]
9. Hróbjartsson A, Gøtzsche PC. Placebo interventions for all clinical conditions. Cochrane Database Syst Rev 2004;(2):CD003974.
10. Hoffman GA, Harrington A, Fields HL. Pain and the placebo: what we have learned. Perspect Biol Med 2005;48: 248-65.[ISI][Medline]
11. Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev 2005;(1):CD001351.
12. Melchart D, Streng A, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, et al. Acupuncture in patients with tension-type headache: randomised controlled trial. BMJ 2005;331: 376-82.[Abstract/Free Full Text]
13. Vincent C. The safety of acupuncture. BMJ 2001;323: 467-8.[Free Full Text]

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This article has been cited by other articles:

• Paterson, C. (2007). Appraisals of specific treatments are needed. BMJ 334: 600-600 [Full text]  
• (2006). Acupuncture for Low Back Pain?. JWatch General 2006: 4-4 [Full text]  

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Acupuncture is safe

Tony Thick
bmj.com, 22 Sep 2006 [Full text]

A biased editorial.

Richard G Richards
bmj.com, 6 Oct 2006 [Full text]