BMJ  2005;331:880-881 (15 October), doi:10.1136/bmj.38625.575903.79

Paper

Cost effectiveness of complementary treatments in the United Kingdom: systematic review

Peter H Canter, research fellow1, Joanna Thompson Coon, research fellow1, Edzard Ernst, director of complementary medicine1

1 Complementary Medicine, Peninsula Medical School, Universities of Exeter and Plymouth, Exeter EX2 4NT

Correspondence to: P H Canter peter.canter{at}pms.ac.uk

Introduction

Cost effectiveness data form a crucial part of the debate surrounding the integration of complementary treatments into the NHS. To our knowledge, studies of the cost effectiveness of complementary therapies in the United Kingdom have not previously been reviewed.

Methods and results

Introduction
 Methods and results
Comment
 References
We systematically searched seven electronic databases and included all prospective controlled studies, done in the UK before April 2005, of the cost effectiveness of complementary treatments (see bmj.com). We excluded cost minimisation studies because complementary treatments are insufficiently tested in the NHS to warrant the assumption that they are as effective as conventional treatments. Five studies, all randomised, were included, one of acupuncture for chronic headache and four of spinal manipulation for different types of spinal pain (table).


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  		Cost effectiveness studies done in the United Kingdom before April 2005 of complementary treatments, excluding cost minimisation studies

 

Acupuncture was an effective addition to usual care for chronic headache.1 Total mean costs, omitting the cost of prescription drugs in the year long study, were higher with additional acupuncture (£403; $710; {euro}590) than for usual care (£217). Cost per quality adjusted life year (QALY) for acupuncture in addition to usual care was estimated as £9180.

The study by Meade et al compared individualised chiropractic spinal manipulation with Maitland mobilisation or manipulation provided by NHS outpatient clinics for back pain.2 Oswestry scores favoured chiropractic at six and 12 months and at two and three years. Direct costs of providing chiropractic and hospital based treatments in the year-long intervention were £165 and £111 per patient, respectively. More chiropractic patients subsequently sought further, uncosted, treatment for back pain.

Burton et al compared private individualised osteopathic spinal manipulation with chemonucleolysis for lumbar disc herniation.3 Both groups improved and health outcomes did not differ after a year. Annual savings per patient with manipulation, based on direct intervention costs and costs of treating therapeutic failure, were estimated as £300. Chemonucleolysis is a relatively expensive procedure, usually used when other conservative treatments have failed.


What is already known on this topic

The cost effectiveness of using complementary treatments in the United Kingdom has been the subject of much speculation and controversy

Rigorous cost effectiveness studies are needed

What this study adds

Cost effectiveness studies show that spinal manipulation and acupuncture represent an additional cost to usual care in the United Kingdom; estimates of cost per quality adjusted life year compare favourably with other treatments approved for use in the NHS, but it is not certain that the benefits are clinically relevant


Additional spinal manipulation in a primary care based osteopathy clinic was more effective than usual care alone for subacute spinal pain at two months but not at six months.4 Mean healthcare costs attributed to spinal pain for the six month trial were £129 for osteopathy and £64 for usual care. The authors estimated the cost as £3560 per QALY for osteopathy, but this was subject to a high random error.

The UK back pain exercise and manipulation trial compared Roland Morris disability scores after spinal manipulation, exercise classes, or manipulation followed by exercise in addition to care for chronic back pain by general practitioners.5 Exercise was superior to primary care at three months but not after a year. Manipulation and manipulation followed by exercise were significantly better than primary care at three and 12 months. Effect sizes were small to moderate. The mean incremental treatment cost relative to general practitioner care was £195 for manipulation, £140 for exercise, and £125 for combined treatment. The authors estimated the cost per QALY relative to general practitioner care as £3800 for combined treatment and £4800 for manipulation. Exercise alone was more expensive and achieved less than combined treatment.

Comment

Complementary treatments represent an additional healthcare cost in four out of the five rigorous cost effectiveness studies conducted in the UK. These studies are confined to acupuncture and spinal manipulation. Estimates of cost per QALY from three studies compare favourably with other treatments approved for use in the NHS, but for spinal manipulation the health benefits were small to moderate and are of questionable clinical significance. Measurement of costs was incomplete in all studies and omitted follow-on costs. Standard modelling methods were not used. Absence of blinding and sham control treatments may have increased non-specific treatment effects. Estimates of cost effectiveness may be less favourable in situations for which the complementary treatment is offered routinely rather than in the novel situation of a clinical trial.

Editorial by Thompson and Feder

{webplus.f1}Methodological details are on bmj.com

Contributors: PHC conceived and designed the review. PHC and JTC analysed and interpreted the data. PHC, JTC and EE critically revised the article. All the authors drafted the article. PHC is guarantor.

Funding: No additional funding.

Competing interests: None declared.

Ethical approval: Not needed.

References

  1. 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: 747.[Abstract/Free Full Text]
  2. Meade TW, Dyer S, Browne W, Frank AO. Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up. BMJ 1995;311: 349-51.[Abstract/Free Full Text]
  3. Burton AK, Tillotson KM, Cleary J. Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation. Eur Spine J 2000;9: 202-7.[CrossRef][Web of Science][Medline]
  4. Williams NH, Edwards RT, Linck P, Muntz R, Hibbs R, Wilkinson C, et al. Cost-utility analysis of osteopathy in primary care: results from a pragmatic randomized controlled trial. Fam Pract 2004;21: 643-50.[Abstract/Free Full Text]
  5. UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ 2004;329: 1381.[Abstract/Free Full Text]
(Accepted 5 September 2005)


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Rapid Responses:

Read all Rapid Responses

Cost effectiveness of complementary treatments- all of them or only selected ones
Reinhard W SCHWARZ
bmj.com, 14 Oct 2005 [Full text]
CAM can be cost-effective: good evidence but still doubted
Charlotte Paterson
bmj.com, 17 Oct 2005 [Full text]
Is it a fitting systematic review?
Luigi Gori, et al.
bmj.com, 17 Oct 2005 [Full text]
Author's reply
Peter H Canter
bmj.com, 19 Oct 2005 [Full text]
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