Acupuncture treatment for persistent non-specific low back pain confers a modest benefit to health, as measured by quality adjusted life years (QALYs), at relatively minor extra cost to the NHS compared with usual care. This finding is complemented by the clinical results detailed in the accompanying paper, which found weak evidence of an effect on pain at 12 months but stronger evidence of a small benefit at 24 months.5
We estimated the incremental cost effectiveness to be £4241 per QALY gained in the base case. This represents a conservative estimate because it excludes cost savings associated with productivity gains. From a societal perspective when gains in productivity are included then acupuncture care for low back pain becomes dominant in that it is less expensive and confers greater health benefits than usual care. It is likely, however, that this represents an underestimate of the cost per QALY because the quality of life measure will in part take into account this improved productivity.
A potential limitation of the cost effectiveness study relates to the use of a patient completed questionnaire to obtain information on use of resources. This method can be criticised on the basis that it may be the subject of recall bias. On a practical level, however, this method offers an appropriate and efficient mechanism for obtaining this information. To minimise the risk of recall bias for hospital episodes related to low back pain, the date and duration of hospital stays were collected from the resource use questionnaire and cross referenced directly with the relevant hospital. A further limitation is the proportion of missing data for the base case analysis. This amount of missing data is not unusual for community based interventions and also reflects the extended duration (24 months) of the randomised controlled trial. Principally this indicates failure of a proportion of patients to complete the SF-36 at all four time points. Although the amount of missing data may affect the generalisability of the findings, the characteristics of patients excluded from the base case analysis were broadly similar to those who were included.
We assessed the cost effectiveness of acupuncture treatment for low back pain using systematic and transparent methods. A previous study assessed the cost effectiveness of acupuncture for headache using similar methods to those reported here but over a shorter period (12 months) and estimated the incremental cost effectiveness ratio to be £9180.18
As the authors note, however, the incremental cost effectiveness ratio is likely to reduce over longer periods because of increased gains in QALYs. It is difficult to assess the extent to which our results are comparable to those of other studies assessing interventions for low back pain because few studies have assessed the relative costs and effectiveness of treatments for low back pain. Studies have tended to assess effectiveness or costs in isolation and have tended not to use a generic outcome measure such as QALYs that would facilitate comparisons across alternative interventions. One study concluded that chiropractic treatment was more effective than outpatient management for patients with chronic or severe low back pain but did not assess the relative costs of each intervention.19
More recently trials have been reported of physiotherapy, exercise, and manipulation for low back pain.20,21
The trial of physiotherapy did not report cost effectiveness.20
The United Kingdom back pain exercise and manipulation trial showed exercise to have an incremental cost effectiveness ratio of £8300 compared with “best care,” but it did not compare interventions with usual care.21
The open and pragmatic nature of our trial allowed acupuncture care to be compared with usual care in everyday practice. Given that usual care comprised a mix of interventions,5
it was, however, not possible to isolate the costs and effectiveness of individual treatments as part of the package of usual care.22
Recent guidance from NICE indicates that a ceiling ratio of £20 000 per QALY represents the threshold of what the NHS can afford to pay for additional QALYs, unless other arguments exist for adopting the technology.6
If £20 000 is taken as the maximum acceptable cost effectiveness ratio, then acupuncture for the treatment of low back pain seems cost effective.
On the basis of our findings of cost effectiveness, longer term reduction in pain, and the acceptability of acupuncture care to patients as reported in the accompanying clinical paper,5
commissioners of musculoskeletal services would be justified to consider making available the referral of patients in primary care to a short course of traditional acupuncture care for persistent non-specific low back pain.
An evidence base showing the cost utility of acupuncture and other short term packages of care, such as massage, osteopathy, chiropractic, or physiotherapy could facilitate the development of NHS policy on the basis of affordability and allow patients with low back pain to choose their treatment.
What is already known on this topic
Many people seek acupuncture care for low back pain
No rigorous assessments have been made of the cost effectiveness of such care
What this study adds
A short course of acupuncture (up to 10 sessions) for low back pain is associated with increased costs to the United Kingdom's health service but improved health related quality of life in the long term
If decision makers are willing to pay up to £20 000 to gain one quality adjusted life year, then acupuncture for low back pain seems cost effective