About 80% of patients with knee osteoarthritis who attended MSK CATS in 2008 and were considered candidates for TKR surgery were willing to try acupuncture first. Ninety patients were screened for acupuncture in this NHS service offering treatment in groups. Of these 90 patients, we know that at least 31 had not had TKR within the following 2 years.
The strengths of this evaluation are the completeness of MSK CATS and clinic records and the detail of patient follow-up attendance data throughout their association with the clinics. Given the age and health status of many who attended, it is remarkable that only 30% of patients had to be classified as lost to follow-up. The evaluation's limitations include missing MYMOP scores on a proportion of patients owing to pressures on clinic nurses’ time and lack of administrative support and lack of information on the eventual outcome of patients who discontinued acupuncture. Another limitation is due to a subtle shift in reason for referral to MSK CATS over time: GPs started to refer patients to MSK CATS specifically for acupuncture treatment, including some who did not want, or were not fit for, surgery. It was decided that to deny them acupuncture would be unethical and so some patients who do not meet the criteria were included on a case-by-case basis.
Estimating the cost consequences of these acupuncture clinics is necessarily somewhat speculative. We set out our data, assumptions and estimations in the web-based Appendix
. Practices charge £20 per treatment, which comfortably covers running costs. The estimated cost to the primary care trust of providing acupuncture for these 90 patients was £16 440 in the first year and about £30 000 over the whole period of this evaluation. The NHS tariff cost of uncomplicated TKR (code 9HB21C) is £5456.17
A total of 41 patients had acupuncture and not surgery in the first 12 months, of whom 31 had not had surgery at the end of 2 years—and anecdotally were unlikely to undergo surgery in the near future since none discussed this with nurses in the clinics. Deferring treatment costs frees up resources for the current year, and health economists reflect this benefit by ‘discounting’ costs at the current rate, which is 3.5%.18
Assuming that only about two-thirds of patients offered surgery would take up the offer in the first year, our ‘best guess’ estimate of realistic cost consequences is that the acupuncture service would achieve savings of about £100 000 a year. Sensitivity analysis using different assumptions suggests that maximum savings might be in the region of £171 000 a year and in the ‘worst-case scenario’ the service could generate net costs of about £7000 a year.
We are reluctant to extrapolate the data from this service evaluation to other health trusts and other settings, but we note that there are four commissioning groups in this primary care health trust and there are about 100 similar trusts in England altogether.
The numbers of recorded episodes of TKR for STAHCOM and the neighbouring three commissioning groups are presented in . The original data are presented in the web-based Appendix
. Rate fluctuations are considerable and likely to be due to many factors, but in the third and fourth years after introduction of the acupuncture service in the STAHCOM commissioning group, this group had the lowest proportional number of TKRs: about 3% lower than the Dacorum area practised-based commissioning group (DACCOM) in 2010 and 10% lower in 2011. The same differences are seen using 2007 or 2008 as baseline, but using 2006 as baseline, STAHCOM shared the lowest place with DACCOM. In addition, orthopaedic surgeons reported to one of us (MB) that referrals from the MSK CATS were more appropriate in STAHCOM than the other commissioning groups, which could be partly due to the availability of acupuncture.
Annual episodes of knee replacement surgery for St Albans and Harpenden practice based commissioning group (STAHCOM) compared with neighbouring groups (data standardised to 2005–6 baseline). Acupuncture clinic started in 2008.
The savings achieved by avoiding TKR in some patients could be used to make acupuncture treatment available for others, even if not specifically to avoid surgery. For example, some decline the offer—as many as 30% of patients in one survey19
—and others are not eligible. Criteria for surgery are highly variable and there is no clear indication who will have the best results.20
Although TKR is successful in the sense that revision rates are low, as many as 15% of patients experience severe knee pain 3–4 years later21
and 18% are dissatisfied with the results.22
Experts recommend that all conservative options should be offered before resorting to surgery.20
The evidence published on acupuncture in patients with knee osteoarthritis shows that it is safe23
and effective in reducing pain and improving function,24
thus qualifying it as an appropriate conservative treatment for this condition.
Similar cost savings from reduced use of secondary care through acupuncture have been described before. Three randomised controlled trials of acupuncture for knee pain reported an incidental finding of reduced demand for surgery.25–27
Lindall used (individual) acupuncture in primary care for patients who would otherwise have been referred to orthopaedic or rheumatology outpatients: savings were calculated to be about £232 per patient (1999 figures) in consultation costs alone.28
Other reports have suggested that acupuncture achieves reduced drug expenditure.29
Formal economic analyses have assessed cost-effectiveness of acupuncture for knee osteoarthritis as £3889 per quality-adjusted life-year (QALY) for health costs alone31
and €22 314 per QALY from a societal perspective.32
Possible concerns about delaying surgery include risk of clinical deterioration. There is evidence that surgery in patients with a worse condition is less likely to be successful, particularly with valgus deformity progressing beyond 25°.33
It is important to monitor all patients attending such clinics specifically for valgus deformity and for overall function for example with the Oxford Knee Score.34
In conclusion, this first evaluation of nurse-led group acupuncture clinics for patients with knee osteoarthritis, including 2 year follow-up, shows the practicability of offering a low-cost acupuncture service as an alternative to knee surgery and its success in achieving long-term symptom relief in about a third of patients. The realistic cost consequences for the local commissioning group are an estimated saving of about £100 000 a year.
Additional data are published online only. To view this file please visit the journal online (http://dx.doi.org/10.1136/acupmed-2012-010151).
- Nurse-led group acupuncture is offered to patients who would be referred for orthopaedic surgery.
- 80% of patients accept, and 30% who try it gain sufficient symptom relief to avoid surgery.
- Savings for this commissioning group were about £100,000 per annum.