Cost-Effectiveness of Acupuncture Needling for Older Adults With Chronic Low Back Pain

Abstract

Study design: Preplanned economic evaluation alongside a clinical trial.

Objective: Determine the 1-year cost-effectiveness from health care sector and Medicare perspectives of adding either standard acupuncture (SA; ≤15 treatment sessions over 12 wk) or enhanced acupuncture (EA; SA plus ≤ 6 additional sessions) to usual medical care (UMC) versus UMC alone.

Summary of background data: Chronic low back pain (CLBP) is common and expensive to treat largely due to the use of non-guideline-concordant pharmaceuticals and procedures. CLBP is also more common in older populations. Acupuncture has been shown to be effective and cost-effective for CLBP, but no studies have focused specifically on older adults.

Methods: Cost-utility and cost-effectiveness analyses comparing SA and EA to UMC using data from a randomized trial across three US health care systems. Bias-corrected and accelerated bootstrap techniques were used to generate 95% CIs.

Results: EA (n=225) reduced annual back pain-related health care sector costs by $491 (CI: -$2861, $1144) per participant versus UMC (n=225), and reduced Medicare-reimbursed costs by $421 (CI: -$2707, $1249) per participant. These cost savings came with a statistically and clinically significant gain in quality-adjusted life-years (QALYs; 0.037; CI: 0.013, 0.062), and a significant increase in the percentage of participants achieving a clinically meaningful improvement (CMI) in their Roland-Morris Disability Questionnaire scores (18.5% points; CI: 9.0%, 27.9%). SA (n=222) was more expensive than UMC; the incremental cost-effectiveness ratio from the health care sector perspective was $52,897/QALY. The QALY gains (0.014; CI: -0.014, 0.043) and increase in percentage of participants with a CMI (6.9%; CI: -2.7%, 16.4%) in SA versus UMC were not statistically significant.

Conclusion: EA was cost-saving and SA may be cost-effective from the health care sector and Medicare perspectives compared with UMC for older adults with CLBP in three large health care systems in California and Washington State.

Level of evidence: Level II.

Keywords: acupuncture; chronic low back pain; cost savings; cost-effectiveness analysis; cost-utility analysis; economic evaluation; health care utilization; maintenance care; medicare; older adults.

Figure 1.

Flow of participants through the trial comparing standard acupuncture with enhanced acupuncture and usual medical care for older adults with chronic low-back pain. *Full healthcare utilization data were not available at Institute for Family Health sites as they only provide primary care. A total of 5 subjects were also dropped because they were no longer enrolled in their health plan for the study year.

Figure 2.

Cost-effectiveness plane showing total healthcare-sector cost and quality-adjusted life-year (QALY) gain pairs over 1000 bootstrapped replications for standard acupuncture (SA) versus usual medical care (UMC; diamonds) and enhanced acupuncture (EA) versus usual medical care (UMC; squares) for chronic low-back pain in older adults over 1 year. Cost-QALY pairs below the dashed line have incremental cost-effectiveness ratios that are less than $100,000 per QALY.

Figure 3.

Cost-effectiveness acceptability curves showing the probability of cost-effectiveness from a healthcare-sector perspective across different assumptions as to willingness to pay for a quality-adjusted life-year (QALY) for standard acupuncture (SA) compared to usual medical care (UMC; dashed line) and enhanced acupuncture (EA) compared to usual medical care (UMC; solid line).