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

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

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).

Table 1.

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

Modality, year	Participants and indication	Design and interventions	Results for main outcome measures	Economic analysis
Acupuncture, 20041	Primary care patients (18-65 years)	12 month RCT	12 month headache score (patients' diaries) reduced by 34% in A, 16% in UC (P=0.0002)	Total costs: UC £217; A £403
	Chronic headache mainly migraine (n=401)	UC=usual care, A=usual care and acupuncture (up to three sessions in three months)		NHS costs: UC £89; A £290
				Patient's costs: UC £129; A £114
				Incremental cost to NHS excluding prescriptions: £205
				Incremental health gain: 0.021 QALY (P=0.02).
				Cost per QALY: £9180.
Manipulation, 19952	Patients attending hospital or chiropractic clinics (18-65 years)	12 month RCT	Oswestry back pain questionnaire favoured C; mean change (95% CI):	Direct treatment costs: C £165; H £111
	Back pain (n=741)	C=individualised chiropractic manipulation (up to 10 sessions in 12 months)	1.69 (−0.74 to 4.12; NS] at six weeks,
		H=individualised Maitland mobilisation or manipulation by hospital staff	3.31 (0.51 to 6.11; P<0.05) at six months
			2.04 (−0.71 to 4.79; NS) at 12 months
			3.02 (0.08 to 5.96; P<0.02) at two years
			3.18 (0.16 to 6.20, P<0.05) at three years
Manipulation, 20003	Orthopaedic patients (18-60 years)	12-month RCT	Leg pain: NS at two weeks, six weeks, and 12 months	Direct treatment costs: CN £800; M £220
	Symptomatic lumbar disc herniation (n=40)	CN=chemonucleolysis	Back pain: favoured M at two weeks and six weeks (P=unreported), NS at 12 months	Estimated incremental cost of CN over M in a year including cost of therapeutic failures: £300 a patient
		M=osteopathic manipulation (variable number of 15 minute sessions in 12 weeks)	Roland disability questionnaire: favoured M at two weeks (P=unreported), NS at six weeks and 12 months
Manipulation, 20044	Primary care patients (16-25 years)	Six month RCT	Extended Aberdeen spine pain scale: Favoured M over UC (95% CI 0.7 to 9.8) at two months, NS at six months	Mean healthcare costs for spinal pain for six month of trial: M £129; UC £64
	Subacute spinal pain (n=210)	UC=usual primary care		Total mean health care costs: M £328; UC £307
		M=usual primary care and osteopathic spinal manipulation (three sessions)		Cost per QALY: M relative to UC £3560
Manipulation and exercise, 20045	Primary care patients (18-65 years)	12 month RCT	Roland Morris disability score (95% CI):	Incremental cost relative to PC: E £140; M £195; EM £125
	Chronic back pain (n=1334)	PC=primary care	E>PC at three months 1.4 (0.6 to 2.1), NS at 12 months	Cost per QALY: E dominated by EM and excluded; M relative to PC £4800; M relative to EM £8700; EM relative to PC £3800.
		M=primary care and manipulation (2-8 sessions in 12 weeks)	M>PC at three months 1.6 (0.8 to 2.3) and 12 months 1.0 (0.2 to 1.8)
		E=primary care and exercise classes (up to eight in 4-8 weeks and refresher at 12 weeks)	EM>PC at three months 1.9 (1.2 to 2.6) and 12 months 1.3 (0.5 to 2.1)
		EM=primary care and manipulation (up to eight in six weeks) and exercise classes (up to eight in next six weeks and refresher at 12 weeks)

RCT=randomised clinical trial; NS=not statistically significant; QALY=quality adjusted life years.

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; €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.