Editor—We would like to correct an error in Thompson and Feder's description of the methodology of our systematic review of UK cost effectiveness studies of complementary and alternative medicine (CAM).1,2 We did not search for randomised studies. We included all prospective, controlled studies of any CAM modality carried out in the UK. All five happened to be randomised.
That there were only five such studies restricted to spinal manipulation (four studies) and acupuncture (one) and that only three of them make useful comparisons with usual care, underlines the paucity of such data in the UK. A further study on acupuncture for back pain has a similar result: a small effect size of questionable clinical significance in a trial design without patient blinding or sham control and a favourable estimate of cost per quality adjusted life year (QALY).3 Such studies may simply be estimating the cost effectiveness of placebo treatment. Pragmatic designs do not, as is often argued, resemble real life treatments any more than gold standard randomised clinical trials; they are just methodologically weaker.
Counting Cochrane reviews is a simplistic method of assessing the current evidence base in CAM and seems to contradict Thompson and Feder's call for each modality to be assessed on its own merits. It makes more sense to look at the most recent and comprehensive systematic reviews for each modality. Sixteen systematic reviews of spinal manipulation for various indications have been published since 2000, 13 of them concluding that its effectiveness remains unproved. Acupuncture has enjoyed a stronger evidence base, but an updated systematic review to be published shortly seems to show that effect sizes are becoming smaller as clinical trials use more rigorous designs and larger sample sizes.4 The results of large scale clinical trials of acupuncture carried out in Germany will also be published shortly and are expected to indicate that the effectiveness of real and sham treatment are similar.4
Despite this and the paucity of cost effectiveness data, Thompson and Feder advocate getting on with the incorporation of CAM into NHS guidelines and appear nervous in case that task is left to the National Institute for Health and Clinical Excellence (NICE). This debate is clearly more to do with politics than with scientific medicine.
Competing interests: None declared.
References
- 1.Thompson T, Feder G. Complementary therapies and the NHS. BMJ 2005;331: 856-7. (15 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Canter PH, Thompson Coon J, Ernst E. Cost effectiveness of complementary treatments in the United Kingdom: systematic review. BMJ 2005;331: 880-1. (15 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Thomas KJ, MacPherson H, Ratcliffe J, Thorpe L, Brazier J, Campbell M, et al. Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain. Health Technology Assessment 2005;9:No 32. [DOI] [PubMed]
- 4.Linde K. Acupuncture for chronic pain: an update of systematic reviews. Twelfth annual symposium on complementary health care, Exeter, September 2005.