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

Introduction

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).

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.

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.

Editorial by Thompson and Feder Methodological details are on bmj.com