BMJ Open 2: doi:10.1136/bmjopen-2012-001046
  • Health economics
    • Research

Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations

Table 4

Summary of results of complementary and integrative medicine (CIM) economic evaluations that met five study-quality criteria (31 articles representing 28 studies)

CIM therapy compared to usual care alone* Treatment duration/study duration Patient population Primary outcome(s) Setting (information often limited by what was reported) Sample size Study design and quality scores† Resource use (trials), parameters (models), and unit costs (both) reported separately? Form and perspective of economic evaluation Incremental cost-effectiveness ratio (2011 US$)‡
Acupuncture studies
 Brown et al54 Adjunctive acupuncture, manual therapy, injections and other pain management Up to 1 year/1 year Patients referred for an orthopaedic outpatient consultation who were classified as unlikely to require surgery Clinical: SF-36 and, if appropriate, Aberdeen Low Back Pain Scale or Edinburgh Knee Function Scale; economic: EQ5D Individualised care from one 'physical medicine’ physician in a hospital outpatient clinic in Scotland 829 R (2) 81% Yes CEA-H Cost saving
BMJ CUA-H Cost saving
 van den Berg et al91 Adjunctive breech version acumoxa 2 visits/from 33 weeks to delivery Pregnant women with breech presentation at 33 weeks Economic: percentage of breech presentations at delivery—two ‘main analyses’—with and without the option of external cephalic versions 2 instructional visits to an acupuncturist followed by daily home self-care, the Netherlands NA Decision tree model Yes CEA-P Cost savings
81% BMJ CEA-P Cost savings
 Ratcliffe et al85 and Thomas et al89 Adjunctive acupuncture 3 months/2 years Patients with low-back pain Clinical: bodily pain fm SF-36; economic: QALYs fm SF-6D Up to 10 treatments from a TCM-trained acupuncturist in acupuncture clinic in the UK 239 R (3) Yes CUA-S Cost saving
Tufts 5 CUA-P US$8755/QALY
94%/94% BMJ
 Kim et al81 Adjunctive acupuncture 10 treatments in 3-month cycles/5 years 60-year-old women with first time acute low-back pain Clinical: Roland-Morris Disability, symptom bothersomeness; economic: QALYs fm literature Hospital-based licensed oriental medical doctors in South Korea NA Markov model Yes CUA-S US$3086/QALY
Tufts 4.5
94% BMJ
 Witt et al97 Adjunctive acupuncture 3 months/6 months Patients with dysmenorrhoea Clinical: pain intensity VAS; economic: QALYs fm SF-6D Up to 15 sessions with a physician trained in acupuncture (A-diploma) in Germany 201 R (3) No CUA-S US$4708/QALY§
Tufts 5.5
77% BMJ
 Witt et al96 Adjunctive acupuncture 3 months/6 months Patients with chronic low-back pain Clinical: Hannover Functional Ability Questionnaire; economic: QALYs fm SF-6D Up to 15 sessions with a physician trained in acupuncture (A-diploma) in Germany 2518 R (3) No CUA-S US$16230/QALY§
Tufts 4.5
73% BMJ
 Witt et al99 Adjunctive acupuncture Up to 15 treatments/3 months Patients with headache Economic: QALYs fm SF-6D 10–15 sessions with physician trained in acupuncture (A-diploma) in Germany 3182 R (2) No CUA-S US$18225/QALY§
Tufts 5.5
88% BMJ
 Willich et al94 Adjunctive acupuncture Up to 15 treatments/3 months Patients with chronic neck pain Clinical: Neck Pain and Disability Scale; economic: QALYs fm SF-6D 10–15 sessions with physician trained in acupuncture (A-diploma) in Germany 3451 R (2) No CUA-S US$19226/QALY§
Tufts 5
88% BMJ
 Wonderling et al100 and Vickers et al93 Adjunctive acupuncture 3 months/1 year Patients with chronic headache Clinical: headache severity score; economic: QALYs fm SF-6D Acupuncture-trained physiotherapists in own clinics in the UK 401 R (3) Yes CUA-S US$19785/QALY
Tufts 5 CUA-P US$21074/QALY
97%/93% BMJ
 Reinhold et al86 Adjunctive acupuncture 3 months/3 months Patients with chronic hip or knee osteoarthritis Economic: QALYs fm SF-6D 10–15 sessions with physician trained in acupuncture (A-diploma), Germany 489 R (3) No CUA-S US$27900/QALY§
Tufts 4
87% BMJ
 Witt et al98 Adjunctive acupuncture Up to 15 treatments/3 months Patients with allergic rhinitis Economic: QALYs fm SF-6D 10–15 sessions with physician trained in acupuncture (A-diploma) in Germany 981 R (3) No CUA-S US$28137/QALY§
Tufts 4
94% BMJ
Manipulative and body-based practices—see also Brown et al
 Korthals-de Bos et al82 Manual therapy 6 weeks/1 year Patients with neck pain Clinical: perceived recovery, pain VAS, and Neck Disability Index; economic: All clinical plus QALYs fm EQ-5D Up to 6 weekly 45 min sessions with a physiotherapist who is also a registered manual therapist in the Netherlands 183 R (3) Yes CEA-S Cost saving
Tufts 6.5 CEA-S Cost saving
83% BMJ CEA-S Cost saving
CUA-S Cost saving
 Williams et al71 Adjunctive osteopathic spinal manipulation 2 months/6 months Patients with subacute (2–12 week) back pain Clinical: Extended Aberdeen Spine Pain Scale; economic: QALYs fm EQ-5D 3 or 4 sessions with a general practitioner who is a registered osteopath at own clinic in UK 187 R (3) Yes CUA-P US$8730/QALY
Tufts 5
89% BMJ
 UK BEAM Trial Team68 Adjunctive spinal manipulation and exercise 3 months/1 year Patients with low-back pain Economic: QALYs fm EQ-5D 8 sessions with a chiropractor, osteopath, or physiotherapist at a private or NHS site in the UK 1287 R (3) Yes CUA-P US$8425/QALY
Adjunctive spinal manipulation Tufts 6 CUA-P US$10642/QALY
93% BMJ
 Hollinghurst et al62 Alexander technique 6 lessons/1 year Patients with chronic or recurrent non-specific back pain Clinical: Roland-Morris Disability Questionnaire (RMDQ); economic: above plus QALYs fm EQ-5D Alexander technique teachers and massage therapists at own locations in the UK 579 R (3) Yes CUA-P US$13300/QALY
CEA-P US$255/RMDQ pt
  Alexander technique plus exercise¶ 6 lessons/1 year Tufts 5.5 CUA-P US$12022/QALY
CEA-P US$144/RMDQ pt
Massage 6 sessions/1 year 97% BMJ CUA-P Dominated
CEA-P US$1010/RMDQ pt
Massage plus exercise¶ 6 sessions/1 year CUA-P US$11959/QALY
CEA-P US$354/RMDQ pt
 Haas et al60 Treatment in a chiropractic clinic Unspecified/1 year Patients with acute low-back pain Clinical and economic: pain severity 100 mm VAS and revised Oswestry Disability Questionnaire Doctors of Chiropractic in own clinics in Oregon, the USA 1943 MC No CEA-P US$21/pain mm
Patients with chronic low-back pain 837 66% BMJ CEA-P US$0.73/pain mm
Natural products
 Braga et al102 Adjunctive preoperative arginine and ω-3 fatty acid supplementation 5 days/5 days plus hospital stay Patients with gastrointestinal cancer undergoing surgery Economic: percentage of patients without complications 12.5 g arginine, 3.3 g ω-3 fatty acids and 1.2 g RNA in liquid daily taken orally for 5 days before surgery, Italy 204 R (3) No CEA-H Cost saving
88% BMJ
 Stevenson et al103 and Stevenson et al88 Vitamin K1 10 years/10 years Postmenopausal women with osteoporosis/osteopenia Clinical: osteoporotic fracture; economic: QALYs fm the literature 10 mg/day of vitamin K1 daily, the UK NA Patient-level simulation model Yes CUA-P Cost saving
Tufts 4.5
81%/84% BMJ
 Trevithick et al90 Adjunctive antioxidants (vitamins C and E and β-carotene) 25 years/25 years Cohort of Ontario residents aged 50–54 (prevention of cataracts) Clinical: cataract formation 750 mg/day vitamin C, 600 mg/day vitamin E and 18 mg/day β-carotene daily, Canada NA Markov-type cohort model Yes CEA-P Cost saving
79% BMJ
 Schmier et al87 Adjunctive ω-3 fatty acid supplementation 42 months/42 months Males with a history of a heart attack Economic: fatal MIs and cardiovascular deaths ‘Fish oil pills', the USA NA Decision analytic model Yes CEA-S Cost saving
77% BMJ CEA-P US$11903/fatal MI avoided
 Lamotte et al83 Adjunctive ω-3 polyunsaturated fatty acids 3.5 years/lifetime Patients after an acute myocardial infarction Economic: life-years saved ∼465 mg EPA and ∼385 mg DHA ethyl esters in a daily gelcap, Australia, Belgium, Canada, Germany and Poland NA Decision tree model Yes CEA –P US$5413/LYG Australia
89% BMJ CEA –P US$8184/LYG Belgium
CEA –P US$4476/LYG Canada
CEA –P US$6750/LYG Germany
CEA –P US$7747/LYG Poland
 Quilici et al84 Adjunctive ω-3 polyunsaturated fatty acids 4 years/lifetime Patients after an acute myocardial infarction Economic: life-years gained (LYG), QALYs fm the literature, deaths avoided ∼465 mg EPA and ∼385 mg DHA ethyl esters in a daily gelcap, the UK NA Markov model Yes CEA –P US$28420/LYG
Tufts 5 CUA-P US$35940/QALY
93% BMJ
 Franzosi et al79 Adjunctive ω-3 polyunsaturated fatty acids 3.5 years/3.5 years Patients with recent myocardial infarction Clinical: death and non-fatal MI or stroke; economic: LYG ∼465 mg EPA and ∼385 mg DHA ethyl esters in a daily gelcap, Italy 5664 R (4) No CEA-P US$41867/LYG
85% BMJ
 Black et al78 Adjunctive glucosamine sulphate 22.6 years/22.6 years Patients with osteoarthritis of the knee Clinical: pain, function, joint space loss; economic: QALYs fm the literature Glucosamine sulphate powder 1500 mg daily in oral solution, the UK NA Cohort simulation model Yes CUA-P US$59053/QALY
84% BMJ
Other complementary and integrative medicine therapies
 Wilson and Datta95 Adjunctive yang-style tai chi 1 year/1 year Nursing home residents at average risk for a fall Economic: hip fractures avoided 2 classes/week monitored by a certified tai chi instructor and an assistant, the USA NA Decision tree model Yes CEA-P Cost saving
96% BMJ
 Herman et al80 Adjunctive naturopathic care including acupuncture, relaxation exercises, dietary and exercise advice 3 months/6 months Patients with chronic low-back pain Clinical: Oswestry Disability Questionnaire; economic: QALYs fm SF-6D Twice weekly visits to licensed naturopathic doctors also trained in acupuncture in a worksite clinic in Canada 70 R (3) Yes CUA-S Cost saving
Tufts 5 CEA-E US$191/absentee day avoided
96% BMJ CBA-E Cost saving
 Van Tubergen et al92 Combined spa-exercise therapy 3 weeks/40 weeks Patients with ankylosing spondylitis Clinical: Bath Ankylosing Spondylitis Functional Index (BASFI 10pts), pain VAS, well-being VAS and morning stiffness in minutes; economic: above plus QALYs fm EQ-5D 3-week stay at one of two spa-resorts with therapy provided by trained physiotherapists, the Netherlands 120 R (3) Yes CEA-S US$2159/BASFI pt (spa in Austria)
Tufts 4.5 CEA-S US$4215/BASFI pt (spa in the Netherlands)
90% BMJ CUA-S US$12703/QALY (spa in Austria)
CUA-S US$31609/QALY (spa in the Netherlands)
 Zijlstra et al101 Adjunctive spa therapy 2.5 weeks/1 year Patients with fibromyalgia Economic: QALYs fm VAS and SF-6D 18-day stay at a spa in Tunisia with a variety of treatments, the Netherlands 128 R (3) Yes CUA-S US$46443/QALY (VAS)
Tufts 4 CUA-S US$92886/QALY (SF-6D)
97% BMJ
  • *The use of the term ‘adjunctive’ in this column indicates complementary and alternative medicine (CAM) therapies used in addition to usual care for that condition unless otherwise indicated.

  • †Study design: R, randomised; MC, matched controls and/or results statistically adjusted for baseline differences. A modified Jadad score (maximum score = 4) is provided if the study was randomised. If the study was a CUA and a quality score was available from the Tufts Medical Center Institute for Clinical Research and Health Policy Studies CEA Registry (, it is reported. Quality scores range from 1 to 7 with 7 representing the highest quality. The last number is the percent of the applicable items on the BMJ 35-item quality checklist that this study met. If a study had more than one publication, both percentages were reported. The BMJ checklist is found in Drummond et al.41

  • ‡The costs reported in each study were first converted to US$ using the Federal Reserve annual exchange rate (, accessed 30 Jan 2012) for the study's currency year and then inflated to 2011 values using the medical care component of the Consumer Price Index (, accessed 30 Jan 2012). In comparisons labelled as cost saving the CIM therapy both improved health and lowered costs compared to usual care. In the comparison labelled dominated the CIM therapy had worse health outcomes and higher costs than usual care.

  • §These studies did not report a currency year so it was estimated as being 1 year prior to publication.

  • ¶Compared to usual care plus exercise.

  • CBA, cost-benefit analysis; CEA, cost-effectiveness analysis; CUA, cost-utility analysis; DHA, Docosahexaenoic acid; E, employer perspective; EPA, Eicosapentaenoic acid; H, hospital perspective; MI, myocardial infarction; P, payer perspective; QALY, quality-adjusted life-year; S, societal perspective; VAS, visual analogue scale.

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