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$92886/QALY (SF-6D) | ||||||||
| 97% BMJ | ||||||||||
-
*The use of the term ‘adjunctive’ in this column indicates complementary and alternative medicine (CAM) therapies used in addition to usual care for that condition unless otherwise indicated.
-
†Study design: R, randomised; MC, matched controls and/or results statistically adjusted for baseline differences. A modified Jadad score (maximum score = 4) is provided if the study was randomised. If the study was a CUA and a quality score was available from the Tufts Medical Center Institute for Clinical Research and Health Policy Studies CEA Registry (https://research.tufts-nemc.org/cear/Default.aspx), it is reported. Quality scores range from 1 to 7 with 7 representing the highest quality. The last number is the percent of the applicable items on the BMJ 35-item quality checklist that this study met. If a study had more than one publication, both percentages were reported. The BMJ checklist is found in Drummond et al.41
-
‡The costs reported in each study were first converted to US$ using the Federal Reserve annual exchange rate (http://www.federalreserve.gov/releases/g5a/20090102/, 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 (http://www.bls.gov/cpi/cpi_dr.htm#2007, 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.
