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

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Abstract

Objective

A comprehensive systematic review of economic evaluations of complementary and integrative medicine (CIM) to establish the value of these therapies to health reform efforts.

Data sources

PubMed, CINAHL, AMED, PsychInfo, Web of Science and EMBASE were searched from inception through 2010. In addition, bibliographies of found articles and reviews were searched, and key researchers were contacted.

Eligibility criteria for selecting studies

Studies of CIM were identified using criteria based on those of the Cochrane complementary and alternative medicine group. All studies of CIM reporting economic outcomes were included.

Study appraisal methods

All recent (and likely most cost-relevant) full economic evaluations published 2001–2010 were subjected to several measures of quality. Detailed results of higher-quality studies are reported.

Results

A total of 338 economic evaluations of CIM were identified, of which 204, covering a wide variety of CIM for different populations, were published 2001–2010. A total of 114 of these were full economic evaluations. And 90% of these articles covered studies of single CIM therapies and only one compared usual care to usual care plus access to multiple licensed CIM practitioners. Of the recent full evaluations, 31 (27%) met five study-quality criteria, and 22 of these also met the minimum criterion for study transferability (‘generalisability’). Of the 56 comparisons made in the higher-quality studies, 16 (29%) show a health improvement with cost savings for the CIM therapy versus usual care. Study quality of the cost-utility analyses (CUAs) of CIM was generally comparable to that seen in CUAs across all medicine according to several measures, and the quality of the cost-saving studies was slightly, but not significantly, lower than those showing cost increases (85% vs 88%, p=0.460).

Conclusions

This comprehensive review identified many CIM economic evaluations missed by previous reviews and emerging evidence of cost-effectiveness and possible cost savings in at least a few clinical populations. Recommendations are made for future studies.

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Most cited references 67

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Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey.

D M Eisenberg, R B Davis, S L Ettner … (1998)

A prior national survey documented the high prevalence and costs of alternative medicine use in the United States in 1990. To document trends in alternative medicine use in the United States between 1990 and 1997. Nationally representative random household telephone surveys using comparable key questions were conducted in 1991 and 1997 measuring utilization in 1990 and 1997, respectively. A total of 1539 adults in 1991 and 2055 in 1997. Prevalence, estimated costs, and disclosure of alternative therapies to physicians. Use of at least 1 of 16 alternative therapies during the previous year increased from 33.8% in 1990 to 42.1% in 1997 (P < or = .001). The therapies increasing the most included herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy. The probability of users visiting an alternative medicine practitioner increased from 36.3% to 46.3% (P = .002). In both surveys alternative therapies were used most frequently for chronic conditions, including back problems, anxiety, depression, and headaches. There was no significant change in disclosure rates between the 2 survey years; 39.8% of alternative therapies were disclosed to physicians in 1990 vs 38.5% in 1997. The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly between 1990 (64.0%) and 1997 (58.3%) (P=.36). Extrapolations to the US population suggest a 47.3% increase in total visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all US primary care physicians. An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and/or high-dose vitamins (18.4% of all prescription users). Estimated expenditures for alternative medicine professional services increased 45.2% between 1990 and 1997 and were conservatively estimated at $21.2 billion in 1997, with at least $12.2 billion paid out-of-pocket. This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations. Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $27.0 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services. Alternative medicine use and expenditures increased substantially between 1990 and 1997, attributable primarily to an increase in the proportion of the population seeking alternative therapies, rather than increased visits per patient.

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Unconventional medicine in the United States. Prevalence, costs, and patterns of use.

D M Eisenberg, R C Kessler, C. Foster … (1993)

Many people use unconventional therapies for health problems, but the extent of this use and the costs are not known. We conducted a national survey to determine the prevalence, costs, and patterns of use of unconventional therapies, such as acupuncture and chiropractic. We limited the therapies studied to 16 commonly used interventions neither taught widely in U.S. medical schools nor generally available in U.S. hospitals. We completed telephone interviews with 1539 adults (response rate, 67 percent) in a national sample of adults 18 years of age or older in 1990. We asked respondents to report any serious or bothersome medical conditions and details of their use of conventional medical services; we then inquired about their use of unconventional therapy. One in three respondents (34 percent) reported using at least one unconventional therapy in the past year, and a third of these saw providers for unconventional therapy. The latter group had made an average of 19 visits to such providers during the preceding year, with an average charge per visit of $27.60. The frequency of use of unconventional therapy varied somewhat among socio-demographic groups, with the highest use reported by nonblack persons from 25 to 49 years of age who had relatively more education and higher incomes. The majority used unconventional therapy for chronic, as opposed to life-threatening, medical conditions. Among those who used unconventional therapy for serious medical conditions, the vast majority (83 percent) also sought treatment for the same condition from a medical doctor; however, 72 percent of the respondents who used unconventional therapy did not inform their medical doctor that they had done so. Extrapolation to the U.S. population suggests that in 1990 Americans made an estimated 425 million visits to providers of unconventional therapy. This number exceeds the number of visits to all U.S. primary care physicians (388 million). Expenditures associated with use of unconventional therapy in 1990 amounted to approximately $13.7 billion, three quarters of which ($10.3 billion) was paid out of pocket. This figure is comparable to the $12.8 billion spent out of pocket annually for all hospitalizations in the United States. The frequency of use of unconventional therapy in the United States is far higher than previously reported. Medical doctors should ask about their patients' use of unconventional therapy whenever they obtain a medical history.

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Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold.

Scott D Grosse (2008)

Cost-effectiveness analyses, particularly in the USA, commonly use a figure of $50,000 per life-year or quality-adjusted life-year gained as a threshold for assessing the cost-effectiveness of an intervention. The history of this practice is ill defined, although it has been linked to the end-stage renal disease kidney dialysis cost-effectiveness literature from the 1980s. The use of $50,000 as a benchmark for assessing the cost-effectiveness of an intervention first emerged in 1992 and became widely used after 1996. The appeal of the $50,000 figure appears to lie in the convenience of a round number rather than in the value of renal dialysis. Rather than arbitrary thresholds, estimates of willingness to pay and the opportunity cost of healthcare resources are needed.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date (Print): 2012

Publication date Collection: 2012

Publication date (Electronic): 3 September 2012

Volume: 2

Issue: 5

Electronic Location Identifier: e001046

Affiliations

[1 ]Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, Arizona, USA

[2 ]Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA

[3 ]Institute for Social Medicine, Epidemiology and Health Economics, Charite’ University Medical Center, Berlin, Germany

[4 ]Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA

[5 ]Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA

[6 ]Harvard School of Public Health, Boston, Massachusetts, USA

[7 ]Samueli Institute, Alexandria, Virginia, USA

Author notes

[Correspondence to ] Dr Patricia M Herman; pherman@ 123456rand.org .

Article

Publisher ID: bmjopen-2012-001046

DOI: 10.1136/bmjopen-2012-001046

PMC ID: 3437424

PubMed ID: 22945962

SO-VID: 31df1660-505f-4b09-800e-92a91d0d91e9

Copyright © © 2012, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

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

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Abstract

Objective

Data sources

Eligibility criteria for selecting studies

Study appraisal methods

Results

Conclusions

Related collections

Point-of-Care Testing for Infectious Diseases Super Collection

Most cited references 67

Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey.

Unconventional medicine in the United States. Prevalence, costs, and patterns of use.

Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold.

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