Using economic evaluations to support acupuncture reimbursement decisions: current evidence and gaps

Health technology assessment in traditional and complementary medicine: a scoping review of international activity and examples of acupuncture

BACKGROUND

Traditional therapies are crucial in maintaining and improving human well-being. China's healthcare policymakers are attempting to use health technology assessment (HTA) as a decision-making supportive tool. The value assessment framework for Chinese patent medicine (CPM) has been developed and is being adopted and validated widely by research institutions. Subsequently, the healthcare decision-makers particularly hanker for the value framework of traditional non-pharmacological therapies.

METHODS

To construct a practical value framework for traditional non-pharmacological therapies, a scoping review methodology was adopted to identify the evaluation domains and obstacles. A search, screening, and analysis process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Evidence was retrieved from scientific databases and HTA agencies' websites.

RESULTS

The search strategy identified 5 guidelines records and 17 acupuncture HTA reports. By synthesizing the valuable reports of CPM and acupuncture evaluation in representative countries, this study found that Mainland China was promoting the comprehensive value assessment of CPM, whereas the United Kingdom, Singapore, Canada, the United States, and Malaysia had carried out the HTA evaluation of acupuncture for various conditions among which chronic pain was the most common. UK and Singapore applied the HTA results to support acupuncture reimbursement decisions. Three domains, including safety, effectiveness, and economy, were commonly adopted. The identified biggest challenge of evaluating traditional non-pharmacological therapies is the scarce high-quality clinical evidence.

CONCLUSIONS

This study identified value domains and issues of traditional therapies, and pointed out future research implications, to promote the development value framework of traditional therapies.

Overview and quality assessment of health economic evaluations for homeopathic therapy: an updated systematic review

INTRODUCTION

Likewise other medical interventions, economic evaluations of homeopathy contribute to the evidence base of therapeutic concepts and are needed for socioeconomic decision-making. A 2013 review was updated and extended to gain a current overview.

METHODS

A systematic literature search of the terms 'cost' and 'homeopathy' from January 2012 to July 2022 was performed in electronic databases. Two independent reviewers checked records, extracted data, and assessed study quality using the Consensus on Health Economic Criteria (CHEC) list.

RESULTS

Six studies were added to 15 from the previous review. Synthesizing both health outcomes and costs showed homeopathic treatment being at least equally effective for less or similar costs than control in 14 of 21 studies. Three found improved outcomes at higher costs, two of which showed cost-effectiveness for homeopathy by incremental analysis. One found similar results and three similar outcomes at higher costs for homeopathy. CHEC values ranged between two and 16, with studies before 2009 having lower values (Mean ± SD: 6.7 ± 3.4) than newer studies (9.4 ± 4.3).

CONCLUSION

Although results of the CHEC assessment show a positive chronological development, the favorable cost-effectiveness of homeopathic treatments seen in a small number of high-quality studies is undercut by too many examples of methodologically poor research.

Acupuncture and Doxylamine-Pyridoxine for Nausea and Vomiting in Pregnancy : A Randomized, Controlled, 2 2 Factorial Trial

BACKGROUND

An effective and safe treatment for nausea and vomiting of pregnancy (NVP) is lacking.

OBJECTIVE

To assess the efficacy and safety of acupuncture, doxylamine-pyridoxine, and a combination of both in women with moderate to severe NVP.

DESIGN

Multicenter, randomized, double-blind, placebo-controlled, 2 × 2 factorial trial. (ClinicalTrials.gov: NCT04401384).

SETTING

13 tertiary hospitals in mainland China from 21 June 2020 to 2 February 2022.

PARTICIPANTS

352 women in early pregnancy with moderate to severe NVP.

INTERVENTION

Participants received daily active or sham acupuncture for 30 minutes and doxylamine-pyridoxine or placebo for 14 days.

MEASUREMENTS

The primary outcome was the reduction in Pregnancy-Unique Quantification of Emesis (PUQE) score at the end of the intervention at day 15 relative to baseline. Secondary outcomes included quality of life, adverse events, and maternal and perinatal complications.

RESULTS

No significant interaction was detected between the interventions (P = 0.69). Participants receiving acupuncture (mean difference [MD], -0.7 [95% CI, -1.3 to -0.1]), doxylamine-pyridoxine (MD, -1.0 [CI, -1.6 to -0.4]), and the combination of both (MD, -1.6 [CI, -2.2 to -0.9]) had a larger reduction in PUQE score over the treatment course than their respective control groups (sham acupuncture, placebo, and sham acupuncture plus placebo). Compared with placebo, a higher risk for births with children who were small for gestational age was observed with doxylamine-pyridoxine (odds ratio, 3.8 [CI, 1.0 to 14.1]).

LIMITATION

The placebo effects of the interventions and natural regression of the disease were not evaluated.

CONCLUSION

Both acupuncture and doxylamine-pyridoxine alone are efficacious for moderate and severe NVP. However, the clinical importance of this effect is uncertain because of its modest magnitude. The combination of acupuncture and doxylamine-pyridoxine may yield a potentially larger benefit than each treatment alone.

PRIMARY FUNDING SOURCE

The National Key R&D Program of China and the Project of Heilongjiang Province "TouYan" Innovation Team.

Descriptions of sham acupuncture in randomised controlled trials: a critical review of the literature

BACKGROUND

Sham acupuncture is usually used to assess the specific effects of acupuncture. However, the reporting quality of sham acupuncture remains unclear despite its critical importance in understanding and analyzing the effects of acupuncture. This paper presents a literature review aimed at assessing the quality of reporting of sham acupuncture in randomized controlled trials (RCTs) based on STRICTA 2010 and TIDieR-Placebo.

METHODS

Three electronic English-language databases (PubMed, MEDLINE and Embase) were searched from inception to March 7, 2022, and RCTs of sham acupuncture were identified. The reporting quality of sham acupuncture was assessed in accordance with the items recommended in STRICTA 2010 and TIDieR-Placebo. The reporting quality of other items related to sham acupuncture apart from items from these two checklists was also captured to further assess the reporting quality of sham acupuncture.

RESULTS

A total of 609 eligible studies were included. For all of the items recommended in STRICTA 2010 and TIDieR-Placebo, 100% of the studies reported a brief name that described the sham acupuncture, 93.9% studies reported the needle type, and 90.0% reported the names of the points used. Other items for which the reporting rates were above 50% included the number, frequency and duration of treatment sessions; needle retention time; and number of needle insertions per subject per session. Overall, 49.4% of the studies revealed the rationale why sham acupuncture was chosen, 39.7% of the studies involving insertion processes reported the depth of insertion, and 37.9% of the studies reported the needle manufacturer. Other items for which the reporting rates were below 30% included practitioner-related information, response sought, evaluation of blinding, intervention mode and environment, assisting tools, and the extent to which the treatment was varied. The items "Modifications", "How well (planned)" and "How well (actual)" were not reported in any of the analyzed studies.

CONCLUSIONS

The overall reporting quality of sham acupuncture in RCTs was suboptimal. Although STRICTA 2010 and TIDieR-Placebo could be beneficial for describing sham acupuncture, neither can offer recommendations specifically for sham acupuncture. There is thus an urgent need to develop specialized guidelines for reporting sham acupuncture in clinical trials.

Cerebral Blood Flow Velocity Modulation and Clinical Efficacy of Acupuncture for Posterior Circulation Infarction Vertigo: A Systematic Review and Meta-Analysis

Background

Vertigo is a cardinal symptom of posterior circulation infarction (POCI). Acupuncture is demonstrated to have a beneficial effect on posterior circulation infarction vertigo (PCIV). However, the mechanism of acupuncture therapy is not clarified. This study aims to assess the cerebral blood flow velocity modulation and clinical efficacy of acupuncture for PCIV patients.

Methods

We conducted this systematic review for clinical randomized controlled trials (RCTs) regarding acupuncture on PCIV. The study duration was from September 2020 to September 2021. We searched the PubMed, EMBASE, Cochrane Library, Web of Science, Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Wanfang Database, and VIP. The publication date was set from inception to August 31, 2020. Based on the inclusion and exclusion criteria, two researchers independently screened literature and extracted data including basic study information, intervention details, outcome details, and adverse events. Outcome measures included the blood flow velocities of vertebrobasilar arteries and the Clinical Effective Rate of posterior circulation infarction vertigo. Pooled data were presented as standardized mean differences (SMDs) and relative risks (RR), with 95% confidence intervals (CIs). The meta-analysis was conducted using Review Manager software version 5.3.0.

Results

A total of 20 eligible RCTs (1541 participants) were included in this review, which compared acupuncture therapy (1 RCT) or acupuncture combined with pharmaceutical therapy (19 RCTs) to pharmaceutical therapy in patients with posterior circulation infarction vertigo. 7 studies assessed the blood flow velocities of the basilar artery examined by Transcranial Doppler (TCD), 8 studies assessed the bilateral vertebral arteries, and 13 studies evaluated the Clinical Effective Rate of posterior circulation infarction vertigo. Meta-analysis results showed that blood flow velocities of the basilar artery (SMD = 0.58, 95% CI = 0.40-0.76; P < 0.05), left vertebral artery (SMD = 0.48, 95% CI = 0.22-0.73; P < 0.05), and right vertebral artery (SMD = 0.44, 95% CI = 0.19-0.69; P < 0.05) were significantly higher in the acupuncture group compared with the control group. Clinical Effective Rate (RR = 1.22, 95% CI = 1.15-1.29; P  =  0.792) was significantly better in the acupuncture group compared with the control group.

Conclusions

This study shows that acupuncture therapy is useful in improving the blood flow velocity of vertebrobasilar arteries and Clinical Effective Rate in patients with posterior circulation infarction vertigo. However, double-blind, sham-controlled trials with large sample sizes are required to support our conclusions.