Economic evaluation of acupuncture as an adjunctive treatment with usual care for mild-to-moderate knee osteoarthritis: A Markov model-based analysis
Hyun et al. · Integrative Medicine Research · 2023
Evidence Level
MODERATEOBJECTIVE
Evaluate the cost-effectiveness of acupuncture combined with conventional care in Korean women with mild-to-moderate knee osteoarthritis
WHO
Korean women aged 50 years with mild-to-moderate knee osteoarthritis
DURATION
10-year model with 6-month cycles
POINTS
Traditional Chinese manual acupuncture per physician guidance
🔬 Study Design
Conventional Care
n=5000
Diagnosis, basic physical therapy, and oral medications/injections
Collaborative Care
n=5000
Conventional care + 12 acupuncture sessions
📊 Results in numbers
Incremental cost-effectiveness (base case)
Probability of cost-effectiveness
Cost-effectiveness range
Additional cost per cycle
Percentage highlights
📊 Outcome Comparison
Total 10-year cost (USD)
Total utility (QALY)
This study shows that adding acupuncture to conventional treatment for knee osteoarthritis is economically advantageous in Korea. Although the cost is higher, the quality-of-life benefits justify the investment, and the approach is considered cost-effective by international standards.
Article summary
Plain-language narrative summary
Knee osteoarthritis (KOA) is a chronic condition that affects more than 650 million people worldwide and is particularly prevalent in Asia, especially in Korea. This innovative study conducted the first economic evaluation of acupuncture as an adjunctive treatment for mild-to-moderate knee osteoarthritis in Korean women, using a sophisticated Markov model analysis. The research was motivated by the growing need for economic evidence supporting integrative therapies, considering that Korea has a unique health care system in which conventional medicine and traditional Korean medicine officially coexist. The researchers developed a Markov model that simulated disease progression over 10 years, comparing two therapeutic strategies: conventional care alone versus collaborative care (conventional care plus acupuncture).
The model included five health states based on the Kellgren-Lawrence classification, ranging from minor osteoarthritis to death, with particular focus on mild-to-moderate osteoarthritis, where medical interventions are implemented. Conventional treatment was defined based on international clinical guidelines and included diagnosis by physical examination and radiography, basic physical therapy, oral nonsteroidal anti-inflammatory drugs, and intra-articular hyaluronic acid injections. Collaborative treatment added 12 sessions of traditional Chinese manual acupuncture performed by physicians specialized in Korean medicine. The economic analysis was conducted from three perspectives: limited societal, full societal, and health care system, including direct medical, direct non-medical, and indirect costs.
Costs were estimated using micro-costing based on the Korean health care system, in which acupuncture is reimbursed by national health insurance at a relatively low cost of 7 USD per session. Utilities were based on the EuroQol-5D questionnaire and quality-adjusted life years, with evidence derived from international randomized clinical trials. The results consistently demonstrated that collaborative care is cost-effective. In the base-case analysis, the incremental cost-effectiveness ratio was 11,085 USD per quality-adjusted life year, well below the 20,000 USD/QALY threshold used in Korea.
All univariate sensitivity analyses maintained ratios below the threshold, ranging from -2,577 to 16,748 USD/QALY. Particularly striking was the result from the societal perspective, which showed a negative ratio, indicating that collaborative care may be economically dominant when indirect costs are taken into account. The probabilistic sensitivity analysis confirmed these findings, with a 70.27% probability of cost-effectiveness at the established threshold. The clinical implications are significant for health care systems considering the integration of acupuncture into knee osteoarthritis management.
The study suggests that, at least in the Korean context, adding acupuncture to conventional care represents an efficient use of health care resources. This is particularly relevant given that acupuncture is associated with improvements in pain, quality of life, and function, as established in Korean guidelines. The study acknowledges several important limitations, including a limited evidence base for effectiveness, with data derived mainly from international studies that may not perfectly reflect the Korean context. In addition, the analysis was restricted to women aged 50 years, limiting generalizability to other populations.
The potential performance bias in acupuncture studies due to the difficulty of blinding also represents a methodological limitation. Despite these limitations, this pioneering study provides valuable evidence for health policy decision makers, suggesting that integrative medicine may be an economically viable strategy for the management of knee osteoarthritis.
Strengths
- 1First economic evaluation of acupuncture for knee osteoarthritis in Korea
- 2Sophisticated Markov model with expert validation
- 3Multiple sensitivity analyses confirming robustness of results
- 4Inclusion of direct and indirect costs across multiple perspectives
- 5Based on official clinical guidelines and national statistical data
Limitations
- 1Effectiveness evidence based on heterogeneous international studies
- 2Analysis restricted to women aged 50 years limiting generalizability
- 3Potential performance bias due to inability to blind
- 4Parameter uncertainty due to limited domestic evidence
Expert Commentary
Dr. Marcus Yu Bin Pai
MD, PhD · Pain Medicine · Physical Medicine and Rehabilitation · Medical Acupuncture
▸ Clinical Relevance
The economic evaluation of interventions for knee osteoarthritis is directly relevant for clinicians who manage chronic musculoskeletal pain, because the decision to incorporate acupuncture into the protocol is no longer purely clinical but now has quantifiable economic support. With an incremental cost-effectiveness ratio of 11,085 USD per QALY — well below the Korean threshold of 20,000 USD — and a 70.27% probability of cost-effectiveness in the probabilistic analysis, the model offers concrete arguments for health care administrators and payers who still view acupuncture as an additional cost with no measurable return. The most applicable scenario is the middle-aged woman with mild-to-moderate osteoarthritis and incomplete response to NSAIDs and conventional physical therapy — precisely the profile that populates physiatry and rheumatology clinics. The full societal perspective, which reached negative ratios, signals that reduced absenteeism and lost productivity may make the intervention economically dominant, a relevant argument for mixed systems such as the Brazilian one.
▸ Notable Findings
The most robust finding is the consistency of the Markov model across all univariate sensitivity analyses: the incremental ratio never exceeded the adopted cost-effectiveness threshold, ranging from -2,577 to 16,748 USD per QALY. This broad but always acceptable range indicates that the conclusion is stable when faced with the main sources of parameter uncertainty. Even more telling is the negative ratio observed under the full societal perspective — which technically constitutes economic dominance of the acupuncture strategy when indirect costs are counted. For clinicians treating knee osteoarthritis in an economically active population, this repositions acupuncture from a complementary therapy to a global cost-reduction strategy. The additional cost per cycle of 1,416 USD for 12 sessions, in a system where each session cost approximately 7 USD with subsidies, demonstrates that the model is sensitive to the reimbursement context — a relevant point when extrapolating to other health care systems.
▸ From My Experience
In my musculoskeletal pain clinic practice, the profile that benefits most from adjunctive acupuncture for knee osteoarthritis is precisely the patient between 50 and 65 years of age, with Kellgren-Lawrence grade II or III, who maintains moderate pain and functional limitation despite optimized physical therapy and anti-inflammatory therapy. I typically observe noticeable clinical response starting from the third or fourth session — VAS reduction and improved function on stairs and prolonged walking — and I use an initial cycle of eight to twelve sessions to consolidate response. I routinely combine this with kinesiotherapy to strengthen the quadriceps and gluteus medius, since the combination appears to synergize functional gains more durably than any single modality. Patients with advanced osteoarthritis and an established surgical indication do not gain useful time from acupuncture alone — I refer them for surgery without delay. What the Markov model in this study confirms numerically is something I have observed empirically: acupuncture is not expensive when one considers the total cost of chronic management, including follow-up visits, repeated joint injections, and lost workdays.
Full original article
Read the full scientific study
Integrative Medicine Research · 2023
DOI: 10.1016/j.imr.2023.100982
Access original articleScientific Review
Marcus Yu Bin Pai, MD, PhD
CRM-SP: 158074 | RQE: 65523 · 65524 · 655241
PhD in Health Sciences, University of São Paulo. Board-certified in Pain Medicine, Physical Medicine and Rehabilitation, and Medical Acupuncture. Scientific review and curation of every entry in this library.
Learn more about the author →Medical disclaimer: This content is for educational purposes only and does not replace consultation, diagnosis, or treatment by a qualified professional. Some information may be assisted by artificial intelligence and is subject to inaccuracies. Always consult a physician.
Content reviewed by the medical team at CEIMEC — Integrated Centre for Chinese Medicine Studies, a reference in Medical Acupuncture for over 30 years.
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