An economic evaluation of Alexander Technique lessons or acupuncture sessions for patients with chronic neck pain: A randomized trial (ATLAS)

The ATLAS study represents an important economic evaluation of complementary therapies for chronic neck pain, a condition that affects millions of people worldwide and represents a substantial economic burden on health systems. The research was conducted as a pragmatic multicenter randomized controlled trial, comparing acupuncture and the Alexander Technique with usual medical care in 509 participants with chronic non-specific neck pain. The study was carried out at general medicine clinics in York, Sheffield, Leeds, and Manchester, in the United Kingdom, representing real-world clinical practice. Participants were selected through screening of medical clinic databases, identifying people with neck pain for at least 3 months and a specific score on the NPQ questionnaire.

The study methodology followed NICE guidelines for health economic evaluations, using both an NHS health system perspective and a broader societal perspective. The acupuncture group received up to 12 sessions of 50 minutes with practitioners registered with the British Acupuncture Council, totaling 600 minutes of contact. The Alexander Technique group received up to 20 individual lessons of 30 minutes with teachers registered with the Society of Teachers of the Alexander Technique, also totaling 600 minutes. Interventions were typically offered weekly initially, then biweekly, over approximately 5 months.

The results showed modest but clinically relevant gains in quality-adjusted life years (QALYs) for both interventions. Acupuncture demonstrated a gain of 0.032 QALYs compared with usual care, while the Alexander Technique showed a gain of 0.025 QALYs. In terms of incremental costs, acupuncture cost £451 more per participant, mainly due to the costs of providing the intervention, since there were no significant differences in NHS resource use between the groups. The Alexander Technique presented an incremental cost of £667 per participant, reflecting its more time-intensive nature.

The cost-effectiveness analysis revealed that acupuncture has a 71% probability of being cost-effective at the NICE threshold of £20,000 per QALY, increasing to 85% at the £30,000 threshold. The incremental cost-effectiveness ratio (ICER) for acupuncture was £18,767 per QALY gained. In contrast, the Alexander Technique showed only a 33% probability of being cost-effective at the lower threshold but may be viable at the £30,000 threshold with a 57% probability, presenting an ICER of £25,101 per QALY. Sensitivity analyses tested various assumptions and confirmed the robustness of the main results.

When societal costs including productivity losses and private care were considered, both interventions became less cost-effective. An analysis focusing only on neck pain-related costs slightly improved cost-effectiveness, but it must be interpreted with caution because of missing data. The main limitation of the study was the high level of missing data, with only 58% of participants having complete data for economic analysis. Comparisons revealed that participants with complete data were generally healthier and had less use of health resources than those with missing data.

Multiple imputation analyses to address missing data substantially reduced the cost-effectiveness of both interventions, introducing considerable statistical uncertainty. The clinical implications suggest that acupuncture represents an economically viable therapeutic option for chronic neck pain, especially considering its proven effectiveness and relatively low cost. The Alexander Technique, although effective, faces cost-effectiveness challenges due to its more intensive nature, but may be considered in cases where acupuncture is not an option.