Cost-effectiveness for acupuncture in seasonal allergic rhinitis: economic results of the ACUSAR trial

The ACUSAR study represents one of the most robust economic evaluations of acupuncture for seasonal allergic rhinitis ever conducted. Conducted in Germany between 2008 and 2009, this randomized controlled clinical trial investigated not only the efficacy but also the economic feasibility of acupuncture as adjuvant treatment for this common allergic condition, which affects up to 25% of adults. Seasonal allergic rhinitis imposes a substantial economic burden on health systems, with average annual costs of €1,543 per affected adult, including both direct costs and indirect costs related to lost productivity. The study design was particularly rigorous, comparing three groups: verum acupuncture plus rescue medication, sham acupuncture plus rescue medication, and a control group receiving only rescue medication with cetirizine.

Of the 422 patients initially randomized, 364 provided complete data for the economic analysis. Participants were adults between 16 and 45 years old with a clinical diagnosis of moderate to severe seasonal allergic rhinitis for at least two years. Exclusion criteria included perennial allergic rhinitis, allergic asthma, moderate to severe atopic dermatitis, and prior use of acupuncture for the condition. The cost analysis was conducted from two perspectives: societal (including direct and indirect costs) and third-party payer (limited to direct costs).

Acupuncture costs were calculated at €35 per session from the societal perspective and €21 from the payer perspective. Participants received a mean of 12 acupuncture sessions during the first 8 weeks. Effectiveness was measured through health-related quality of life using the SF-36, converted into quality-adjusted life years (QALYs). The results demonstrated that acupuncture was significantly more effective than control in improving quality of life (p=0.001), while sham acupuncture showed no significant differences.

However, both intervention groups generated substantially higher costs than the control group. From the societal perspective, mean costs at 8 weeks were €427.3 for acupuncture, €564.2 for sham, and only €58.1 for control. The cost-effectiveness analysis revealed incremental cost-effectiveness ratios (ICERs) ranging between €31,241 and €118,889 per QALY gained from the societal perspective, and between €20,807 and €74,585 from the payer perspective, depending on the scenarios analyzed. Using the commonly accepted threshold of €50,000 per QALY gained, the probability of acupuncture being cost-effective varied dramatically by scenario: only 1.3% in the most conservative base case (8 weeks) up to 81.8% in scenarios assuming prolonged benefits.

Clinical implications are complex. Although acupuncture demonstrates real clinical efficacy in improving the quality of life of patients with seasonal allergic rhinitis, its widespread implementation faces significant economic challenges. The authors suggest that acupuncture may be more cost-effective in chronic conditions where benefits extend over longer periods, in contrast to seasonal rhinitis where natural recovery occurs at the end of the pollen season. Limitations include the inability to directly compare after 8 weeks, when the control group also received acupuncture, requiring statistical modeling for long-term scenarios.

Furthermore, the transferability of economic results to other countries is limited due to differences in health systems and cost structures.