Cost-effectiveness of acupuncture needling for older adults with chronic low back pain

This study represents an important milestone in the economic evaluation of acupuncture for chronic low back pain in older adults, a particularly vulnerable population that consumes a significant share of healthcare resources allocated to back pain treatment. The Back-In-Action (BIA) study was a pragmatic, multicenter, randomized clinical trial that evaluated 672 participants aged 65 years or older, distributed into three groups: usual medical care (225 participants), standard acupuncture plus usual care (222 participants), and enhanced acupuncture plus usual care (225 participants). The research was conducted in four healthcare systems in the United States, including Kaiser Permanente Washington, Kaiser Permanente Northern California, and Sutter Health, over 12 months of follow-up. The standard acupuncture protocol included up to 15 treatment sessions over 12 weeks, using only manual stimulation (without electroacupuncture), while the enhanced protocol added up to 6 maintenance sessions over the following 12 weeks.

The economic results were surprisingly favorable to acupuncture. Enhanced acupuncture proved to be dominant compared with usual medical care — that is, it was simultaneously more effective and less costly, generating an average savings of $491 per participant over one year from the healthcare sector perspective. These savings resulted primarily from a significant reduction in hospitalization costs (-$1,127) for the enhanced acupuncture group. In terms of quality of life, participants in enhanced acupuncture showed a significant gain of 0.037 quality-adjusted life years (QALYs) and a 18.5 percentage point increase in the proportion of patients who achieved clinically significant improvement.

Standard acupuncture, although it cost more than usual care ($759 additional per participant), showed a cost-effectiveness ratio of $52,897 per QALY, a value considered acceptable by international standards (below the $100,000 per QALY threshold). Bootstrap analyses demonstrated that 99.6% of estimates for enhanced acupuncture and 74.8% for standard acupuncture fell below the cost-effectiveness threshold, with 64.3% and 16.0%, respectively, showing cost savings. This study has particular relevance given that U.S. Medicare began covering acupuncture for chronic low back pain in 2020, and the results suggest that this investment may be economically justifiable.

The clinical implications are substantial, especially considering that the older adult population is often subjected to high-cost, low-functional-benefit pharmacologic and invasive treatments. Acupuncture emerges as a safe and potentially economical alternative. Limitations include the inability to obtain complete data from one participating center, the use of estimative algorithms for Medicare costs instead of real claims data, and limited generalizability beyond the studied healthcare systems. Sensitivity analyses confirmed the robustness of the results, even when different assumptions about acupuncture and medication costs were applied.