Quality of life and cost-effectiveness of acupuncture treatment in patients with osteoarthritis pain

This German multicenter study evaluated for the first time the cost-effectiveness of acupuncture in patients with osteoarthritis, a condition that affects millions of people and represents one of the main causes of disability in Europe. With population aging, the number of patients with osteoarthritis is expected to double over the next 15 years, making the search for effective and economically viable treatments urgent. The research was conducted as part of the ARC (Acupuncture in Routine Care) studies and enrolled 489 patients with chronic pain from knee or hip osteoarthritis, recruited from 255 general clinics in Germany. Participants were aged 40 years or older, with pain for at least 6 months, radiologic evidence of osteoarthritis, and at least 15 days of pain in the month prior to the study.

The methodology used a randomized controlled design, in which patients were allocated to receive immediate acupuncture (intervention group) or acupuncture after 3 months (waiting-list control group). Both groups maintained free access to conventional medical care offered by the German healthcare system. Participating physicians had a minimum of 140 hours of acupuncture training (A-diploma), with most being general practitioners followed by orthopedists. The protocol called for 10-15 acupuncture sessions per patient, reflecting real-world German clinical practice, where variations in acupuncture styles exist according to individual training.

Outcome measures included quality of life assessed by the SF-36 questionnaire, direct and indirect healthcare costs, and cost-effectiveness analysis. Costs were measured from a societal perspective, including acupuncture sessions (€35 each), medical consultations, hospital admissions, and prescription medications. Indirect costs for lost work days were estimated at €78 per day using the human capital approach. Data were obtained through German statutory health insurance funds.

Results demonstrated significant improvements in quality of life for patients treated with acupuncture across virtually all SF-36 dimensions, except for the mental health component, general health perception, and emotional functioning. The most pronounced impact was observed on the SF-36 physical score. The study also used the WOMAC questionnaire, specific for osteoarthritis, confirming the observed benefits. The cost-effectiveness analysis, performed on 421 patients with complete data, revealed a gain of 0.0241 QALYs (quality-adjusted life years) in the acupuncture group.

This benefit was accompanied by additional costs of €469.50, resulting in an incremental cost-effectiveness ratio (ICER) of €17,845 per QALY gained in the overall analysis, and €20,256 in the osteoarthritis-specific analysis. These values are below the hypothetical threshold of €50,000 per QALY adopted in the study, indicating that acupuncture is cost-effective. An important finding was the significant difference between sexes in cost-effectiveness. Women had much more favorable ratios (€15,485 per QALY) compared with men (€282,602 per QALY), especially in cases of knee osteoarthritis.

For hip osteoarthritis, sex differences were less pronounced. Sensitivity analyses explored different scenarios of acupuncture costs (€15-55 per session) and effect durations (1-5 years), confirming the robustness of the main findings. Cost-effectiveness acceptability curves showed approximately 95% probability of cost-effectiveness in women versus 45% in men at different willingness-to-pay thresholds. The study has some important limitations.

The observation period of only 3 months does not allow assessment of long-term economic benefits, although follow-up studies have shown maintenance of effects for at least 6-12 months. Costs included only statutory health insurance data, excluding direct private patient expenditures. The use of SF-36 as the main outcome measure, although validated for osteoarthritis, may generate slightly higher ICERs compared with other instruments. The findings have significant clinical implications, providing the first robust evidence of acupuncture cost-effectiveness in osteoarthritis.

The results influenced health policy decisions in Germany, contributing to the decision by the Federal Joint Committee of Physicians and Health Insurers to include acupuncture as a reimbursable treatment option for knee osteoarthritis pain starting in January 2007.