Cost-Effectiveness of Pharmacopuncture Versus Conventional Acupuncture for Insomnia: An RCT-Based Economic Evaluation with a Markov Model
Cho et al. · Neurology and Therapy · 2026
Evidence Level
STRONGOBJECTIVE
To assess the cost-effectiveness of pharmacopuncture compared with conventional acupuncture for insomnia
WHO
126 patients with moderate-to-severe insomnia (ISI ≥ 15), aged 19–80 years
DURATION
4 weeks of treatment plus 4 weeks of follow-up
POINTS
Individualized points with extracts of Placenta Hominis, Hwangryunhaedok-tang, or other formulas
🔬 Study Design
Pharmacopuncture
n=83
Acupuncture with injection of herbal extracts at specific points
Conventional acupuncture
n=43
Traditional acupuncture or electroacupuncture
📊 Results in numbers
4-week remission — pharmacopuncture
4-week remission — conventional acupuncture
Incremental cost per remission (8 weeks)
ICER per QALY (6 months)
Percentage highlights
📊 Outcome Comparison
ISI reduction (4 weeks)
This study showed that pharmacopuncture (acupuncture combined with herbal medicines) is more effective than traditional acupuncture for treating insomnia, but it costs more. At about USD 270 more per cured patient over 2 months, it can be considered a worthwhile health investment.
Article summary
Plain-language narrative summary
This innovative study evaluated, for the first time, the cost-effectiveness of pharmacopuncture for insomnia, comparing it with conventional acupuncture in a pragmatic clinical trial in South Korea. Pharmacopuncture combines traditional acupuncture with the injection of herbal extracts at the points, offering theoretical synergistic effects between physical stimulation and pharmacologic action. The study enrolled 126 patients with moderate-to-severe insomnia, randomized 2:1 to pharmacopuncture or conventional acupuncture (traditional acupuncture or electroacupuncture). Treatment consisted of 10 sessions over 4 weeks, followed by 4 weeks of follow-up.
The methodology employed two Markov models to assess short-term (8-week) and long-term (24-week) cost-effectiveness. Results demonstrated clinical superiority of pharmacopuncture. Both groups showed clinically meaningful improvements in Insomnia Severity Index (ISI) scores, with mean reductions exceeding the 6-point threshold considered a clinically important change. Pharmacopuncture showed significantly greater reductions in ISI at 4 weeks (10.46 vs.
8.19 points, p = 0.005) and maintained this advantage at 8 weeks (10.63 vs. 8.30 points, p = 0.007). Remission rates (ISI < 8) were consistently higher in the pharmacopuncture group: 64% vs. 58% at 4 weeks and 61% vs.
44% at 8 weeks. Particularly notable was the efficacy in severe insomnia, where pharmacopuncture achieved 50% remission compared with 0% for conventional acupuncture. The economic analysis revealed that pharmacopuncture incurs an additional cost of approximately KRW 368,000 (USD 270) per patient achieving remission at 8 weeks. In the long-term analysis, the incremental cost-effectiveness ratio was KRW 16,940,000 (USD 12,600) per quality-adjusted life-year (QALY), below the Korean cost-effectiveness threshold of KRW 27,660,000.
Sensitivity analyses showed that cost-effectiveness is sensitive to the price of pharmacopuncture. With a 25% price reduction, the intervention becomes even more economically attractive, but increases of 25–50% exceed acceptable thresholds. Extending treatment duration improves cost-effectiveness, suggesting benefits of longer protocols. The clinical implications are significant.
Pharmacopuncture demonstrated more sustained effects than conventional acupuncture during the period without intervention, with differences in remission rates more pronounced at follow-up than immediately after treatment. This suggests better maintenance of therapeutic effects. The 61% remission rate at 6 months is comparable to or higher than cognitive behavioral therapy for insomnia (55–62%), while conventional acupuncture (44%) is comparable to hypnotic pharmacotherapy (48%). The study has important methodological strengths, including a pragmatic design that reflects real-world clinical practice, comprehensive cost data collection, and a Markov model with multiple severity states based on validated ISI categories.
The use of the HINT-8 instrument instead of the EQ-5D-5L reduced ceiling effects and may have better captured changes in health-related quality of life. Limitations include a relatively small sample, reliance on data from a single trial for model parameters, and a context specific to the Korean health system that may limit generalizability. Severity stratification resulted in small subgroups, particularly in the control group for severe insomnia. In addition, the specific contributions of different herbal extracts were not clarified, limiting understanding of mechanisms.
This study provides robust evidence that pharmacopuncture represents a cost-effective option for insomnia management compared with other acupuncture modalities, especially considering a threshold of KRW 400,000 per additional responder at 2 months. The findings support consideration for inclusion of pharmacopuncture in the coverage of the Korean National Health Insurance, potentially improving access and reducing financial barriers for patients.
Strengths
- 1Pragmatic design reflecting real-world clinical practice
- 2Rigorous economic analysis with Markov models
- 3Comprehensive cost data collection
- 4Use of multiple severity states based on the validated ISI
Limitations
- 1Relatively small sample with limited subgroups
- 2Reliance on single-trial data for model parameters
- 3Generalizability limited to the Korean context
- 4Specific contributions of herbal extracts not clarified
Expert Commentary
Prof. Dr. Hong Jin Pai
PhD in Sciences, University of São Paulo
▸ Clinical Relevance
The economic evaluation presented here opens a necessary dialogue between clinical effectiveness and health-system sustainability — a dimension often missing from acupuncture trials. For the physician working with sleep disorders, the data are direct: pharmacopuncture with 10 sessions over four weeks produced remission in 64% of patients with moderate-to-severe insomnia, exceeding the 58% achieved with conventional acupuncture, at an incremental cost of approximately USD 270 per additional remission at eight weeks. The ICER of USD 12,600 per QALY remains below the Korean cost-effectiveness threshold, which positions the intervention favorably in technology-adoption analyses. Even outside the Korean context, these numbers guide clinical reasoning: when a patient does not respond adequately to conventional acupuncture — especially in cases of severe insomnia — pharmacopuncture represents a therapeutic escalation supported by cost-effectiveness data, not merely by prescriber preference.
▸ Notable Findings
The finding that most deserves attention is the divergent behavior of the groups during the period without intervention: while both improved during the four weeks of treatment, the advantage of pharmacopuncture became more pronounced over the following four weeks, with remission of 61% versus 44% for conventional acupuncture. This suggests a consolidation effect — possibly mediated by the prolonged pharmacodynamic action of the injected herbal extracts — that is not captured at the immediate end of the protocol. Even more striking is the performance in severe insomnia: 50% remission with pharmacopuncture versus 0% with conventional acupuncture, a difference that, even considering the small size of the control subgroup, points to a clinically relevant efficacy gap in this patient profile. The comparison with cognitive behavioral therapy for insomnia — the non-pharmacologic gold standard, with remission between 55% and 62% — is also worth noting: pharmacopuncture achieves equivalent performance with a short-duration protocol.
▸ From My Experience
In my practice at the Pain Center of HC-FMUSP, pharmacopuncture with herbal extracts — analogous to the aquapuncture we perform with various injectable substances — typically shows a noticeable response as early as the first three or four sessions, often before conventional acupuncture in the same patient. The profile that responds best, in my observation, is the insomniac with a marked anxious component and resistance to hypnotics, where the combination of mechanical stimulation of the point with local pharmacologic action seems to sustain the effect beyond the session. I usually pair the protocol with structured sleep hygiene guidance and, when indicated, referral for CBT-I, since these approaches do not compete — they add up. Biweekly maintenance protocols after the initial sessions, which we routinely use, appear to sustain the remission gains that the article showed persisting at eight weeks. The caveat I share with colleagues: in patients with insomnia secondary to chronic pain or untreated apnea, the response is less predictable, and an etiologic workup precedes any decision to escalate to pharmacopuncture.
Full original article
Read the full scientific study
Neurology and Therapy · 2026
DOI: 10.1007/s40120-026-00936-w
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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