Acupuncture with Maintenance Sessions Is Economically Dominant for Low Back Pain in Older Adults

Chronic low back pain in older adults represents a particular clinical and economic challenge: in addition to pain and functional disability, patients aged 65 years or older accumulate comorbidities, polypharmacy, and greater vulnerability to adverse effects of analgesics — especially NSAIDs (gastrointestinal and renal risk) and opioids (sedation, falls, dependence). In this context, demonstrating that a non-pharmacologic intervention is simultaneously clinically effective and economically favorable has profound implications for health policy.

The BackInAction trial, a pragmatic randomized clinical trial conducted in three large U.S. health systems, had already demonstrated that acupuncture improves pain and disability in adults aged 65 or older. Now, a pré-planned economic analysis published in Spine (Vol. 51, No. 3, p. E65–E75, Feb 2026), conducted by the RAND Corporation with Patricia M. Herman as principal analyst, answers the inevitable question: is it worth it financially? The data from 672 participants, with one-year follow-up, show that the answer is robustly positive — acupuncture with maintenance sessions not only improves clinical outcomes but reduces total health system costs.

Study design: three arms, three health systems

The BackInAction trial compared three strategies in 672 patients aged 65 or older with chronic low back pain, recruited at three large U.S. health systems — Kaiser Permanente Northern California, Kaiser Permanente Washington, and Sutter Health (California). The pragmatic design, with three-arm randomization, reflects real-world conditions of care.

The mechanism of the savings: does less acupuncture pay more?

The most relevant finding for health managers and physicians is counterintuitive: adding maintenance sessions of acupuncture generates savings to the system. The explanation is clear: the cost reduction of US$491/year per patient did not come from the acupuncture sessions themselves — it was generated by the drop in consumption of other health resources. Patients who received intensified acupuncture used significantly fewer consultations, imaging tests, medications, and procedures for low back pain over the year, offsetting and exceeding the cost of the additional maintenance sessions.

This pattern is clinically coherent: acupuncture that produces lasting pain control reduces demand for analgesics, injections, repeat tomographies, and hospitalizations for acute exacerbations — especially relevant in older adults, whose frequency of health system utilization is naturally elevated.

Standard vs. intensified acupuncture: the difference is in the maintenance

A central aspect of the results is the difference between the two acupuncture protocols. Standard acupuncture (without maintenance) produced an incremental cost-effectiveness ratio (ICER) of US$52,897 per QALY gained — below the conventional threshold of US$100,000, making it potentially cost-effective. However, the QALY gain (0.014) did not reach statistical significance, and the clinical improvement on the Roland-Morris (+6.9 percentage points) was also not significant.

Intensified acupuncture — which adds up to 6 maintenance sessions after the initial protocol — was economically dominant: it generated savings of US$491/year per patient in the health sector and US$421/year from the Medicare perspective, while producing significant gains in QALYs (+0.037) and clinically relevant improvement on the Roland-Morris (+18.5 percentage points). In health economics, an intervention that reduces costs and improves outcomes simultaneously is classified as “dominant” — the most favorable scenario possible.