result was robust to sensitivity analysis. Cost per QALY dropped substan-
tially when the analysis incorporated probable QALY differences for the
years after the trial. It was concluded that acupuncture for chronic headache
improves health-related quality of life at a small additional cost; it is relatively
cost-effective compared with a number of other interventions provided by
the NHS.
Canter et al. systematically searched seven electronic databases, and
included all prospective controlled studies carried out in the UK before April
2005, for rigorous cost-effectiveness studies of complementary treat-
ments.^133 Five studies, all randomised, met the criteria set and were included,
one of acupuncture for chronic headache and four of spinal manipulation
for different types of spinal pain. The provision of the treatments represents
an additional healthcare cost in four out of the five studies considered. Esti-
mates of cost per QALY from three studies compared favourably with other
treatments approved for use in the NHS, but for spinal manipulation the
health benefits were small to moderate and of questionable clinical signifi-
cance. The authors acknowledged that estimates of cost-effectiveness may
be less favourable in situations for which the complementary treatment is
offered routinely rather than in the novel situation of a clinical trial.
Ratcliffe et al. have assessed the cost-effectiveness of acupuncture in the
management of persistent non-specific low back pain.^134 Lower back pain is a
common ailment that places a considerable burden on society in terms of
reduced quality of life and lost productivity.^135 The study was based on a well-
conducted pragmatic RCT, which found weak evidence of an effect of
acupuncture on persistent non-specific low back pain at 12 months, but
stronger evidence of a small benefit at 24 months.^136
Availability of acupuncture in the USA
Acupuncture has been increasingly embraced by practitioners and patients
in the USA since the appearance of an article describing successful post-
appendectomy pain management using acupuncture needles.^137 California
became the first state to license acupuncture as an independent healthcare
profession in 1976.^138 Since then, 40 states and the District of Columbia
have adopted similar laws. Most states (27) allow herbal medicine within
the scope of acupuncture practice; only a few states (10) require the super-
vision of a physician for the almost 11 000 practising non-physician
acupuncturists. The number of acupuncturists is rapidly growing and is
projected to quadruple by 2015.^139 A National Health Interview Survey
carried out in the USA revealed that 4.1% of the respondents reported life-
time use of acupuncture and 1.1% reported recent use.^140 This utilisation of
acupuncture was somewhat lower than expected given its significant
national and international recognition and its visibility in the media, This
may in part be a function of provider availability.
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