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kellyilseman
Feb 2714 min read

Cost-Effectiveness of Acupuncture

written by Kelly Ilseman, LAc/OAA Research Committee Chair


Audience: Oregon Health Authority, Oregon Pain Management Commission, Medical Providers 

Outline: 

*Bullet Points

A. Supporting Agencies 

B. Clinical Effectiveness

C. Cost-Effectiveness 

D. Mechanisms

E. Insurance Coverage

F. References 


*Bullet Points:A. Supporting Agencies: The use of acupuncture as an effective, evidence-based pain-management option has strong support from leading healthcare institutions.

(1-7) B. Clinical Effectiveness: Acupuncture is a safe, effective, and evidence-based non-pharmacological pain management option for chronic and acute pain,(8-30) lower need for opioids,(31-36) and improved mental-health outcomes,(37-53) and The benefits persist over time, further underscoring the cost-effectiveness of acupuncture. (9,54-69)

C. Cost-Effectiveness: Acupuncture and electroacupuncture are cost-effective first-line treatments for chronic pain (9, 54-68) and for the opioid epidemic.(69)

 

D. Mechanisms: Biomedical understanding of the mechanisms of acupuncture is emerging at the forefront of biological research at a level of physiological detail on par with other biological science disciplines, and is understood to work via the connective tissue stimulating biochemical, bioelectrical, and molecular cascades, producing tangible physiological effects that can reduce pain and the experience of pain. (70-106)


E. Insurance Coverage: Leading Oregon health plans cover acupuncture for chronic pain management, including the Oregon Health Plan (OHP) as well as other private insurance carriers.(107-121)


Note: Due to Wix features, there is not enough room to host the entire document. This blog post contains the cost-effectiveness portion of this paper. Please see past and future blog posts for the rest of the story, or click here for the full document. Additionally, due to limitations of the Wix platform, AMA citations appear in parentheses rather than superscript.



C. Cost-Effectiveness 1. Cost-Effectiveness and Persistence of Acupuncture Effects for Chronic Pain

McDonald J, Janz S. The acupuncture evidence project: a comparative literature review. Australian Acupuncture and Chinese Medicine Association. January 2017. (9) 

● Cost-effectiveness of acupuncture identified for 10 conditions: chronic pain, low back pain, migraine, neck pain, osteoarthritis, ambulatory anesthesia, depression, dysmenorrhea, headache, post-operative nausea and vomiting, and allergic rhinitis

MacPherson H, Vertosick EA, Foster NE, Lewith G, Linde K, Sherman KJ, Witt CM, Vickers AJ. The persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with chronic pain. Pain. 2017 May; 158(5): 784–793. doi:10.1097/j.pain.0000000000000747 (54) 

 

  • 29 trials involving 17,922 patients with chronic musculoskeletal pain (low back, neck, and shoulder pain), knee osteoarthritis, and headache/migraine pain 

  • Meta-analysis comparing pre- and post-treatment pain scores

  • Long-term follow-up data for 20 trials involving 6,376 patients 

  • Treatment effect persisted at 3 months (95% CI: −0.014 to 0.037, p = 0.4) for trials comparing acupuncture vs control (wait-list, usual care) 

  • “The central estimate [expected values of liabilities] suggests that about 90% of the benefit of acupuncture relative to controls would be sustained at 12 months.” 

  • As expected, acupuncture vs sham acupuncture demonstrated a lower comparable effect at 3 months (95% CI: 0.000 to 0.050, p = 0.050) and about a 50% reduction in effect size at 12 months.

  • Authors concluded: 

  • The effects of acupuncture treatment for chronic pain can be expected to last at least 12 months. 

  • “Patients can generally be reassured that treatment effects persist.” 

  • “Studies of the cost-effectiveness of acupuncture should take [these] findings into account when considering the time horizon of acupuncture effects.”


2. Cost-Effectiveness of Acupuncture for Chronic and Acute Low Back Pain

Elton D (Optum Insurance). The National Academies of Science, Engineering, Medicine. Session 3 [Video]. YouTube. Published Dec 7, 2018. Accessed January 22, 2022.  https://www.youtube.com/watch?v=vQO5CsuzfRM. (55)

  • Percentage of non-surgical low back pain patients who see providers for first-line care:

  • specialists (38.3%)

  • chiropractors/physical therapists/acupuncturists (31.3%)

  • primary care physicians (30.4%)

  • Total medical episode costs: 

  • chiropractors/physical therapists/acupuncturists ($619)

  • primary care physician visits ($728)

  • specialist care ($1,728)

  • Summary

  • Health care cost savings of over $100 per medical non-surgical low back pain event when patients saw conservative integrative care providers (acupuncturists/chiropractors/physical therapists) first compared to primary care physicians 

  • $1,000 savings per medical event when patients saw conservative integrative providers first compared to receiving specialist care

Taylor P, Pezzullo L, Grant SJ, Bensoussan A. Cost-effectiveness of acupuncture for chronic non-specific back pain. Pain Pract. 2014;14(7):599-606. (56)

  • Authors assessed the cost-effectiveness of acupuncture, acupuncture plus standard care, sham acupuncture, and routine care to relieve chronic low back pain via systematic review and meta-analyses 

  • Participants receiving acupuncture plus standard care vs standard care only experienced “a significant improvement in pain” 

  • For acupuncture plus standard care vs sham acupuncture plus standard care, “a weak positive effect was found for weeks 12 to 16, but this was not significant.” 

  • For acupuncture versus standard care, “a significant positive effect was found at week 8, but not at weeks 26 or 52.” 

  • Outcomes measured: incremental cost-effectiveness ratio (ICER) presented as cost (A$) per disability-adjusted life-year (DALY) saved using World Health Organization (WHO) benchmarks

  • “A very highly cost-effective intervention is one that costs less than gross domestic product per capita per quality-adjusted life-year (QALY) gained or DALY averted, or less than around $A52,000 in 2009.”

  • Results

  • According to the established WHO benchmarks, “acupuncture as a complement to standard care for relief of chronic LBP is highly cost-effective, costing around $48,562 per DALY avoided.” Cost reduces to $18,960 per DALY avoided “when comorbid depression is alleviated at the same rate as pain.” 

  • Acupuncture was found to be a cost-effective treatment strategy in patients with chronic low back pain

Witt CM, Jena S, Selim D, Brinkhaus B, Reinhold T, Wruck K, Liecker B, Linde K, Wegscheider K, Willich SN. Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. Am J Epidemiol. 2006;164(5):487–496. doi:10.1093/aje/kwj224 (57)

  • 11,630 German patients (average age 52.9 years; 59% female) with chronic low back pain were allocated to an acupuncture group (N = 1,549), a no-acupuncture control group (N = 1,544), or a nonrandomized acupuncture group (N = 8,537).

  • Outcomes measured at baseline and after 3 and 6 months: back function (Hannover Functional Ability Questionnaire), pain, and quality of life 


  • “At 3 months, back function improved by 12.1 (standard error (SE), 0.4) to 74.5 (SE, 0.4) points in the acupuncture group and by 2.7 (SE, 0.4) to 65.1 (SE, 0.4) points among controls (difference 9.4 points (95% confidence interval 8.3, 10.5); p < 0.001).”

  • Nonrandomized acupuncture group participants demonstrated improvements on par with the randomized acupuncture treatment group participants.

  • “The incremental cost-effectiveness ratio was €10,526 [$11,485.34] per quality-adjusted life year.”

  • Conclusions: “Acupuncture plus routine care was associated with marked clinical improvements in these patients and was relatively cost-effective.”


Skonnord T, Fetveit A, Skjeie H, Brekke M, Grotle M, Klovning A, Aas E. Cost-effectiveness analysis of acupuncture compared with usual care for acute non-specific low back pain: secondary analysis of a randomised controlled trial. Acupunct Med. 2022 Apr;40(2):123-132. doi: 10.1177/09645284211055747. Epub 2021 Nov 30. (58)

  • Objective: Researchers sought to determine cost-effectiveness of a single acupuncture treatment plus usual care for acute low back pain

  • Study involved secondary analysis of a Norwegian randomized controlled trial involving 171 participants with acute low back pain for more than or equal to 14 days

  • Outcomes measured: quality-adjusted life years (QALYs), health care costs and societal costs at days 28 and 365, incremental cost-effectiveness ratio (ICER), and net monetary benefit (NMB)

  • 86 participants in control group; 81 participants in acupuncture group 

  • No QALY gain at day 28; “at day 365, the incremental QALY of 0.035 was statistically significant.” 

  • Differences between “health care costs and societal costs were not statistically significant.” 

  • Cost savings and positive net monetary benefits at the end of one year (365 days):

  • incremental cost-effectiveness ratio: “USD -568 per QALY”

  • net monetary benefit: “USD 1265, with 95.9% probability of acupuncture being cost-effective”

  • Conclusions: “This is the first cost-effectiveness analysis of acupuncture for [acute non-specific low back pain]” and “the findings indicate that acupuncture may be cost-effective [for acute non-specific low back pain] from a 1-year perspective.”

Martin BI, Gerkovich MM, Deyo RA, Sherman KJ, Cherkin DC, Lind BK, Goertz CM, Lafferty WE. The association of complementary and alternative medicine use and health care expenditures for back and neck problems. Med Care. 2012 December;50(12): 1029–1036. doi:10.1097/MLR.0b013e318269e0b2. (59)


  • Study Design: Analysis of the 2002–2008 Medical Expenditure Panel Survey involving > 17 years old with self-reported neck and back issues who either used complementary and alternative medicine (CAM) or did not. Linear 

  • Statistical Analysis: survey-weighted generalized linear regression and propensity matching 

  • Results: 12,036 survey responses received, including 4,306 (35.8%) CAM users  

  • CAM users: 

  • significantly better “health, education, and comorbidity” 

  • adjusted annual medical costs 

  • spine care costs: $424 lower (95%CI $240, $609; p <0.001) based on weighted linear regression // $526 lower (p<0.001) based on propensity matching

  • total health care costs: $796 lower (95%CI $121, $1470; p = 0.021) // $298 lower  (p=0.403) based on propensity matching

  • “expenditure differences were primarily due to lower inpatient expenditures among CAM users.”

  • Conclusions: CAM users had lower medical costs for spine (neck and back) care than non-CAM users.


Lind BK, Lafferty WE, Tyree PT, Diehr PK. Comparison of health care expenditures among insured users and nonusers of complementary and alternative medicine in Washington state: a cost minimization analysis. JACM. 2010;16(4):411-417. doi: 10.1089=acm.2009.0261 (60)


  • Design: Insurance claims data (2000-2003) analyzed from Washington state, where CAM care coverage is required. CAM-using patients with back pain, fibromyalgia, or menopause symptoms were compared with non-CAM patients with similar symptoms and equivalent insurance “based on age group, gender, index medical condition, overall disease burden, and prior-year expenditures.” Unadjusted tests and linear regression were used to analyze the data.

  • Results: 

  • “CAM users had lower average expenditures [higher outpatient expenses balanced by lower inpatient and imaging costs] than nonusers.” 

  • Unadjusted: $3,797 expenses for CAM users versus $4,153 for non-CAM users (p = 0.0001)

  • β from Linear Regression -$367 for CAM users

  • CAM-using patients with high disease burdens spent an average $1,420 less than nonusers (p < 0.0001)

  • CAM-using patients with lower disease burdens had “slightly higher average expenditures of $158” 

  • Conclusions: Insured patients with back pain, fibromyalgia, and menopause symptoms who use CAM care will in general have lower insurance costs than non-CAM users, especially if they have a high disease burden.


3. Cost-Effectiveness of Acupuncture for Pelvic and Low Back Pain in Pregnancy

Nicolian S, Butel T, Gambotti L, Durand M, Filipovic-Pierucci A, Mallet A, Kone M, Durand-Zaleski I, Dommergues M. Cost-effectiveness of acupuncture versus standard care for pelvic and low back pain in pregnancy: a randomized controlled trial. PLoS One. 2019 Apr 22;14(4):e0214195. doi: 10.1371/journal.pone.0214195. eCollection 2019. (61)

  • Randomized controlled trial

  • 199 pregnant women with pelvic and low back pain received 5 acupuncture treatments (N=96) or standard care (N=103) 

  • Outcomes

  • (1) self-assessed pain by Numerical Rating Scale (NRS) ≤ 4/10 and Mean Oswestry Disability Index (MODI)

  • (2) cost-effectiveness: incremental cost per days with NRS ≤ 4/10

  • (3) indirect non-healthcare costs (daily compensation for sick leave and productivity loss)

  • Results

  • Acupuncture group

  • more days with NRS ≤ 4/10 (61% vs 48%, p = 0.007)

  • lower Mean Oswestry disability scores (33 versus 38, Δ = 5, 95% CI: 0.8 to 9, p = 0.02) 

  • slightly higher health system costs (not including employer and out-of-pocket costs) 

  • (€1512 versus €1452, Δ = €60, 95% CI: -272 to +470) 

  • [$1,650.18 vs $1,584.70]

  • Control group 

  • Higher total average costs (€2947) [$3,216.21] vs acupuncture group (€2635, Δ = -€312, 95% CI: -966 to +325), [$2,875.81] 

  • Conclusion

  • Acupuncture was the clinically most effective and cost-effective compared with standard care when employer costs were factored into the equation.

  • Authors reported “a 100% probability of cost-effectiveness was obtained for a willingness to pay of €100 [$109.14] per [day] with pain NRS ≤ 4.”


4. Cost-Effectiveness of Acupuncture for Chronic Neck PainWillich SN, Reinhold T, Selim D, Jena S, Brinkhaus B, Witt CM. Cost-effectiveness of acupuncture treatment in patients with chronic neck pain. Pain. 2006;125(1):p 107-113.| doi: 10.1016/j.pain.2006.06.006 (62)

  • 3,451 patients 18 years of age or older with chronic neck pain (> 6 months) randomized into acupuncture treatment (1,753) and control/routine care (1,698) groups; total of 31% men, (age 53.5 ± 12.9 years); 69% women, (49.2 ± 12.7 years)

  • Outcomes at baseline and 3 months: 

  • “Direct and indirect [insurance] cost differences” (not including “private medical expenses such as over the counter medication”) and incremental cost-effectiveness ratio (ICER)

  • Health related quality of life (SF-36) surveys 

  • Acupuncture “associated with significantly higher costs” … “compared to routine care” (€925.53 ± 1,551.06 vs. €648.06 ± 1,459.13; mean difference: €277.47 [95% CI: €175.71–€379.23]).

  • In dollars, these numbers equate to: ($1,009.92 ± $1,692.49 vs $707.15 ± $1,592.17; mean difference $302.77 [95% CI: $191.73-$413.81]).

  • The incremental cost-effectiveness ratio was €12,469 ($13,605.92) per QALY gained and “proved robust in additional sensitivity analyses.” 

  • Conclusions: 

  • “According to international cost-effectiveness threshold values, [even though it may cost more] acupuncture is a cost-effective treatment strategy in patients with chronic neck pain.”

  • “Beyond the 3 months study duration, acupuncture might be associated with further health economic effects.”

5. Cost-Effectiveness of Acupuncture for Osteoarthritis NIH. Evidence Review for the Clinical and Cost-Effectiveness of Acupuncture for People with Osteoarthritis: Osteoarthritis in Over 16s: Diagnosis and Management. NICE Evidence Reviews Collection. London: National Institute for Health and Care Excellence (NICE); 2022 Oct. Accessed November 16, 2023. https://www.ncbi.nlm.nih.gov/books/NBK590294/ (63)

  • 26 randomized controlled trials or systematic reviews of randomized controlled trials involving adults  ≥16 years of age with osteoarthritis in any joint

  • “QALY for electroacupuncture versus usual care were below the NICE cost effectiveness threshold of £20,000 per QALY gained”

  • Weighted average for pooled trials showed probabilistic cost-effectiveness for QALY gained was 97% at £20,000 ($25,070.30) and 99% at £30,000 ($37605.45)

  • All individual trials “showed that electroacupuncture was cost effective versus usual care” for treating osteoarthritis pain.

Woods B, Manca A, Weatherly H, Saramago P, Sideris E, Giannopoulou C, Rice S, Corbett M, Vickers A, Bowes M, MacPherson H, Sculpher M. Cost-effectiveness of adjunct non- pharmacological interventions for osteoarthritis of the knee. PLOS ONE. March 7, 2017;  :1-18. doi:10.1371/journal.pone.0172749 (64)


  • 88 studies including 7,507 participants selected for meta-analysis; analysis was done for all trials and then only for trials with “low risk of selection bias”  

  • Results

  • TENS found to be the most cost-effective per quality-adjusted life-year (QALY) in all studies.

  • Studies with low risk of selection bias: acupuncture most cost-effective versus TENS.

  • Effectiveness varied among interventions based on TENS intensity modulation.

Reinhold TR, Witt CM, Jena S, Brinkhaus B, Willich SN. Quality of life and cost-effectiveness of acupuncture treatment in patients with osteoarthritis pain. Eur J Health Econ. 2007 July 19;9:209–219 (65)

  • 489 participants with chronic osteoarthritis knee or hip pain from 255 general medical practices in Germany were included in this randomized controlled trial.

  • Outcome measures baseline and 3 months: QoL and costs (health insurance funds data and standardized surveys)

  • Compared with routine care patients, acupuncture patients experienced improved QoL 

  • “significantly higher costs over the 3 month treatment period”  

  • (mean cost-difference: € [95%CI €135.80–€803.19]) 

  • (mean cost-difference in dollars: $ [95%CI $512.31-$876.42])

  • Incremental cost-effectiveness ratios (ICERs): “€17,845 [$19,472.11] per QALY gained.” 

  • Females experienced higher cost-effectiveness.

  • Conclusions: “Acupuncture was a cost-effective treatment strategy in patients with chronic osteoarthritis pain.”


6. Cost-Effectiveness of Acupuncture for Chronic Non-Cancer Pain Sutton D, McCormack S. Acupuncture for Chronic Non-Cancer Pain: A Review of Clinical Effectiveness, Cost Effectiveness and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2019 Oct 29. Accessed November 16, 2023. https://www.ncbi.nlm.nih.gov/books/NBK551954/  (66)

  • Systematic review of existing health technology assessments, systematic reviews, meta-analyses, network meta-analyses, economic studies, and evidence-based guidelines

  • 33 publications included, including 23 systematic reviews (18 meta-analyses, 4 network meta-analyses, 1 economic study comprising 155 randomized controlled trials from 1975-2018), and 9 evidence-based guidelines 

  • Strength of evidence and strength of recommendations rated using multiple rigorous, reliable methods

  • Outcome measures: Visual Analog Scale (VAS), Numerical rating scale (NRS), Western Ontario and McMaster Osteoarthritis Index (WOMAC) pain score, National Institutes of Health – Chronic Prostatitis Symptom Index (NIH-CPSI); Utilities (quality of life) measured by the EQ-5D instrument, average cost-effectiveness ratio (ACER); quantity of adverse events

  • Majority of studies “suggested evidence of effectiveness” of acupuncture when compared with sham acupuncture or medication, but “overall were variable depending on the patient population.”

  • Electroacupuncture was shown to be more cost-effective than 6 different NSAIDS for treating chronic low back pain.

7. Cost-Effectiveness of Acupuncture for Peripheral Neuropathic Pain Zhao W, Huang H, Liu K, Wang S, Lin S, Long W, Li L, Zeng J, Lin G. Acupuncture and moxibustion for peripheral neuropathic pain: a frequentist network meta-analysis and cost-effectiveness evaluation. Evid Based Complement Alternat Med. 2022 Mar 16:2022:6886465. doi: 10.1155/2022/6886465. eCollection 2022. (67)

  • Review yielded 16 randomized controlled trials involving 1,308 participants with peripheral neuropathic pain (PNP)

  • Treatments: 7 acupuncture and/or moxibustion treatments and two pharmaceutical interventions

  • All acupuncture and moxibustion treatments (except acupoint injection) “showed superior improvements” in peripheral neuropathic pain and “were more cost-effective as compared to pharmaceutical treatments.”

  • Most effective treatments were warm needling, fire needling, and moxibustion.

  • “Fire needling showed the lowest incremental cost per additional responder (ICPR) relative to the nonsteroidal anti-inflammatory drugs in the cost-effectiveness analysis of direct and indirect costs.”

  • Conclusions: Acupuncture and moxibustion clinically effective and cost-effective treatments for peripheral neuropathic pain.

8. Cost-Effectiveness of Acupuncture for Dysmenorrhea Witt CM, Reinhold T, Brinkhaus B, et al. Acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and cost-effectiveness in usual care. Am J Obstet Gynecol. 2008 Feb;198(2):166.e1-8. doi: 10.1016/j.ajog.2007.07.041. (68)

  • Randomized controlled trial with non-randomized cohort

  • 201 participants with dysmenorrhea (mean age 36.1 +/- 7.1 years) randomized to 15 acupuncture treatments over 3 months or to a non-acupuncture control group. Everyone received usual medical care as needed.

  • Outcomes: average pain intensity (NRS 0-10) at baseline and 3 months

  • Results for acupuncture group

  • “Lower average pain intensity” at 3 months 

  • (NRS 0-10) 

  • 3.1 (95% CI 2.7; 3.6) vs. 5.4 (4.9; 5.9), difference -2.3 (-2.9; -1.6); P<.001

  • Higher quality of life; higher costs (average ICER € 3,011 or $3,285.54/QALY)

  • Conclusion: Acupuncture “associated with improvements in pain and quality of life as compared to treatment with usual care alone and was cost-effective within usual thresholds.”

9. Cost-Effectiveness of Acupuncture to Address the Opioid Crisis

Fan Y, Miller DW, Bolash B, Bauer M, McDonald J, Faggert S, He H, Ming Y, Matecki A, Camardella L, Koppelman ML, Stone JAM, Meade L, Pang J. Acupuncture’s role in solving the opioid epidemic: evidence, cost-effectiveness, and care availability for acupuncture as a primary, non-pharmacologic method for pain relief and management - white paper 2017. J Integr Med. October 17, 2017;15(6):411-425. (69)

  • “Acupuncture can address the national opioid epidemic as a medically effective, evidence-based, safe, cost-effective, non-pharmacological pain-management intervention.”



References

9. McDonald J, Janz S. The acupuncture evidence project: a comparative literature review. Australian Acupuncture and Chinese Medicine Association. January 2017. https://www.asacu.org/wp-content/uploads/2017/09/Acupuncture-Evidence-Project-The.pdf 

54. MacPherson H, Vertosick EA, Foster NE, Lewith G, Linde K, Sherman KJ, Witt CM, Vickers AJ. The persistence of the effects of acupuncture after a course of treatment: A meta-analysis of patients with chronic pain. Pain. 2017 May; 158(5):784–793. doi:10.1097/j.pain.0000000000000747

55. 10. Elton D (Optum Insurance). The National Academies of Science, Engineering, Medicine. Session 3 [Video]. YouTube. https://www.youtube.com/watch?v=vQO5CsuzfRM. Published Dec 7, 2018. Accessed January 8, 2024. 

56. Taylor P, Pezzullo L, Grant SJ, Bensoussan A. Cost-effectiveness of acupuncture for chronic non-specific back pain. Pain Pract. 2014;14(7):599-606.

57. Witt CM, Jena S, Selim D, Brinkhaus B, Reinhold T, Wruck K, Liecker B, Linde K, Wegscheider K, Willich SN. Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. Am J Epidemiol. 2006;164(5):487–496. doi:10.1093/aje/kwj224

58. Skonnord T, Fetveit A, Skjeie H, Brekke M, Grotle M, Klovning A, Aas E. Cost-effectiveness analysis of acupuncture compared with usual care for acute non-specific low back pain: secondary analysis of a randomised controlled trial. Acupunct Med. 2022 Apr;40(2):123-132. doi: 10.1177/09645284211055747. Epub 2021 Nov 30.

59. Martin BI, Gerkovich MM, Deyo RA, Sherman KJ, Cherkin DC, Lind BK, Goertz CM, Lafferty WE. The association of complementary and alternative medicine use and health care expenditures for back and neck problems. Med Care. 2012 December;50(12): 1029–1036. doi:10.1097/MLR.0b013e318269e0b2. 

60. Lind BK, Lafferty WE, Tyree PT, Diehr PK. Comparison of health care expenditures

among insured users and nonusers of complementary and alternative medicine in Washington state: a cost minimization analysis. JACM. 2010;16(4):411-417. doi: 10.1089=acm.2009.0261

61. Nicolian S, Butel T, Gambotti L, Durand M, Filipovic-Pierucci A, Mallet A, Kone M, Durand-Zaleski I, Dommergues M. Cost-effectiveness of acupuncture versus standard care for pelvic and low back pain in pregnancy: a randomized controlled trial. PLoS One. 2019 Apr 22;14(4):e0214195. doi: 10.1371/journal.pone.0214195. eCollection 2019.

62. Willich SN, Reinhold T, Selim D, Jena S, Brinkhaus B, Witt CM. Cost-effectiveness of acupuncture treatment in patients with chronic neck pain. Pain. 2006;125(1):p 107-113. doi:

10.1016/j.pain.2006.06.006

63. NIH. Evidence Review for the Clinical and Cost-Effectiveness of Acupuncture for People with Osteoarthritis: Osteoarthritis in Over 16s: Diagnosis and Management. NICE Evidence Reviews Collection. London: National Institute for Health and Care Excellence (NICE); 2022 Oct. Accessed November 16, 2023.

64. Woods B, Manca A, Weatherly H, Saramago P, Sideris E, Giannopoulou C, Rice S, Corbett M, Vickers A, Bowes M, MacPherson H, Sculpher M. Cost-effectiveness of adjunct non- pharmacological interventions for osteoarthritis of the knee. PLOS ONE. March 7, 2017;  :1-18. doi:10.1371/journal.pone.0172749 

65. Reinhold TR, Witt CM, Jena S, Brinkhaus B, Willich SN. Quality of life and cost-effectiveness of acupuncture treatment in patients with osteoarthritis pain. EurJ Health Econ. 2007 July 19;9:209–219.

66. Sutton D, McCormack S. Acupuncture for Chronic Non-Cancer Pain: A Review of Clinical Effectiveness, Cost Effectiveness and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2019 Oct 29. Accessed November 16, 2023. https://www.ncbi.nlm.nih.gov/books/NBK551954/

67. Zhao W, Huang H, Liu K, Wang S, Lin S, Long W, Li L, Zeng J, Lin G. Acupuncture and moxibustion for peripheral neuropathic pain: a frequentist network meta-analysis and cost-effectiveness evaluation. Evid Based Complement Alternat Med. 2022 Mar 16:2022:6886465. doi: 10.1155/2022/6886465. eCollection 2022

68. Witt CM, Reinhold T, Brinkhaus B, Roll S, Jena S, Willich SN. Acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and cost-effectiveness in usual care. Am J Obstet Gynecol. 2008 Feb;198(2):166.e1-8. doi: 10.1016/j.ajog.2007.07.041.

69. Fan Y, Miller DW, Bolash B, Bauer M, McDonald J, Faggert S, He H, Ming Y, Matecki A, Camardella L, Koppelman ML, Stone JAM, Meade L, Pang J. Acupuncture’s role in solving the opioid epidemic: evidence, cost-effectiveness, and care availability for acupuncture as a primary, non-pharmacologic method for pain relief and management - white paper 2017. J Integr Med. October 17, 2017;15(6):411-425. 

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