Inspired by Lu et al 2024.[1]
ABCHIP – Alberta Complementary Health Integration Project
EQ-5D-5L – EuroQol Group 5D-5L instrument [2]
QALY – quality adjusted life year
QoL – quality of life
CEA – cost effectiveness analysis
CBA – cost benefit analysis
CAD – Canadian dollars– key to acronyms
This paper reports the economic evaluation of a government funded project (ABCHIP) in Alberta, Canada, that I highlighted on the blog in September 2024: Acupuncture in Alberta 2024.[3]
The project essentially provided free acupuncture to address pain, mental health, and addiction issues for the youth and elderly in Alberta. Patients needed to be either 24 and below, or 55 and above. Outcome measures were well organised (see previous blog) and included the EQ-5D-5L, which measures 5 dimensions of health (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). Responses to the EQ-5D-5L can be converted to a single utility value from 1 (perfect health) to 0 (death). Negative values are possible, but not desirable, as these imply a state worse than death. The conversion involves using a country specific value set – see page 13 of the EQ-5D-5L User Guide.
QALYs are calculated by multiplying the utility value by the time in years spent in that state. If an intervention such as acupuncture improves a patient’s QoL, this can be measured in terms of QALYs gained. The cost of providing the service can then be used to estimate the cost per QALY gained (CEA), and this figure is used by some governments to decide whether or not an intervention should be publicly funded.
The CEA revealed a figure of CAD12,171 overall per QALY, which is just under £7k, so well under the NICE threshold of £20,000 to £30,000.
The research group also performed a CBA. This involved using estimates of the per-person costs of relevant diseases in Canada (depression, pain, anxiety, sleep issues) together with the data from ABCHIP of the reduced severity of these conditions in the cohort of patients treated with acupuncture. They then used conservative estimates of how quickly the benefits would wear off (treatment effect depreciation rates).
The CBA revealed an annual average cost saving of CAD3,371 attributed to a course of acupuncture treatment. For context, the per-capita cost of healthcare in Alberta (2022) was CAD8,812. This saving includes the cost of providing the acupuncture in the first place.
The only query I have about these analyses relates to the fact that, as mentioned in the previous blog on ABCHIP, the population receiving acupuncture were mostly immigrant Chinese, but this ethnic group only makes up less than 10% of the population in Calgary. I wonder to what degree this affects the validity of the country specific value set used to calculate the utility value, and possibly also the cost burden in Canada of the specific diseases studied here.
I have emailed the lead author Professor Mingshan Lu, who is an economist at the University of Calgary as well as a recently trained acupuncture practitioner, to ask whether this unrepresentative ethnic distribution in the sample population might influence the CEA or CBA. A Canadian value set would have been used to calculate a mean utility value from the EQ-5D-5L responses, yet the sample (n=500) was predominantly of East Asian origin, so not representative of the population used to derive the value set. I guess a sensitivity analysis might have performed analysis using a value set from China. I will append an addendum if I hear back from the professor.
References
1 Lu M, Sharmin S, Tao Y, et al. Economic evaluation of acupuncture in treating patients with pain and mental health concerns: the results of the Alberta Complementary Health Integration Project. Front Public Health. 2024;12:1362751. doi: 10.3389/fpubh.2024.1362751
2 EQ-5D-5L. EuroQol. https://euroqol.org/information-and-support/euroqol-instruments/eq-5d-5l/ (accessed 29 August 2024)
3 Lu M, Sharmin S, Tao Y, et al. Effectiveness of acupuncture in treating patients with pain and mental health concerns: the results of the Alberta Complementary Health Integration Project. Front Neurol. 2024;15:1366685. doi: 10.3389/fneur.2024.1366685
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