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Complementary and alternative medicine costs a systematic literature review

Use and Acceptance of Complementary and Alternative Medicine

cost savings were also seen for manual therapy delivered by a physiotherapist, who is also a registered manual therapist, for neck pain in terms of perceived recovery, pain, neck disability and qalys82; for preoperative oral supplementation with arginine and ω-3 fatty acids for patients with gastrointestinal cancer undergoing surgery102; for vitamin k1 supplementation for postmenopausal women with osteopenia and osteoporosis in terms of qalys103; for supplementation with vitamins c and e and β-carotene for cataract prevention90; for fish oil supplementation in men with a history of heart attack87; for tai chi to prevent hip fractures in nursing home residents95 and for naturopathic care offered through a worksite clinic for chronic low-back pain in terms of both reductions in absenteeism and gains in qalys. various indicators of study quality were captured for all full economic evaluations, and more detailed data and results were captured only for those full economic evaluations that met five quality criteria. the discount rate is reported in two of these studies (one with a time horizon of 42 months [25] and the other that included a 12-year projection [78]), but only one justified the choice of discount rate [78]. an interesting study by kelner et al [85] asked chiropractors, homeopaths, and reiki practitioners about the need to demonstrate the effectiveness, safety and cost effectiveness of their therapies.† if tests of statistical significance were performed, costs must be significantly higher or lower (and health effects significantly better or worse), or they were considered "similar. although non-english language articles were collected, they are not analysed in this review. also, since many cam therapies target chronic disease, it is important that the study period be long enough to capture the full benefits and costs of each therapy, and that future costs and benefits be discounted to the present for comparison. cost effectiveness of combined spa-exercise therapy in ankylosing spondylitis: a randomized controlled trial. these analyses are conducted according to explicit, systematic, and consistent criteria, and take into account both the positive and negative consequences of each alternative. health, maximizing wellness, and enhancing well-being are patient-centered outcomes – ones that by definition require subjective measurement [99]. the cost of conventional care was similar between cam and non-cam users.–48 in 2007, researchers at the university of washington analyzed insurance claims to evaluate healthcare expenditures in patients with fms under the care of conventional providers and cam providers., there are several additional issues specific to cam humanistic and economic outcome measurement which must be considered. the type(s) of cim evaluated and the target population were captured for all economic evaluations. recently a trial was conducted to evaluate the naturopathic approach to cvd prevention and to determine the cost-effectiveness of such an approach. inclusion and exclusion criteria for cost data should be established in the protocol, as for clinical outcome measurements, but provision must be made to add extra categories of costs which only become apparent after the trial has commenced [1, 20]. coverage may also be restricted to the standardized forms of botanical medicines, nutritional supplements, or protocols used in the studies [86]. removed duplicates from the search results and selected papers that reported original data on specific cam therapies from any form of standard economic analysis, analysis of costs, or economic modeling. if cam providers wish to increase the provision of therapies to improve population health, they must report the potential outcomes of cam therapies widely and well. more consideration be given to modelling as a method to estimate economic outcomes for existing effectiveness trial results, and to generalise existing quality economic evaluation results to other jurisdictions. fourteen studies [25, 27, 32, 34, 35, 50, 51, 53–55, 68, 74, 76, 82] met all study quality criteria, and a summary of their results is shown in table 5. changes in resource use be reported separately from unit costs in economic evaluations alongside clinical trials and that model parameters and unit costs be clearly reported in decision-analytic modelling studies. dme participated in the early design of the study, including the data extraction plan, inclusion/exclusion criteria and the interpretation of results. therefore, there is evidence that even though complementary therapies are given in addition to usual care, they can improve clinical outcomes without increasing costs. whereas the number and quality of these studies has increased in recent years and more cam therapies have been shown to be good value, there are still not enough studies to measure the cost effectiveness of the majority of cam. a jadad score50 with minor modifications (the two possible points for blinding were replaced with one point for the use of a blinded assessor)51 was calculated for the economic evaluations that included a randomised trial. costs of complementary and alternative medicine (cam) and frequency of visits to cam practitioners: united states, 2007. cam providers and naturopathic physicians should identify barriers to health screenings and should continue to encourage their patients to receive appropriate preventative services. cost-effectiveness analysis registry: institute for clinical research and health policy studies. you will be able to get a quick price and instant permission to reuse the content in many different ways. searching was restricted to english language journals and human studies with the keywords: complementary medicine or alternative medicine, and costs or cost analysis or cost-benefit or cost-effective or economic analysis or economic evaluation. et al, 2001 [25], prospectively gathered health and economic outcomes during the 3.–23 five of these prior reviews attempted to capture all economic evaluations of cim therapies across all conditions. ,68 four involved osteopathic manipulation; one for chronic71 and one for subacute back pain72 and two for musculoskeletal conditions including back pain. papers that reported original data on specific cam therapies from any form of standard economic analysis were included. the last two studies evaluated a musculoskeletal physician (treatment ‘with a combination of manual therapy, injections, acupuncture and other pain management techniques’) for orthopaedic referrals;54 and a finnish folk medicine practice called ‘bone setting’ for the treatment of patients with chronic back pain. this study demonstrated that among patients with ibs, cam users were more likely to have more severe symptoms than non-cam users but that the cost of cam was equivalent to expenditure on over-the-counter drugs and a fraction of the cost of conventional provider-based care. strengths of this study are the comprehensive search strategy, which revealed a substantial number of published economic evaluations of cim, the use of two reviewers and the use of multiple measures of study quality. a review of the literature on care delivery and associated costs in patients treated by cam providers and naturopathic physicians can shed light on what can be expected if these providers and services are broadly included as intended in the language of the affordable care act. cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. given the fact that americans are currently receiving only half the recommended screening services,41 one of the goals of healthcare reform is to increase access and coverage of preventative services. the context of use considers treatment/condition combinations and excludes those ‘currently considered to be standard treatment’, and the setting of use generally includes self-care and therapies delivered by cim providers, but excludes therapies ‘delivered exclusively by conventionally credentialed medical personnel or exclusively within hospital settings’. for integrative medicine, university of maryland school of medicine, baltimore, maryland, usa. all authors contributed to the drafting and editing of the manuscript. the two other studies were modeling studies [49, 78] where reviews were used as the source of effectiveness estimates. terms used for the pubmed search: (complementary therapies (medical subject headings (mesh)), dietary supplements (mesh), micronutrients (mesh), trace elements (mesh), vitamins (mesh), acupuncture, alternative medicine, ayurvedic medicine, chiropractic, biofeedback, collaborative medicine, complementary and alternative medicine, botanical medicine, complementary medicine, diet, energy medicine, herbal medicine, herbs, homeopathy, hypnosis, integrated medicine, integrative medicine, massage, meditation, mind-body medicine, minerals, naturopathic medicine, naturopathy, nutrients, nutritional supplements, relaxation, spa therapy, traditional chinese medicine or vitamins) and (cost-benefit analysis (mesh), cost control (mesh), cost savings (mesh), costs and cost analysis (mesh), economics (mesh), economics (subheading), insurance (mesh), cost benefit, cost effectiveness, cost identification, cost minimisation, cost utility, economic evaluation, insurance claims, managed care or technology assessment). costs, outcomes, and patient satisfaction by provider type for patients with rheumatic and musculoskeletal conditions: a critical review of the literature and proposed methodological standards. quality of life and cost-effectiveness of acupuncture treatment in patients with osteoarthritis pain. cost-effective osteopathic manipulative medicine: a literature review of cost-effectiveness analyses for osteopathic manipulative treatment. unfortunately, other reviewers have found that these search terms do not capture all cim studies,24 ,25 which may be a reflection of the difficulty in defining what is and is not cim. only one-third of studies stated the perspective of the analysis, however, it could be determined from the costs included for all studies. unlike herman et al’s recently published systematic review, this review was not a systematic review and therefore is subject to author bias. attributes of the process of using cam that may have value include patient empowerment, the operationalization of patient preference for a particular type of intervention, the length and process of the consultation, and still having treatment options open when other medical approaches have failed [4, 98]. for health outcomes and pharmacoeconomic research, college of pharmacy, university of arizona, tucson, arizona, usa. the more well-known instruments used to measure health status in these studies included the sf-6d [35] and the euroqol (eq-5d), and health status was translated into quality of life units using population-based preferences [27, 51]. in addition, some of the natural health products used in the study (and factored into the cost analysis) were offered to participants at a discounted rate, possibly lowering the cost of naturopathic care; however the cost of these products was representative of prices available elsewhere.

Is complementary and alternative medicine (CAM) cost-effective? a

-de bos et al, 2003 [27], performed an economic evaluation alongside a randomized controlled trial to compare manual therapy, physiotherapy, and care by a general practitioner for neck pain. nhps are defined as vitamins, minerals, herbal medicines, homeopathic remedies, probiotics, amino acids, and essential fatty acids. many ways the economic evaluation of cam therapies is similar to that of conventional medicine. the bulk of the studies presented cost-effectiveness analyses (36 or 92%), five presented cost-utility analyses, and one was a cost-minimization study [24]. limitations include the reliance of self-reports to track the use of natural health products and presenteeism. are the results of the higher-quality, more recent (and likely most cost-relevant) economic evaluations of cim? clearly, a reduction in gestational diabetes cases has measurable implications in quality of life and economic units, but the creation of a summary measure is not necessary to address the decision maker's question. the reviewers were not blinded to journals and article authors, which may have influenced results. roughly 30 million people in the united states meet the diagnostic criteria for irritable syndrome (ibs) alone, and fbd is associated with high healthcare costs and more frequent healthcare visits.’ affiliations(1)program in integrative medicine, university of arizona(2)department of pharmacy, university of arizona(3)recanati center for internal medicine and research, rabin medical center (beilinson campus). this resulted in an average net reduction in societal costs by ,138 per participant and a reduction in employer costs by ,187 per participant compared to usual care alone. in our systematic review we found only two clinical trials that followed patients prospectively longer than one year: a five-year study of relaxation therapy for patients with a previous myocardial infarction [54], and a 3.); however despite the increased morbidity and more frequent cam office visits, overall annual healthcare costs were similar for patients under the care of a cam provider (,638 ± ,660) than those who did not use cam (,728 ± ,564, ns), likely due to the lower cost of care per visit with a cam provider. the perspective (or point of view) taken for the analysis also influences the selection and measurement of consequences, because not all outcomes are important to all decision makers. nevertheless, these evaluations will be done and they will be better done with practitioner involvement. reviewers (pmh and blp) evaluated all articles for inclusion and extracted all data. the searches are dated; the search strategy in the most recent review only captured articles published through 2007. this comprehensive review identified many cim economic evaluations missed by previous reviews and emerging evidence of cost-effectiveness and possible cost savings in at least a few clinical populations. section 2706 dictates non-discrimination among healthcare providers, specifically listing complementary and alternative medicine providers.* miscellaneous cam therapies include: multivitamins, shoe orthoses, electrodermal screening, and aromatherapy. full economic evaluations were subjected to two types of quality review. file 1: descriptions of included studies ordered by complementary and alternative medicine (cam) modality, form of economic evaluation, and publication date. advantages of performing cost-benefit and cost-utility analyses are that multiple outcomes are summarized into a single unit, either monetary units such as dollars (cba) or qalys (cua) and that therapies with different sets of health outcomes can be compared based on the differences in the summary measures. with mixed conditions‡ 3/2  2/1  0/1   0/110back, neck, and/or leg pain1/0 5/0   1/0    1/08surgery     2/1 2/0    5cardiac patients    2/0  1/01/0   4rheumatic disorders 0/1 1/0     1/0  3epilepsy        0/3   3general costs0/1 0/2         3allergy 0/1         1/02cancer chemotherapy    2/0       2diabetic ulcers          2/0 2dyspepsia1/01/0          2eent in children 1/1          2headache/migraine2/0           2midwifery/obstetrics         1/0 0/12miscellaneous§ 1/0 2/01/0 1/01/22/0   10totals†511738327622460. systematic review of the cam economic evaluation literature (presented below) revealed no cost-consequence studies and no cost-benefit analyses. also unlike herman et al’s systematic review, we focused our attention on naturopathic medicine and services provided by naturopathic physicians, the only cam providers trained in comprehensive primary care services. an economic approach to clinical trial design and research priority-setting. there was an average drop in 3-month medication costs after homeopathy of (1998 us$) or 54% per person. the review was performed on 48 consecutive self-referred patients in one clinic over one year with a diagnosis of an atopic condition who agreed to a classical homeopathic treatment in addition to usual conventional care. a systematic review of randomized controlled trials of acupuncture for neck pain. economic outcomes represent the consumption and production of resources and their monetary value from the perspective of a decision maker. in addition, because researchers cannot study all clinical interventions or measure disease progression over a lifetime, the authors relied on several models to estimate future costs, quality of life, and health outcome data. quality of life and cost of care of back pain patients in finnish general practice. if healthcare reform proceeds in a direction favoring lower-cost approaches, rebuilding the primary care work force and promoting preventative medicine, further integration of cam and naturopathic primary care providers may be beneficial.–59 two studies on gastrointestinal disorders60,61 and 1 study on urinary tract infections62 showed that the addition of a nhp resulted in a 19%–73% reduction in costs. it should be noted that 20% of the articles (68 of 338) in this review were identified through bibliography searches and from expert lists. this could dramatically change how cam is practiced by decreasing the use of multidimensional multicomponent interventions, by institutionalizing care into conventional health care systems, and by limiting the individualization of care. two studies on cardiovascular disorders demonstrated that supplementation with vitamin e both improved health outcomes post-myocardial infarction and resulted in a cost savings,63 while supplementation with essential fatty acids significantly improved health outcomes but did not result in a cost savings. for each evaluation the following are reported: therapies compared, study population, study design and sample size, whether it was a full or partial economic evaluation, form of the evaluation, perspective, and summary results. of the four full evaluations of acupuncture, two (one of which was included in table 5[32]) met stricta reporting standards. therefore, therapies such as chemotherapy regimens (eg, chronotherapy32), and therapies requiring surgical implantation (eg, neuroreflexotherapy33) or the placement of a feeding tube34 were not included even though these therapies appeared in our search. following data were extracted from each of the included studies: full citation information (author(s), date, title, journal, etc), form of economic evaluation (stated or inferred), the therapies being compared and whether the cam therapies were being used in addition to usual care (complementary) or instead of usual care (alternative), the perspective of analysis (stated or inferred), the study design, the sample size, and summary results. therefore, the checklist is mainly a measure of reporting quality and not necessarily of study quality. a brief pain management program compared with physical therapy for low back pain: results from an economic analysis alongside a randomized clinical trial. vitamin k to prevent fractures in older women: systematic review and economic evaluation. contribution of complementary and alternative medicine to sustainable healthcare in europe(pdf). first, the reader was not blinded to journals and article authors, which may have influenced results. challenges in systematic reviews of complementary and alternative medicine topics. data sources used were medline, amed, alt-healthwatch, and the complementary and alternative medicine citation index; january 1999 to october 2004. randomized osteopathic manipulation study (romans): pragmatic trial for spinal pain in primary care. nevertheless, the negative correlation between cam use and chlamydia screening warrants further investigation given that chlamydia is often asymptomatic and can result in serious health consequences if left untreated. these include the appropriateness of population-based studies when individualized treatments are used and individualized outcomes are expected [89–91], reductionist focus on one therapy for one outcome when that therapy comes from a holistic healing system [92–94], the difficulties with blinding when no appropriate placebo is available [94, 95], and the requirement for randomization when most cam users have strong preferences for their therapy of choice and will often either refuse to be randomized, or will bypass the randomization if it is not to their liking [94]. all studies measuring the effectiveness of cim at least consider also measuring input costs and economic outcomes. white and ernst19 identified 34 economic evaluations of cam published 1987–1999; 11 of which were full economic evaluations. hospital-based acupuncture by licensed oriental medical doctors in south korea for 60-year-old women with first-time acute low-back pain,81 acupuncture from physicians with at least 140 h of training (a-diploma) in germany for patients with dysmenorrhoea,97 osteopathic spinal manipulation by a general practitioner who is a registered osteopath in the uk for patients with subacute back pain,71 and an exercise programme plus spinal manipulation from a chiropractor, osteopath or physiotherapist at a private or national health service (nhs) site in the uk for low-back pain. criteria for selecting studies studies of cim were identified using criteria based on those of the cochrane complementary and alternative medicine group.

Complementary and Alternative Medicine Costs – a Systematic

Use and Acceptance of Complementary and Alternative Medicine

Are complementary therapies and integrative care cost-effective? A

unfortunately, their search strategy included the term "alternative medicine" but not "complementary medicine. we also report available results from several other general reviews of economic evaluations of conventional therapies that use this checklist for comparison. examples of instruments used to capture these general health states include the euroqol (eq-5d) [16] and the health utilities index [17]. pmh conceived of the idea for the paper, designed the search strategy, reviewed the references found, extracted the data from each included article and is the guarantor for this study. these discussions led to a homogeneous approach being taken to both the application of the reporting quality criteria and the definition as to what constitutes an economic evaluation. pragmatic trials offer a compromise between the goals of internal and external validity. for the purpose of this study, naturopathic treatment consisted of a specific 3-month protocol of acupuncture, relaxation training, exercise, dietary advice and written education on back care; it was compared to a 3-month standardized physiotherapy program consisting of written education on back care.↵center for the evaluation of value and risk in health. observational studies should also include these data, and as information accumulates regarding economic impacts, these costs and cost savings can be estimated more accurately. the intent of the ppaca is to increase access to healthcare, lower costs, and improve quality of care by expanding health insurance coverage, encouraging the use of preventative medicine, and rebuilding the primary care workforce. cmw provided practical insight and an international perspective to the design of the paper and interpretation of results. details of the 31 recent higher-quality full economic evaluations indicate potential cost-effectiveness and cost savings across a variety of cim therapies applied to different conditions. extensive systematic review was conducted on economic evaluations of complementary and integrative medicine (cim) published between 2001 and 2010, resulting in 204 research studies that contained economic evaluations of cim. we found that 69% (27 of 39) of the cohort of full economic evaluations collected cost data prospectively as compared to 45% (5 of 11) in white and ernst's review. 2007, a systematic review of randomized controlled trials on natural health products (nhps) was performed. as these types of guidelines are not yet available for all cam therapies, we did not assess whether cam therapies were applied appropriately in the studies reviewed. in addition, because naturopathic care was provided on-site during work hours, the cost of travel and childcare was not included in the analysis.–6 patients report using cam for health promotion and disease prevention7,8 and because it is often “more congruent with their values, beliefs and philosophical orientations towards health and life”9 or when conventional medicine cannot cure their chronic medical conditions. the therapies compared, study design employed, sample size used, and a summary of study results are provided for each study in an appendix [see additional file 1]. acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and cost-effectiveness in usual care. first, although cam therapies can be used to treat acute conditions, they are more commonly used to treat chronic disease, to prevent future disease (risk reduction), and to optimize health and well-being. although in the ideal every cost category shown in table 2 should be measured and outcomes should include a measure of quality-adjusted life-years, the estimation of direct medical costs and savings associated with the therapy (eg, practitioner fees, lab fees, and the cost of herbs or other supplements prescribed) will be fairly straightforward for most studies, and the planned primary outcome of the study can serve as the measure of effects to determine cost effectiveness. hospital resources consumed for surgical morbidity: effects of preoperative arginine and omega-3 fatty acid supplementation on costs. however, there is some evidence that the indexing of these articles in medical databases is improving; studies from bibliographies and expert lists made up 32% of found articles published 2000 and before, but only 12% recent articles. we evaluate study quality in more detail, using both additional study design criteria and quality of reporting criteria, and present a summary of the results from exemplary studies. 4 summary of results of complementary and integrative medicine (cim) economic evaluations that met five study-quality criteria (31 articles representing 28 studies). auditing outcomes and costs of integrated complementary medicine provision–the importance of length of follow up. these quality criteria are based on recommendations made by the us panel on cost effectiveness in health and medicine 42 and by well-known experts in the field,37 and focus on the quality of the underlying study (the first type of quality):Because cost-effectiveness analysis (cea) is comparative, to ensure that results are useful to decision makers, one of the alternatives to which the cim intervention was compared must be some version of commonly available (routine, standard or usual) care. in this sample of exemplar studies, of the nine study comparisons where cam therapies were shown to be superior to usual care (better effects and lower costs, similar effects and lower costs, or better effects and similar costs), four were studies of complementary therapies. naturopathic care was associated with a statistically significant improvement in symptoms and quality of life, as well as a decrease in costs by ,212 per study participant..Of the 28 cost-utility comparisons, one (massage for low-back pain62) was dominated— that is, had worse health outcomes and higher costs than usual care. national center for complementary and alternative medicine (nccam) defines cam as "a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine [28]. sixty-two (54%) of full evaluations met the first four of these and 31 (27%) met all five. of medicine, beth israel deaconess medical center, harvard medical school, boston, massachusetts, usa. analysis must explicitly or implicitly use (and include all relevant costs from) at least one recognised perspective—for example, society, third-party payer, hospital or employer.↵van den berg i, kaandorp gc, bosch jl, et al. a systematic reviewpatricia m herman1email author, benjamin m craig2 and opher caspi3bmc complementary and alternative medicinethe official journal of the international society for complementary medicine research (iscmr)20055:11doi: 10. incremental cost-effectiveness is reported in 2011 us$ and is calculated from reported results by first converting the study currency to us$ using the federal reserve annual exchange rate47 for the study's currency year and then inflated to 2011 values using the medical care component of the consumer price index. furthermore patients have reported using cam because conventional medicine is too expensive, a concern that coincides with the trend that cam users are 4 times more likely to be uninsured. that being said, it is also known that affirmative evidence on economic and health outcomes is a necessary, but not sufficient step toward cam coverage, and not the decision itself. health outcomes are to some extent considered generalisable across settings; however, because resource availability, practice patterns and relative prices can vary greatly, economic outcomes usually are not. searches in the other five databases used the same text words and (where available) analogous controlled vocabulary terms. cost-effectiveness of complementary therapies in the united kingdom—a systematic review. use of complementary and alternative medicine (cam) has steadily grown in recent decades, followed by an increase in insurance coverage for various cam providers (eg, naturopathic physicians, acupuncturists, massage therapist, chiropractors). regardless of perspective, the objective of an economic evaluation is to provide information on consequences relating to alternatives faced by a decision maker. in general, the quality of the recent full economic evaluations has held constant and is in line with what is seen in economic evaluations in conventional medicine. health care cost, quality, and outcomes: ispor book of terms. first, there is a large and growing literature of quality economic evaluations in cim. also since humanistic and economic outcomes are ideally measured alongside health outcomes in the same trials [1, 4, 19, 20], the challenges above are also relevant to their measurement. and hillis, 2000 [24], retrospectively compared government payments to physicians for 1418 quebec health insurance enrollees who practiced the transcendental meditation (tm) to payments for 1418 randomly selected and matched enrollees who did not. judgements as to whether these criteria were met were not always possible from the reports, and were beyond the scope of this review. as such, a thorough and external review of economic and health outcomes of cam is necessary for evidence-based consideration of cam therapies as a covered expense. however, the application of two key items (ie, the proper use of discounting and the inclusion of sensitivity analysis) and the disclosure of funding sources improved significantly, and reporting of the study time horizon worsened significantly. electronic databases were searched from their inception through december 2010: pubmed, cinahl, amed, psychinfo, web of science and embase. for social medicine, epidemiology and health economics, charite’ university medical center, berlin, germany. while naturopathic physicians are often lumped into the designation of cam provider, it is important to note that they are also trained (and licensed in several states) as primary care doctors known for emphasizing health promoting activities and disease prevention.

Is complementary and alternative medicine (CAM) cost-effective? a

The Economic Evaluation of Complementary and Alternative Medicine

‡ comparable estimates available from gerard et al, 2000 [84], a systematic review of cost-utility analyses. a randomized clinical trial comparing two physiotherapy interventions for chronic low back pain.† comparable estimates available from neumann, 2004 [6], a systematic review of cost-utility analyses. in the systematic review, pooled searches of various databases uncovered 585 original studies; however only 9 of these studies included a cost evaluation and excluded populations with a known nutritional deficiency. the cost effectiveness of a randomized controlled trial to establish the relative efficacy of vitamin k1 compared with alendronate. cost effectiveness of biofeedback and behavioral medicine treatments: a review of the literature. ,68 three evaluated massage; two for chronic55 ,62 and one for acute back pain. number of systematic reviews of economic evaluations of cim have been published. of complementary and alternative medicine (cam) therapies studied for various conditions (full/partial economic evaluations). randomized trial comparing traditional chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. on the other hand, an evaluation is only as good as the data upon which it is based. 3 comparison of various quality measures between economic evaluations of complementary and integrative medicine (cim) and conventional medicine. eight of these comparisons involved chiropractic care for back pain; one for chronic,53 one for acute57and six for either type. and alternative medicine (cam) has a reputation for good value among health conscious consumers [1]. costs: medicalintervention costs:practitioner feesdiagnostic coststherapy costsservice costs:facilities and equipment, including hospitalization or clinic/office costs ancillary staffportion paid by health plan included in institutional perspectiveportion paid by patient included in individual perspectiveall included in societal perspectivedirect costs: non-medicaltransportation coststime off work for appointments/hospitalizationusually all paid by the patient, so often included in individual perspectiveall included in societal perspectiveindirect costslost work productivity during recuperationlost leisure timechild care costscosts to care giversusually all paid by the patient, so often included in individual perspectiveall included in societal perspectiveintangible costspainsufferinggriefnot usually included as costs; instead, may be included in humanistic outcomes in cost-utility analysis. theoretically, cam therapies seem effective and a good candidate for cost savings because they avoid high technology, offer inexpensive remedies, and harness the power of vis medicatrix naturae (the body's natural ability to heal itself). et al, 2001 [25]complementary omega-3 polyunsaturated fatty acidspatients with recent myocardial infarctionceabetterhighersmedley et al, 2004 [68]complementary preoperative and post operative oral nutritional supplementationpatients undergoing lower gastrointestinal tract surgerycea. the role of the echo model in outcomes research and clinical practice improvement. items 12 and 13 are appropriate for cost-utility analyses (where health states are valued in terms of utility) and there were four such studies [27, 35, 51, 78], only one of which gave details on the subjects from whom the valuations were obtained [35]. limitations of this study are similar to those of the other reviews. are several implications of this study for policy makers, clinicians and future researchers. cost-benefit analysis requires putting a monetary value on all health outcomes (and ultimately on life), and cost-utility analysis assigns value to health outcomes based on their contribution to quality of life under the presumption of population-based preferences. the objectives of this study are to present an overview of economic evaluation and to expand upon a previous review to examine the current scope and quality of cam economic evaluations. the limited nature of previous systematic reviews, what is the extent of evidence on the economic impacts of complementary and integrative medicine (cim)? healthcare providers knowledgeable in encouraging and supporting patients in adopting long-lasting health-promoting lifestyle modification are needed to address the current diabetes epidemic. in addition, bibliographies of found articles and reviews were searched, and key researchers were contacted. c1 = total costs of alternative 1; c2 = total costs of alternative 2; b1 = monetary value of health outcomes of alternative 1; b2 = monetary value of health outcomes of alternative 2; e1 = health effects of alternative 1; e2 = health effects of alternative 2; qaly1 = quality-adjusted life-years of alternative 1; qaly2 = quality-adjusted life-years of alternative 2. comprehensive systematic review identified 338 economic evaluations of cim; 204 of which were published recently (2001–2010) covering a wide range of cim therapies for a variety of populations. in parallel, blp also reviewed the references found, extracted data from included articles and worked with pmh to resolve any discrepancies between reviewers. because more than half of cim users use multiple cim therapies,35 studies of packages of therapies and coordinated care were identified as such. 2 has been summarized from other references [1, 20, 22] and gives a list of the types of economic outcomes and the perspective of analysis where each is considered. in their study on manual therapy for neck pain, korthals-de bos and colleagues used weekly cost diaries to obtain economic outcomes [27]. cost-utility analysis of osteopathy in primary care: results from a pragmatic randomized controlled trial. exemplary studies summarized in table 5 indicate that a number of cam therapies may be considered cost-effective compared to usual care for a number of conditions: acupuncture for migraine, manual therapy for neck pain, spa therapy for parkinson's, complementary guided imagery for cardiac surgery patients, complementary relaxation therapy for patients with previous myocardial infarction, complementary self-administered stress management for cancer patients undergoing chemotherapy, complementary pre- and post-operative oral nutritional supplementation for lower gastrointestinal tract surgery, potassium-rich diet (rather than potassium supplements) for postoperative cardiac patients, and biofeedback for patients with "functional" disorders such as irritable bowel syndrome." therefore, all single therapy studies in their review are of cam therapies that are usually used as substitutes (alternatives) to conventional care (eg, acupuncture, homeopathy, and spinal manipulation). an additional 68 articles were added through the bibliography and expert-supplied list search for a total of 338 economic evaluations of cim. cost minimization analysis of low back pain claims data for chiropractic vs medicine in a managed care organization. data were collected from insurance claims from visits with both cam providers (naturopathic physicians, chiropractors, acupuncturists, and massage therapist) and conventional providers (medical doctors, osteopathic physicians, advanced registered nurse practitioners, and physician assistants) for back pain, fibromyalgia, and menopause. almost 30% of the 56 cost-effectiveness, cost-utility and cost-benefit comparisons shown in table 4 (18% of the cua comparisons) were cost saving. in addition, economic outcomes are relevant to the licensure and scope of practice of practitioners, industry investment decisions (eg, the business case for integrative medicine), consumers and future research efforts (ie, through identifying decision-critical parameters for additional research10).-of-pocket expenditures of over billion per year in the us are an apparent testament to a widely held belief that complementary and alternative medicine (cam) therapies have benefits that outweigh their costs. of these, 204 (60%) were published from 2001 through 2010 (114 full and 90 partial economic evaluations).§miscellaneous conditions include: anxiety, parkinson's, psoriasis, uterine fibroids, urinary tract infection, macular degeneration, severe burn, aids, obesity, and hypertension. studies stated the time horizon for costs and benefits and most (35 or 90%) reported a time horizon of one year or less. matter the approach taken, it is recommended that the estimated outcomes (economic, clinical and humanistic) of health care alternatives used in economic evaluation are best estimated in pragmatic clinical trials that directly and realistically compare the therapies of interest [10]. summary measures of quality of life may not be sensitive enough to pick up short-term changes such as for acute conditions and will not pick up specific clinical outcomes like blood pressure control [15]. since the costs were lower and the qalys higher for manual therapy as compared to usual care, manual therapy is said to dominate general practitioner care and no cost-utility ratio is calculated. cost effectiveness of complementary treatments in the united kingdom: a systematic review. the availability of economic data could improve the consideration and appropriate inclusion of cim in strategies to lower overall healthcare costs. studies were then excluded if they were cited in the white and ernst review [4], or if they were case studies or case series of five or fewer subjects. acupuncture of chronic headache disorders in primary care: randomised controlled trial and economic analysis. limitations of the study include lack of randomization of cam use (which can create self-selection bias), the relatively short time period (1 year) of care from which claims were collected, and that data analysis did not adjust for confounding demographic characteristics like education and race. ,62 ,68 ,71 ,78 ,80–85 87–93 ,95 ,100 ,101 ,103 for those studies which included a randomised trial, the modified jadad scores ranged from 2 to 4 on a scale from 0 to 4. some therapies, such as acupuncture, homeopathy, and manual therapy, were studied mainly as alternative therapies (ie, as substitutes or alternatives for conventional care). the first is that the comparison group was usual care, and the second was that the study was not blinded and not mandatory – ie, that physicians and patients could react realistically to the therapy [10]. weaknesses of this study are similar to those of the other systematic reviews: reviewers were not blinded to journals and article authors, and some aspects of what makes a quality economic evaluation could not be judged from what was reported.

Alternative medicine

‡ this study used both a societal and an institutional perspective, and the results were in the same direction. guidelines for authors and peer reviewers of economic submissions to the bmj. our systematic review found five studies where humanistic outcomes were captured.' contributionsph had the main responsibility for the manuscript and for bringing together the concepts of cam and economics. health economists, as well as experts in cam, recommend that economic evaluations use methods that focus on relative costs in terms of patient-centered outcomes, such as qaly. were categorised as full economic evaluations if they compared the costs (inputs) and consequences (economic, clinical and/or humanistic outcomes36) of two or more therapeutic alternatives applied to the same patient population (ref. standardization and quality will affect both the costs of the therapy and its outcomes. the role of complementary and alternative medicine in the nhs – an investigation into the potential contribution of mainstream complementary therapies to healthcare in the uk. ,19–21 ,23 however, it is unclear as to whether all or even the majority of economic evaluations of cim have been identified by these reviews. part of the attraction to naturopathic medicine may be attributable to psychosocial benefits, such as an increased sense of hope,45 empathy and listening skills of cam providers, and visit lengths sufficient to attend to these psychosocial dimensions. 1990 and 2007, four nationally representative surveys demonstrated that a third or more of us adults routinely used complementary and alternative medicine (cam) therapies to treat their principal medical conditions. this is because individual studies can include analyses using more than one form of economic evaluation and can report costs from more than one perspective. sources pubmed, cinahl, amed, psychinfo, web of science and embase were searched from inception through 2010. we begin with an overview of economic evaluation, including didactic examples from the cam economic literature to help clarify the concepts presented. the increasing popularity of cam, policy makers and insurers invested in addressing the rising cost of healthcare should work to ensure that implementation of the affordable care act proceeds as intended (inclusive of cam providers). searched the following electronic databases from january 1999 to october 2004: medline, amed, alt-healthwatch, and the complementary and alternative medicine citation index via nccam and the national library of medicine (nlm). additional prospective studies are needed to assess the cost-effectiveness of naturopathic medicine. however, we did find examples of a cost-identification study, cost-minimization analysis, cost-effectiveness analysis, and cost-utility analysis. although more prospective outcome studies are needed to evaluate the cost-effectiveness of cam, there have been published research studies demonstrating that cam is cost-effective and may present cost-savings due to inexpensive treatments, lower technology interventions, and its emphasis on preventative medicine. disagreements were resolved by discussion between the two review authors, or, if needed, by the other coauthors.–8 however, despite the popularity of and substantial expenditures on cam therapies, their cost-effectiveness remains ill-defined and controversial. ,30 this review used the one developed by the members of the cochrane cam field31 and then added the terms ‘integrative’, ‘integrated’ and ‘collaborative’ medicine. assessing the quality of reports of randomized clinical trials: is blinding necessary? conventionally, clinical and humanistic outcomes are considered health outcomes, and we follow this convention for the remainder of the article., 35 the study had noteworthy strengths: participant retention was high (91% and 88% for participants receiving naturopathic care and usual care, respectively), missing data was thoughtfully addressed using multiple statistical methods, interventions were evidence-based, and electronic claims and absenteeism data were available for use. they generally involve more effort than other ceas and are required or recommended by various national guidelines. acupuncture and homeopathy were both found to be equivalent in terms of effects and costs to usual care for dyspepsia. a comparison between chiropractic management and pain clinic management for chronic low-back pain in a national health service outpatient clinic. however, one of the limitations of using a cost minimization analysis to evaluate costs is the assumption that health outcomes are equivalent and that interventions are equally efficacious.-seven studies (69%) gathered cost data prospectively and 21 (54%) used randomly assigned comparison groups.”1 reports suggest that between 1997 and 2007, 36% of adults (roughly 72 million adults) used some form of alternative medicine. collection of economic outcome data is complicated by that fact that in the united states and other countries many cam therapies are available over the counter and/or are often paid for out-of-pocket. the prices used to value resources are highly location-specific and setting-specific,39 ,46 we also note, for the articles meeting the above criteria, the presence of a study reporting criterion essential for the transferability of study results (usually via modelling):39 ,40 separate reporting of unit costs from resource use for economic evaluations alongside trials, or from model parameters (eg, transition probabilities) for economic evaluations using models. authors wish to acknowledge and most gratefully thank sandy kramer of the university of arizona health sciences library for her assistance in the development and application of the search strategy and for eliminating duplicates from the search results. an economic analysis of usual care and acupuncture collaborative treatment on chronic low back pain: a markov model decision analysis. some examples of cost savings were seen for acupuncture in reducing breech presentation in the netherlands,68 acupuncture for low back in the united kingdom,69 manual therapy for neck pain,70 vitamin k for preventing osteoporotic fractures,71 and adjunctive use of antioxidants for preventing cataract formation. the 56 comparisons made in these studies, 16 (29%) are cost saving—that is, the added cim therapy had better health outcomes and lower costs than usual care alone. for example, ideally, pragmatic trials enrol patients typical of normal caseload in typical settings with typically trained and experienced practitioners following them under routine conditions (ref. of the results of complementary and alternative medicine (cam) economic evaluations with exemplary study quality. the number and quality of economic evaluations of cam have increased in recent years and more cam therapies have been shown to be of good value, the majority of cam therapies still remain to be evaluated. lastly, participants expressed a strong preference for naturopathic care with higher retention rates in the naturopathic care group compared to the control group (82% and 22% at 6-month follow-up).‡ populations with mixed conditions include: patients with chronic disease, patients at one general practice (4 studies), long-term care workers, persons in quebec health system, inner city children, and older adults (2 studies). this checklist was developed to improve the quality of published economic evaluations, and was chosen because it is thorough, and entails an objective assessment of whether essential components of an economic evaluation are reported in the article. number of economic evaluations of cam has increased in recent years, even if we only count full evaluations of alternative therapies. extracted data were entered into an excel template developed for a previous review. this is noteworthy because the same survey demonstrated that cam users possess many modifiable cardiovascular risk factors, such as hypertension (18%), hyperlipidemia (20%), obesity/overweight (54%), prediabetes/diabetes (9%) and tobacco use (17%). economic evaluation is a comparison of outcomes among alternative ways of achieving common objectives. one such set of reporting standards are the stricta recommendations for acupuncture [88]. bowel disease (fbd) refers to a group of chronic bowel disorders of a physiologic origin (irritable bowel syndrome, functional diarrhea, functional constipation, and functional abdominal pain). the difference in the annual change in payments was statistically significant at a rate between 5 and 13% per year. beyond their use in decisions concerning health insurance coverage, economic outcomes of both cam and conventional therapies also influence health policy, justify licensure of practitioners, inform industry investment decisions, provide general evidence to consumers about potential economic benefits, and can guide future research efforts through identifying decision-critical parameters for additional research [8, 9]. study quality of the cost-utility analyses (cuas) of cim was generally comparable to that seen in cuas across all medicine according to several measures, and the quality of the cost-saving studies was slightly, but not significantly, lower than those showing cost increases (85% vs 88%, p=0. two studies gave an explanation for why they did not discount costs and benefits, however, neither needed to – one had a one-year time horizon [35] and the other stated its time horizon as one course of chemotherapy [55]. goal of this paper is to identify, to the extent possible, all published economic evaluations of cim, describe the types of cim evaluated and the clinical conditions for which they have been evaluated, and identify the recent (and therefore, most cost-relevant) higher-quality studies and highlight their results for policy makers. a smaller number reported the details of adjustments for inflation or currency conversion, but this was not often required in studies collecting and reporting data in the same year and currency. this may have lead to inaccurate reporting of results, and/or a biased interpretation of study quality.

  • BMC Complementary and Alternative Medicine | Home page

    of the recent full evaluations, 31 (27%) met five study-quality criteria, and 22 of these also met the minimum criterion for study transferability (‘generalisability’). we end the paper with a description of the attributes of cam that make economic evaluation challenging and how these issues may be addressed. application of inclusion and exclusion criteria reduced the list to 56 economic evaluations [23–25, 27, 31–82]. readers familiar with this type of analysis can skip this section and proceed directly to the methods section. appraisal methods all recent (and likely most cost-relevant) full economic evaluations published 2001–2010 were subjected to several measures of quality. fortunately, the majority of the higher-quality studies met our measure of study transferability—resource use or model parameters, and unit costs were reported separately. therefore, economic evaluation of cam needs to measure and include this value where appropriate. with the increasing popularity of cam, cam providers' orientation toward health promotion and prevention, and the growing body of research demonstrating the cost-effectiveness of cam, policy makers and insurers invested in addressing the rising cost of healthcare should work to ensure that implementation of the affordable care act proceeds as intended (inclusive of cam providers). however, since the major goal of this study was to establish the extent of the published literature on this topic and to highlight the results of the higher-quality studies, it is not clear that publication bias is relevant here. cost-effectiveness of natural health products: a systematic review of randomized clinical trials. in 32 studies (82%) the physicians and patients were not blinded to the treatment received and participation was not mandatory (a worksite intervention [57]), and therapies were compared to usual care in 34 (87%) of studies. to be as comprehensive as possible, a combination of 11 medical subject headings (mesh) and 39 other search terms were used (box 1). cost comparison of chiropractic and medical treatment of common musculoskeletal disorders: a review of the literature after 1980. humanistic outcomes include quality of life characteristics such as sense of safety, physical comfort, enjoyment, meaningful activity, relationships, functional competence, dignity, privacy, individuality, autonomy, and spiritual well-being. addition of choice of complementary therapies to usual care for acute low back pain: a randomized controlled trial. use of complementary and alternative medicine (CAM) has steadily grown in recent decades, followed by an increase in insurance coverage for various CAM providers (eg, naturopathic physicians, acupuncturists, massage therapist, chiropractors). for example, in our review we interpreted item 1 as whether the study stated either a specific research question or study objectives in terms of economic and health outcomes. outcome and cost-effectiveness of perioperative enteral immunonutrition in patients undergoing elective upper gastrointestinal tract surgery: a prospective randomized study. all but one [49] reported these amounts separate from total costs. therefore, we did not include therapies such as chemotherapy regimens nor therapies requiring surgical implantation (such as neuroreflexotherapy [29]) as cam therapies even though these therapies do appear in searches using the keywords complementary and/or alternative medicine. it is important for cam that this contradictory evidence is also known for best clinical practice and the efficient use of cam resources. the search by maxion-bergemann et al11 also added individual therapies as search terms, but only included homeopathy, phytotherapy, traditional chinese medicine, anthroposophic medicine and neural therapy. improved pain score outcomes achieved through the cooperative and cost-effective use of physical (osteopathic manipulative) medicine in the treatment of outpatient musculoskeletal complaints. the chiropractors agreed that high quality economic evaluations are essential to their practice, but reiki practitioners could see no reason for this research, and the homeopaths were divided on these issues. evaluations allow costs to be included, alongside data on safety and effectiveness, in healthcare policy decisions. costeffectiveness of complementary therapies in the united kingdom-a systematic review. although most patients who use cim use more than one modality35 and despite the attention given to integrative medicine (coordinated access to conventional medicine and cim),105 this systematic review found only one study that examined the effects of use of multiple cim practitioners. in not being part of conventional medicine, individual complementary therapies and emerging models of integrative medicine (ie, coordinated access to both conventional and complementary care)—collectively termed as complementary and integrative medicine (cim)—are often excluded in financial mechanisms commonly available for conventional medicine,2 and are rarely included in the range of options considered in the formation of healthcare policy. cost-minimization analyses evaluate the costs of competing interventions when health outcomes are the same in order to determine which intervention costs least to achieve the same outcome. for comparison, table 4 also contains comparable results from systematic reviews in conventional medicine [6, 83, 84]. this is also the case if both therapies have equal health outcomes and one has lower costs. a comprehensive systematic review of economic evaluations of complementary and integrative medicine (cim) to establish the value of these therapies to health reform efforts. the incremental cost effectiveness ratio of 31 of the higher-quality articles was identified: 13 acupuncture studies, 5 physical medicine studies (massage therapy, osteopathic manipulation, and chiropractics), 9 studies using natural health products, 1 study using tai chi, 1 naturopathic care study, and 2 studies using spa-exercise therapy. effectiveness, safety and cost-effectiveness of homeopathy in general practice—summarized health technology assessment. disease (cvd) is the leading cause of death in the united states29 and is extremely expensive to manage in terms of direct medical costs (medical services) and indirect costs (lost productivity from work absenteeism and presenteeism). regardless of public opinion, there is often little more than anecdotal evidence on the health and economic implications of cam therapies. project was supported by grant #t32 at01287-03 from the national center for complementary and alternative medicine. a study that describes the economic and health outcomes of a single therapy can also be called a cost-identification study. cost effectiveness analysis of a randomised trial of acupuncture for chronic headache in primary care. the use of professionally-administered stress management for cancer patients undergoing chemotherapy was shown to have higher costs, but no additional health benefits over usual care.” they further suggest that coverage of cam by government programs such as medicaid would not increase healthcare expenditures and may actually lower them in sicker patients who require more visits per year.(8) the source(s) of effectiveness estimates are stated38 (100)    (9) details of the effectiveness study are given36 (94) or (10) details of the review or meta-analysis are given2 (50) (11) primary outcome measures are clearly stated39 (95)    (12) methods to value health states are stated4 (100)228 (75)†43 (79)‡   (13) details of the subjects from which values were obtained are given4 (25)228 (76)†43 (46)‡   (14) productivity changes are reported separately8 (88)    (15) the relevance of productivity changes is discussed8 (25) (16) quantities of resources are reported separately from unit costs39 (67)43 (19)‡(17) methods for the estimation of quantities and unit costs are described39 (67) (18) currency and year are recorded39 (41)228 (68)†(19) details of adjustments for inflation or currency conversion are given39 (21)43 (21)*   (20) details of any model used are given3 (100)    (21) the choice of the model and its key parameters are justified3 (100). that is, they provide the data needed to better design future studies that consider both the economic and health outcomes of two or more alternative therapies. and 90% of these articles covered studies of single cim therapies and only one compared usual care to usual care plus access to multiple licensed cim practitioners. the clinical effectiveness of glucosamine and chondroitin supplements in slowing or arresting progression of osteoarthritis of the knee: a systematic review and economic evaluation./free full text↵national institute for health and clinical excellence." we further defined cam as including only those therapies that could be prescribed (or recommended) and/or performed by a cam practitioner who does not also have a conventional medical license (eg, doctor of medicine – md, or doctor of osteopathy – do).,23 by studying insurance claims in washington state, researchers, healthcare policy makers, and insurers may investigate concerns that providing additional coverage may increase healthcare costs. united kingdom back pain exercise and manipulation (uk beam) randomised trial: cost effectiveness of physical treatments for back pain in primary care. a randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis. chiropractic and medical care costs of low back care: results from a practice-based observational study. quality was evaluated by noting whether cost data were collected prospectively and whether comparison groups were comparable – ie, assigned randomly. an increasing number of health plans and hospitals have moved from a simple budgetary focus in formulary decisions to requiring detailed evidence on the economic value of considered therapies relative to alternatives [6, 7]. the study found fibromyalgia patients who used cam were in poorer health and had more frequent medical visits (mean ± sd) (34 ± 25) than those seeking conventional care (23 ± 21, p<0.-effectiveness analysis (cea) is the current standard in the literature, and has the most straight forward interpretation. third, by meeting the five study-quality criteria, the studies shown in table 4 can each be considered a reasonable indicator of the health and economic impacts of the cim therapy studied, at least in that population and setting.
  • References

    the authors conclude that in chronic, debilitating conditions for which conventional medicine cannot offer a cure (such as fms), “cam providers may offer an economical alternative for fms patients seeking symptomatic relief. the large number of economic evaluations found in this study reflects the facts that: (1) all evaluations from previous reviews were included; (2) a number of studies have been published since the last search dates of prior reviews and (3) a more extensive search strategy was used. study quality has also increased, and although reporting quality can use improvement, it is on the whole similar to that seen in economic evaluations of conventional medicine. the study demonstrated that 35% of patients with fbd in this hmo used a cam therapy, at a median annual cost of 0 per participant (ranging between and ,000), which was equivalent to the median annual cost of over-the counter drugs (0) and roughly a third the cost of the median annual cost of prescription drugs (3). lifestyle interventions as a preventative measure in pre-diabetic patients should be employed to curtail the high cost of treating diabetes and also to reduce the rising incidence of diabetes. the first was a 35-item checklist for reporting quality, and the second was a set of four criteria for study quality (randomization, prospective collection of economic data, comparison to usual care, and no blinding). data on each patient's overall health state were gathered at baseline and at one year using a survey instrument called the euroqol [16]. it has been suggested that the ideal situation for data collection is to collect economic data along side health outcomes in a randomized pragmatic trial [10]. are the range of therapies and populations studied, and the quality of published economic evaluations of cim? studies were categorized as either full economic evaluations (defined as a comparison between two or more alternatives and considering both costs and consequences [10]) or partial economic evaluations (those studies that did not contain a comparison, or only addressed costs). the 35-item bmj checklist captures components of both dimensions of quality and was applied to all full economic evaluations. cost-identification studies and cost-minimization analyses only address economic outcomes and are discussed below in that section. when the costs are lower and the effects are higher for one therapy, it is said to dominate the alternative (and the alternative is said to be dominated) and no ratio is presented. the studies with cost-utility icers between us

    Complementary and Alternative Medicine and Cardiovascular

    no studies of complementary therapies (those used in conjunction with conventional care) were included, despite the use of the term "complementary" in their conclusion that spinal manipulative therapy may have benefits for back pain, but "there was a paucity of rigorous studies that could provide conclusive evidence of differences in costs and outcomes between other complementary therapies and orthodox medicine [4]. 232), health outcomes must be from randomised controlled trials or non-randomised controlled trials using either statistical adjustment or matching to address baseline differences. third, only one reader read all the papers and extracted all the data. researchers concluded that compared to metformin, the lifestyle modification program cost less and resulted in better health outcomes. if the health outcomes for one therapy are better than that of its alternative and the economic outcomes are better or equal (lower or equal costs), that therapy is said to dominate (be clearly better than) its alternative. an extensive literature addresses the methodological and theoretical issues involved in the construction of these summary measures. eight of these 9 studies showed that when a nhp was included in a medical intervention, there was both a positive health outcome and a cost savings. of the 31 medication users (prescription and non-prescription allergy-related medications) before the intervention, 27 reduced their use, two increased their use, and two had their medication level unchanged after the intervention."the objectives of this paper are: 1) to introduce concepts commonly applied in economic evaluations of health technologies (often called technology assessment) so that practitioners and cam users can translate and benefit from published evidence; and 2) present a systematic review of the current scope and quality of economic evaluations of cam. the perspective was that of a third-party payer; accordingly only direct health care costs (hospital admissions, laboratory and diagnostic tests, and medications) were considered. the authors found that the biggest concentration of evaluations (19 studies) involved manipulative (chiropractic and osteopathic techniques) and massage therapy for low back pain, although the studies were notably diverse in terms of therapies used and the nature of back pain treated (acute vs chronic). second, the results of the higher-quality studies indicate a number of highly cost-effective, and even cost saving, cim therapies. the substantial number of economic evaluations of cim found in this comprehensive review, even though it can always be said that more studies are needed, what is actually needed are better-quality studies—both in terms of better study quality (to increase the validity of the results for its targeted population and setting) and better transferability (to increase the usefulness of these results to other decision makers in other settings). as healthcare costs rise, the availability of these economic evaluations becomes increasingly important to the formulation of disease management strategies which are both clinically effective and financially responsible. cost savings were seen for acupuncture alone (instructional visits with an acupuncturist followed by home self-care by the partner for pregnant women with breech presentations at 33 weeks in terms of reductions in both breech presentation at birth and ceasareans in the netherlands,91 and treatment by traditional chinese medicine-trained licensed acupuncturists in private acupuncture clinics in the uk for low-back pain in terms of quality-adjusted life-years or qalys from the societal perspective85) and in combination with other therapies (along with manual therapy, injections and other pain management for patients referred to an orthopaedic surgeon's office in scotland who were unlikely to need surgery in terms of both improvements in health-related quality of life and qalys54). from the perspective of third party payers, the use of cam may result in cost savings in patients with back pain, menopausal symptoms, and fibromyalgia; however, additional studies are needed to address the economic impact of cam from societal and patient perspectives. between 1999 and october 2004, herman et al20 identified 56 economic evaluations of cam (39 full evaluations). the surface one might expect that therapies that substitute for usual care (alternative medicine) would be much more likely to be cost effective. at least one arm of the study be some version of commonly available (usual) care, and that usual care and all interventions studied be described in sufficient detail that decision makers in other settings can determine what was done and whether the study's usual care comparator is applicable in their setting. of the recent full economic evaluations almost all (103, 90%) examined the effect of one cim therapy and most of the balance (10, 9%) examined the effect of two or more cim therapies provided by the same practitioner. this coincides with prior studies demonstrating the trend that cam users are more likely to engage in healthy behaviors like regular exercise,38 healthy dietary choices,39 and nonuse of tobacco. and hermoni, 2002 [23], performed a retrospective comparison of medication consumption costs from computerized medication charts three months before and three months after a homeopathic intervention for atopic and allergic disorders. in the study, 3,234 adults with impaired glucose tolerance were randomly assigned to receive metformin (850 mg twice daily), to participate in a lifestyle medication program (designed for 7% weight loss through lower fat intake and 150 minutes of exercise per week), or to receive placebo. in economic evaluations, the safety of a therapy is addressed through accounting for the cost of treating these adverse events as well as through their impact on clinical and quality of life outcomes. quality of an economic evaluation can be judged along two general dimensions: (1) whether the study was a quality measure of outcomes for its target population and location—that is, whether it was internally valid; and (2) whether enough information is provided for the study's results to be transferable (‘generalisable’). the weaknesses of this study are similar to those of the other systematic reviews. of the higher quality studies, 29% were cost-saving, meaning that the addition of a cim therapy resulted in lower costs than usual care alone. the cochrane cam definition starts with the nccam definition9 and then refines it by specifically including all therapies ‘based upon the theories of a medical system outside the western allopathic medical model’ (eg, traditional chinese medicine and reiki), and including others depending on the context and setting of their use. other factors such as historical demand, political expediency, consumer demand, and practitioner enthusiasm may also be considered in the decision to incorporate cam into a health insurance policy [1, 4, 5]. the purpose of economic evaluations is to inform clinical practice and health policy decisions, the best evaluations are timely and use the best data available at the time [10]. here we review the literature regarding the cost-effectiveness of cam and naturopathic medicine. in response to this problem researchers and practitioners of several cam therapies have begun development of standards for research and reporting. although the use of the euroqol for manual therapy for neck pain [27] resulted in a statistically insignificant change in quality of life, two other studies demonstrated small, but statistically significant differences in quality of life using the sf-6d for acupuncture for chronic headache [35], and using the euroqol for spa therapy for ankylosing spondylitis [51]. the debate over managing rising healthcare costs and improving access to quality primary care commences, the stage has been set for a historic change in the american healthcare delivery system with the re-election of president obama and the passing of the patient protection and affordable care act (ppaca)..A notable limitation of this review is that the economic evaluations presented were conducted from a variety of perspectives (patient, payer, society). consequences may include economic, clinical, and humanistic outcomes, known as the echo model [11]. three of these studies showed that perioperative parenteral nutrition in critically ill patients resulted in a reduction in postoperative complications and a concomitant reduction in hospital-related costs.(22) time horizon of costs and benefits is stated39 (100)    (23) the discount rate is stated4 (50)228 (65)†   (24) the choice of discount rate is justified4 (25)43 (16)*34 (21)‡   (25) an explanation is given if costs and benefits not discounted4 (50)8 (12)‡   (26) details of statistical tests and confidence intervals are given for stochastic data38 (87)    (27) the approach to sensitivity analysis is given5 (100)43 (2)*(28) the choice of variables for sensitivity analysis is justified5 (40)39 (79)‡   (29) the ranges over which variables are varied are stated5 (100)228 (57)†38 (66)‡(30) relevant alternatives are compared39 (36)228 (57)†   (31) incremental analysis is reported13 (54)228 (46)†(32) major outcomes are presented disaggregated and aggregated39 (85) (33) the answer to the study question is given39 (69) (34) conclusions follow from the data reported39 (100) (35) conclusions are accompanied by the appropriate caveats39 (67)228 (84)†. pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. other indicators of a study's generalizability, such as the determination of whether study participants could be assumed to represent a normal case load, were not used as they required detailed knowledge as to the appropriateness of the inclusion and exclusion criteria for each condition studied – a level of expertise not held by the study's authors. however, in jefferson et al, 1998 [83], only 16% of the 43 economic evaluations of conventional medicine reviewed where identified as fulfilling item 1. the biggest concentration of full economic evaluations (19 in number) pertained to the use of nccam's definition of manipulative and body-based practices (eg, chiropractic, osteopathic manipulation, massage, etc) for the treatment of back pain. while their review was the first of its kind, economic evaluations in the cam literature have improved greatly in the last five years. also, the approach and assumptions used to determine study quality were discussed at length with the other authors. use and acceptance of classical natural and alternative medicine in germany—findings of a representative population-based survey. patients who were using cam in conjunction with conventional care had increased rates of cervical cancer screening using papanicolaou testing and breast cancer screening using mammography. according to the national center for complementary and alternative medicine (nccam), cam is ‘a group of diverse medical and healthcare systems, practices and products that are not generally considered part of conventional medicine’.* results are calculated when both the costs and the effects (health outcomes) of one therapy are higher than those of another. five (18%) are cost saving,54 ,80 ,82 ,85 ,103 5 (18%) have incremental cost-effectiveness ratios (icers) between us

    Current issues / Reviews / Studies

    the authors described the challenging nature of defining a search strategy for cim as there is no universally accepted definition of cam/cim; the authors also note that 20% of the articles included in the study were identified through bibliographies and article lists obtained by cim researchers. dixhoorn and duivenvoorden, 1999 [54]complementary relaxation therapypatients with previous myocardial infarctioncea. 1 the flow of records and articles through the systematic review. recently, the cost and perceived effectiveness of cam was studied in 1,012 patients with fbd over a 6-month period. how the public classify complementary medicine: a factor analytic study. data extracted for the economic evaluations which meet the five study-quality criteria are: treatment and study duration, primary clinical and economic outcome measures, the setting in which treatment took place, study design and sample size, the type (table 1) and perspective (ie, the point of view used to define costs) of the economic analysis, and incremental cost-effectiveness of the cim alternative compared to usual care. the study used the societal perspective and collected direct and indirect costs (including hours of help from family and friends, and hours of absenteeism from work or other activities) through the use of cost diaries kept by patients over one year. reporting standards do not guarantee that the therapy was used appropriately, but they at least allow determination of what was done. in most cases this was done as a simple statement noting that the results were either similar, or that they were dissimilar and that this might be because of differences in study design.,14 several methods are available for evaluating the economic impact of naturopathic and cam therapies: a cost-benefit analysis (cba) compares the monetary cost of treatments with the monetary benefit of treatments. however, retrospective data collection is seldom fertile, adapted, or exhaustive, and it is subject to bias [18, 20]. the effectiveness of physical modalities among patients with low back pain randomized to chiropractic care: findings from the ucla low back pain study. and alternative medicine (cam), including naturopathic treatments are becoming increasingly common. ten used a societal perspective, and the majority (33 or 85%) used some sort of institutional perspective (eg, health insurance company or hospital). year follow-up period of a large randomized open-label study (n = 5664) of omega-3 polyunsaturated fatty acids (n-3 pufa) as secondary prevention for patients with recent myocardial infarction. patients from a healthcare maintenance organization were followed for 6 months, using questionnaires that assess symptom severity, quality of life, and utilization and expenditures on cam (limited to herbal medicines, homeopathy, hypnotherapy, massage, yoga, biofeedback, and acupuncture). cost-effectiveness of acupuncture in women and men with allergic rhinitis: a randomized controlled study in usual care. unconventional medicine in the united states: prevalence, costs, and patterns of use. in contrast, a cost-effectiveness analysis (cea) compares the costs and health outcomes of competing interventions within a fixed healthcare budget. ,19–21 ,23 this study found a total of 338 economic evaluations of cim published between and including 1979 and 2010; 211 of these were full economic evaluations. ,73–75 nevertheless, it seems as though the quality of cuas of cim is generally comparable to, or slightly better than, that seen in cuas across all medicine, at least in terms of the tufts quality score, disclosure of funding sources and the five items where comparable data are available. the cochrane collaboration defines cam as “all practices and ideas, which are outside the domain of conventional medicine… preventing or treating illness, or promoting health and well being. there were several limitations of the study: the authors chose to ignore the use of probiotics and fiber, suggesting that these are “more likely considered a part of conventional care,” and only insurance claims billed under conventional providers were used. note that these types of economic outcomes should be inclusive of both the full costs of the therapy and of any treatment for adverse effects, which can be expensive. a cost-minimization analysis (cma) explicitly assumes equivalence in health outcome among alternative therapies, and examines only economic outcomes. similarly, we found that 54% (21 of 39) of our studies used randomization to create the comparison groups as compared to 45% (5 of 11) in white and ernst's review. the authors conclude that naturopathic care was more cost-effective than a standard physiotherapy plan. however, it is not clear as to whether publication bias is relevant, given the purposes of this review. are several forms of economic evaluations that can be performed (cost-effectiveness analysis being only one of these) and each differs based on the selection and measurement of health outcomes. two-thirds of studies reported resource use quantities separate from unit costs, or described the methods used to estimate both quantities and unit costs. the lack of administrative claims data on cam therapies in countries where these costs are not covered or reimbursed means that cost studies require primary data collection (eg, patient self-report instruments) [100]. our systematic review we expand upon and update the initial review by white and ernst. in addition, bibliographies of found articles and reviews were searched, and key researchers in various areas of cim were contacted for their lists of known studies. the reporting quality of the full evaluations was poor for certain items, but was comparable to the quality found by systematic reviews of economic evaluations in conventional medicine. cost-utility analyses found were of similar or better quality to those published across all medicine. the appendix contains a table summarizing each of the 56 economic evaluations found in the systematic review. economic evaluations are typically required for the incorporation of therapies under traditional financing mechanisms and for adjustment of coverage under these mechanisms. about half the studies stated the form of the economic evaluation, however, several were stated incorrectly and only one justified the form chosen. to assess study quality, we went beyond white and ernst's [4] criteria of randomization (to reduce bias by creating comparable groups) and prospective collection of economic outcome data (to ensure all costs are captured) to include two additional indicators of whether a pragmatic (effectiveness or "real world") rather than efficacy trial was conducted. strengths of this study are the comprehensive search strategy, the use of two reviewers, the use of multiple measures of study quality and the identification of higher-quality studies, for which results are reported in detail, via an objective short-list of quality criteria, which reduced the potential for bias. future studies should focus on economic evaluations conducted from the societal perspective in order to provide more information to policy makers regarding the economic impact of adding more coverage for cam and naturopathic medicine services.–27 care delivery and associated costs in washington state can be studied as a model by which other states can learn what to expect if cam providers and cam services are broadly included in healthcare reform..Ecpm (european council of doctors for plurality in medicine) www. however, regardless of public opinion, there is often little more than anecdotal evidence on the health and economic implications of cam therapies. second, our measures of study quality depend on the information reported in an article, and no attempt was made to judge the merits of clinical or modeling assumptions made in the analyses. ph also read and evaluated the quality of all papers included in the review. united states healthcare system is not only grappling with rising costs but it is also facing an undeniable shortage of primary care providers, with an estimated projected shortage of 52,000 primary care doctors by 2025. However, with rising healthcare costs, insurers and policy makers have expressed concerns about the cost-effectiveness of healthcare, both conventional and CAM. in the first step, health outcomes of the intervention are measured, and in the second the outcomes are valued in summary units and aggregated. complementary and alternative medicine costs - a systematic literature review. effectiveness and cost-effectiveness analysis of neuroreflexotherapy for subacute and chronic low back pain in routine general practice: a cluster randomized, controlled trial. the databases searched were limited—for example, only one used cinahl,21 and only two others used embase,19 ,23 in addition to medline and amed. economic evaluation of four treatments for low-back pain: results from a randomized controlled trial. higher-quality studies were identified and highlighted for policy makers using a simple objective list of quality criteria, which reduced the potential for bias. we also did not include well-accepted vitamin and mineral supplementation therapies such as calcium and vitamin d for osteoporosis, niacin for dyslipidemia, and vitamin b12 and folic acid for homocysteine reduction. number of economic evaluations of cim found and reviewed by this study far exceeds the numbers found in previous studies. and us 000 per quality-adjusted life-year (qaly),68 ,71 ,81 ,85 ,97 and 89% had icers less than us 000/qaly, a threshold often considered to represent the upper limit of society's value for a qaly.–72 however, even this subgroup is fairly heterogeneous in terms of the therapy (or therapies) tested and/or the type of back pain treated. since the cost of a therapy differs depending on whether you are a patient, a health plan, or a health care provider, the economic outcomes (ie, costs) of each therapy depend on the perspective of the study. all but one only used variations on the terms ‘complementary’ or ‘alternative’ ‘medicine’ or ‘therapy’. higher-quality studies indicate potential cost-effectiveness, and even cost savings across a number of cim therapies and populations. a review of economic evaluation in complementary and alternative medicine. because the results of economic evaluations can rapidly lose relevance with time, mainly due to changes in practice patterns and cost structures, data were extracted only from the economic evaluations published 2001–2010. such evidence on out-of-pocket expenditures is a testament to the widely held belief that cam therapies have benefits that outweigh their costs. and us 000 per qaly were: treatment by traditional chinese medicine-trained licensed acupuncturists in private acupuncture clinics in the uk for low-back pain..One of the challenges in evaluating the economic impact of cam is collecting comprehensive data on the cost of cam services and therapies, which are largely paid for out-of-pocket. productivity changes (items 14 and 15) are appropriate for studies using the societal perspective. however, with rising healthcare costs, insurers and policy makers have expressed concerns about the cost-effectiveness of healthcare, both conventional and cam. generalisability in economic evaluation studies in healthcare: a review and case studies. integrative medicine and the health of the public: a summary of the february 2009 summit. note that the totals by form and perspective add to more than 39. quality of complementary and alternative medicine (cam) economic evaluations and comparable results of similar reviews in conventional medicine. design and analysis issues for economic analysis alongside clinical trials. these issues can roughly be divided into three groups: those involved with the impact of economic evaluation on cam in general, those involving the estimation of health outcomes (ie, issues involved with estimating the efficacy or effectiveness of cam), and those specific to cam's economic and humanistic outcomes. number of full evaluations meeting each of the five study-quality criteria are: comparison to usual care 97 (85%), all costs from a recognised perspective 96 (84%), health outcomes from a randomised or matched-control trial 86 (75%), patient-specific data on costs and outcomes 105 (92%) and sensitivity analyses 37 (32%).,74 given that an estimated 46 million americans do not have access to healthcare due to financial, physical, and geographic barriers,75,76 increasing access to cost-effective primary care is imperative. in all cases the approach and the range of variables tested were stated, but the choice of variables to test was only justified in two cases [35, 51]. between 1994 and may 2004 hulme and long21 identified 19 full economic evaluations of cam, and over a similar period (1995–2007) doran et al23 found 43 economic evaluations (15 full evaluations). their systematic review of cam economic evaluations, white and ernst [4] identified 34 economic evaluations of cam conducted between 1987 and 1999; only eleven of which were full economic evaluations (ie, compared both economic and health outcomes between two or more alternatives) [10].(1) the research question is stated39 (74)43 (16)*(2) the economic importance of the research question is stated39 (51) (3) the perspective of the analysis is stated39 (33)228 (52)†(4) the rationale for choosing the alternatives is stated39 (69) (5) the alternatives being compared are clearly described39 (74)228 (83)†(6) the form of economic evaluation used is stated39 (49) (7) the choice of form of economic evaluation is justified39 (3)43 (7)*. the bernard osher foundation supports a portion of dme's time for research in integrative medicine. to be considered by these decision makers, cam therapies and their outcomes must be known and compared to conventional approaches.–4 total expenditures for cam therapies were estimated at us billion in 1990,1 us billion in 19972 and us billion in 2007. cost-effectiveness of medical and chiropractic care for acute and chronic low back pain. reporting quality was poor for certain items, but was comparable to the quality found by systematic reviews of economic evaluations in conventional medicine [6, 83, 84]. sixty percent of cam users and 64% of non-cam users perceived their respective treatment as effective and were satisfied with the relief of their bowel symptoms at follow-up; cam users appeared to experience more severe symptoms at baseline. having patient-specific data on both costs and outcomes is an advantage for internal validity,44 resource use must be a measured outcome of the study. models (one decision tree model [78] and two multiplicative-type or impact [49, 57] models) were used in three studies and in all cases the details of the model were given and justified. insurance coverage, medical conditions, and visits to alternative medicine providers..As the costs of healthcare and prescription drugs rapidly increase each year,12 policy makers are now focusing their attention on the cost of various therapies and providers in the face of a finite healthcare budget and limited healthcare resources. health care costs continue to rise, decision makers must allocate their increasingly scarce resources toward therapies which offer the most benefit per unit of cost. longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain. we would also like to thank robert scholten and p scott lapinski of the harvard medical school for their assistance with the embase searches. 2 types of individual complementary and integrative medicine (cim) therapies studied for various conditions and in various populations: 2001–2010 (reported as the ratio of the total number of economic evaluations to the number of full economic evaluations). ,60 ,63 ,64 ,67 ,68 five evaluated spinal manipulation and manual therapy provided by physiotherapists for chronic back pain (one),65 acute back pain (two)58 ,69 or either (two). most basic form of economic evaluation is a table that lists the individual economic and health outcomes of alternative interventions. in most cases the major outcomes of the studies were shown disaggregated, and the study question was answered. development and classification of an operational definition of complementary and alternative medicine for the cochrane collaboration. found that 14 (36%) of full economic evaluations met all four study quality criteria and were identified as exemplars. finally, these reviews generally used limited search terms to identify cim studies. as expected, the average overall and individual-item percentages were higher for the higher-quality articles (those meeting the five study-quality criteria) and for cuas of cim. compare this to 9% of 1433 cua comparisons found to be cost saving in a large review of economic evaluations across all medicine. the second, related challenge is that many over-the-counter products, such as certain botanical medicines and nutritional supplements, are not standardized and of inconsistent quality. the remaining forms of economic evaluations summarize economic and health outcomes into a single result (table 1). the societal perspective accumulates all outcomes, while individual and institutional analyses are more selective. increasing the generalizability of economic evaluations: recommendations for the design, analysis, and reporting of studies. finally, since there is often no provider "gatekeeper" controlling access to cam therapies, monitoring of patient use can be complicated and labor intensive.

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