Discussion
chronic cervical pain, NDI, chronic neck pain, neck pain, NRS
MINOR, SENSITIVITY
This economic evaluation was performed based on an RCT that compared pharmacopuncture and usual care for chronic neck pain. Compared to the usual care group, the pharmacopuncture group had higher intervention costs, lower direct non-medical costs, and lower indirect costs (costs due to productivity loss). Consequently, the costs from a societal perspective were significantly lower in the pharmacopuncture group during the entire study period (12 weeks), whereas there were no significant differences in the costs from a healthcare perspective. The pharmacopuncture group tended to show a slightly higher QALY based on EQ-5D and SF-6D, although the differences between two groups were not significant. However, the costs were lower in the pharmacopuncture group. Therefore, ICER analysis was dominant, indicating that pharmacopuncture is more cost-effective from both the societal and healthcare perspectives. Sensitivity analyses with the pharmacopuncture fee set at 1.5 and 2.0 times showed higher costs in the pharmacopuncture group from a healthcare perspective. The ICER was lower than the WTP when the fee was set to 1.5, which confirmed that it is an alternative that is acceptable from a societal perspective not only for base cases but also when the fee is increased by a factor of 1.5. When the pharmacopuncture fee was increased by two times, the costs were still lower from a societal perspective, while the probability of pharmacopuncture being cost-effective was higher.In the sensitivity analysis of this study, not only cost-utility analysis but also cost-effectiveness analysis was performed. Costs were compared with clinical outcomes (NRS score for neck pain and NDI). In many cases of economic evaluation, costs are compared to the QALY based on utility. However, utility is broad in nature and therefore does not accurately reflect disease-specific health status and is relatively insensitive to detecting small changes [Meanwhile, there was little difference in QALY between the two groups when based on the EQ-5D and SF-6D. Both the EQ-5D and SF-6D measure quality of life, but there are minor differences; SF-6D focuses more on social functioning, whereas EQ-5D focuses on physical functioning Direct medical costs were higher in the pharmacopuncture group due to the difference in costs between pharmacopuncture and PT. Medical costs, other than the intervention costs, during the trial were higher in the usual care group, indicating that they had more hospital visits for treatment of neck pain in addition to the treatment in the protocol. Among direct non-medical costs, time cost was significantly lower in the pharmacopuncture group, which was due to the length of the pharmacopuncture treatment being shorter than the usual care time. Compared to PT, which requires more than a certain amount of time, pharmacopuncture is completed with needling; thus, the time required for the treatment is very short. The results showed that pharmacopuncture had a superior effect despite the relatively short procedure time.The indirect costs estimated by the productivity loss score were significantly lower in the pharmacopuncture group, and the difference between the two groups was relatively large. In the primary analysis performed in the present study, productivity loss among waged workers was calculated as overall work productivity, considering both absenteeism and presenteeism. Many economic evaluation studies, including those on chronic neck pain, generally use absenteeism to calculate costs [This economic evaluation offered the benefit of being conducted alongside a well-designed, pragmatic RCT. The pragmatic approach is a design for overcoming the limitations of traditional explanatory RCTs, which could increase the generalizability of the findings by carrying out the trial in an environment closer to the real world and contributing to actual clinical and policy decision making [This study investigated validity indicators and cost expenditures over 12 weeks of follow-up (F/U). This short time horizon is the present study’s limitation. The results of this study couldn’t show the long-term effect of pharmacopuncture on the quality of life of patients with chronic cervical pain. Longer follow-up period studies or modeling studies should be performed in the future. To the best of our knowledge, there have been no economic evaluations of pharmacopuncture for chronic neck pain. While there have been some studies on acupuncture being more cost-effective than usual care [