Complementary medicine – an efficient element for sustainable

health budgets?

Stefan N. WillichInstitute for Social Medicine, Epidemiology

and Health EconomicsCharité University Medical Center Berlin, Germany

www.charite.de/epidemiologie

Medicine from Descartes to Watson/Crick

19th Century 21th Century

Medicine within natural scienceBody/soul dualismHuman as a machineRepair mechanismsPrinciple of causality

„We live forward but we understand backward“(William Jones)

Complementary Medicine (alternative, unconventional, holistic)

Various approaches in theory and medical practise

Encouragement of constitutional regulation

Anthropological image of man

Healing:- Somatic intervention- Salutogenesis- Development by illness

Willich et al., Dtsch Ärzteblatt 2004;101:A1314-1319

Utilization and Cost of Complementary and Alternative Medicine in Germany

Utilization of alternative medicine 70 % Natural remedies in the last 3 months 30-40 % Physicians with education in CAM 10 % Natural remedies (44% prescribed) 2 Bill. Euro Visits at physicians 2 Bill. Euro

Private treatment / over the counter ca. 5 Bill. Euro

RKI 2001; Allensbach/Stat. Bundesamt 2002

Frequency of Complementary Medicine Utilization (12 Months)

Härtel/Volger, Forsch Komplementärmed Klass Naturheilkd 2004;11:327-334

Total (n=1100)

Men (n=551)

Women (n=549)

Naturopathic treatment (%) 57 50 65

Chirotherapy (%) 14 13 15

Homeopathy (%) 15 10 20

Acupuncture (%) 9 6 11

TCM (%) 2 1 2

Ayurveda (%) 1 0,4 1

Anthroposophic treatment (%)

1 0,3 2

Percentage of phytopharmaca

Proportion of Alternative Medication Prescriptions

IMS Health - Panel

Percentage of homeopathica

ARC„study part A“

Partly randomised, Controlled studies

(n=50.000*)

ART„study part C“

Randomised, controlled studies (n=1.200*)

ASH„study part B“

Prospective Observational studies

(n=500.000*)

Efficacy at specific acupuncture points

Effectiveness in routine care

Safety and health economics

Study Program Acupuncture of the Techniker Krankenkasse

and joined insurance funds

* Planned number of patients

Results

• 196.518 Patients

• 65% women (age: 4914 years)

• 35% men (age: 5214 years)

• 103 Acupuncture treatments

Low-back pain45%

Headache34%

Arthritis pain8%

Neck pain9%

Allerg. Rhinitis/ Asthma

4%

Dysmenorrhoe0,3%

Diagnoses

Osteoarthritis of the Knee (Gon-ART)

0

1

2

3

4

5

6

7

0 2 6 12

WO

MA

C S

core

(m

ean

an

d s

d)

Acupuncture

Minimal Acupuncture

Waiting List Control

Waiting List Treated

Months

Witt et al. Lancet 2005;366:136-143

Headache Days (Migrane-ART)

0

1

2

3

4

5

6

7

Hea

dac

he

Day

s (m

ean

an

d s

d)

Acupuncture

Minimal Acupuncture

Waiting List Control

Waiting List Treated

Months

Linde et al. JAMA 2005;293:2118-2125

Comparison of Costs (Over 3 Months)

Costs of Routine Treatment Costs of Acupuncture

To

tal c

ost

per

pat

ien

t 0-

3 m

on

ths

afte

r b

egin

of

stu

dy

Low back pain Headache Arthritis Neck painAll. Rhinitis/

AsthmaDysmenorrhea

10526 11590

17845

12469

25802

3002

0 €

10.000 €

20.000 €

30.000 €

40.000 €

50.000 €

Low back pain(n=2,388)

Head ache(n=2,682)

Arthritis (n=421) Neck pain(n=3,005)

Allerg. Rhinitis /Asthma (n=1,130)

Dysmenorrhea(n=167)

ICE

R (

inkr

emen

telle

s K

ost

enef

fekt

ivit

ätsv

erh

ältn

is))

in

Eur

o pr

o ge

won

nene

s Q

ALY

International threshold values 30,000 GBP – 50,000 €

Cost-Effectiveness-AnalysisIC

ER

, Eu

ro p

er Q

aly

ga

ined

Willich SN et al. submitted

Cost-effectiveness Acceptability Curve and Sensitivity Analyses of Acupuncture in Osteoarthritis Pain

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1€

0

€ 3.

000

€ 6.

000

€ 9.

000

€ 12

.000

€ 15

.000

€ 18

.000

€ 21

.000

€ 24

.000

€ 27

.000

€ 30

.000

€ 33

.000

€ 36

.000

€ 39

.000

€ 42

.000

€ 45

.000

€ 48

.000

threshold value

Pro

bab

ility

th

at In

terv

enti

on

is c

ost

-eff

ecti

ve

€ 35 (base-case)

€ 15

€ 25

€ 45

€ 55

minor8.5%

no91%

major0.8%

(3 cases of pneumothorax)

Adverse Events

261,897 completed treatments

(with 10 sessions of acupuncture each)

Study Design

Prospective, comparative, multicenter cohort study

First treatment by doctorAge > 16 years

Diagnosis of chronic illness:

- Headache

- Low back pain - Depression - Sleep disorders - Sinusitis

Homeopathic Conventional Medicine

Patients

Doctors

Witt C et al., Complement Ther Med 2005;13:79-86

Patients‘ Rating of ComplaintsOverall Diagnoses (Adjusted)

Diagnoses

Headache

Low back pain

Depression

Sleep disorders

Chron. Sinusitis

Witt C et al., Complement Ther Med 2005;13:79-86

Homeopathy oConventional

Physicians’ Rating of ComplaintsOverall Diagnoses (Adjusted)

Witt C et al., Complement Ther Med 2005;13:79-86

Diagnoses

Headache

Low back pain

Depression

Sleep disorders

Chron. Sinusitis Homeopathy oConventional

Total Costs* Overall Diagnoses

*Inpatient, outpatient treatment (incl. homeopathy), drugs, aids to daily living, sick-pay, physical therapy

Witt C et al., Complement Ther Med 2005;13:79-86

Adjusted analysis:Homöo/Schul p=nsHomöo: vor/nach p<0.001Schul: vor/nach p<0.001

Homeopathy (n=66)

Conventional (n=65)

adjusted

adjusted

0

500

1000

1500

2000

2500

3000

12 months before 12 months after

Tot

al C

osts

in €

Nefiodow LA 2000

Kondratieff-CyclesBasic InnovationSteam-engine

Textile industry

Steel

Railway

Electrical/ chemical engineering

Automobile

Petro-chemistry

Information Technology

Psycho-social Health

Major Application

Clothing Transport Mass consumption

Individual mobility

Globalization Communic.

Health Education

1. Kondratieff 2. Kondratieff 3. Kondratieff 4. Kondratieff 5. Kondratieff 6. Kondratieff

1800 1850 1900 1950 1990 20XX

Summary

Widespread utilisation of complementary therapies

Established study methodology applicable to complementary medicine

Acupuncture in routine care: clinical benefit and cost effective within common threshold

Homeopathic treatment tends to be superior to conventional medicine at same cost

Cooperation between complementary and conventional medicine urgently needed