Cost–Utility of Group Versus Individual Acupuncture for Cancer-Related Pain Using Quality-Adjusted Life Years in a Noninferiority Trial

Abstract

Introduction:

Individual acupuncture (AP) is the gold standard method of AP delivery for cancer-related pain; however, costs can be prohibitive. Group AP allows four to six patients to be treated in a single session. This study sought to examine the cost–utility of group AP compared with individual AP from a patient perspective.

Materials and Methods:

Effectiveness and cost data from a noninferiority randomized trial of group versus individual AP for cancer-related pain were used. In the trial, 74 patients were randomly assigned to individual or group AP treatments twice per week for 6 weeks. The EuroQol five-dimension five level questionnaire (EQ-5D-5L) was used to assess health-related quality of life, and the EQ-5D Utility Index was used as a composite measure constituted of five domains (mobility, self-care, usual activities, anxiety–depression, and pain–discomfort). Linear mixed models were used to compare the change in EQ-5D-5L states pre–post intervention between the two arms. A cost–utility analysis was performed in terms of the incremental costs per additional quality-adjusted life year (QALY) gained.

Results:

Group AP participants experienced more significant relief in the pain-discomfort subscale of the EQ-5D-5L measure compared with individual AP participants (group × time, F = 6.18; p = 0.02). The effect size on pain-discomfort for group AP (d = 0.80) was higher than that of individual AP (d = 0.34). There were no significant differences between the two study arms for other subscales of the EQ-5D-5L over time. QALYs at 6 weeks were slightly higher for group AP (0.020) compared with individual AP (0.007) leading to an incremental QALY gained by the group arm of 0.013, but this difference was not statistically significant (p = 0.07). The cost of delivering AP treatment for the group arm over 6 weeks ($201.25) was nearly half of the individual arm ($400).

Conclusions:

Group AP was superior to individual AP in cancer patients. These findings have implications for the use of group AP in low-resource settings and in health care systems where AP for cancer patients is not covered by public health insurance.

ClinicalTrials.gov (NCT03641222). Registered July 10, 2018—Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT03641222

Introduction

Pain is one of the most prevalent but often undertreated symptom in cancer patients. Cancer-related pain can occur throughout different stages of cancer. It is estimated that 40%–85% of cancer patients suffer from pain,^1,2 and about 33% receive inadequate analgesia.³ Pain results in substantial impairment in quality of life (QOL) in both cancer patients and survivors.⁴ Moreover, opioids are frequently used to treat cancer pain but come with undesirable side effects including nausea, constipation, and drowsiness.³ Additionally, due to a surge in opioid abuse, both patients and health care providers are seeking alternative treatments.⁴

The National Comprehensive Cancer Network (NCCN) guidelines for adult cancer pain recommend the use of acupuncture (AP) in conjunction with pharmacologic interventions for cancer pain.⁵ AP is a Traditional Chinese Medical technique, in which fine stainless steel needles are inserted into the body surface to elicit neurohormonal responses of the body system via nerve stimulation. Besides pain, AP is also a safe and effective treatment for other cancer-related symptoms such as chemotherapy-induced nausea and vomiting,^6
–8 cancer fatigue,⁹ and radiation-induced xerostomia.^10
–12 Currently, the specific use of AP by cancer patients is estimated to range between 1.7% and 31%.^13
–15

In Canada, AP is typically performed on an individual basis and is not covered by the universal health care system. Therefore, patients have to pay out of pocket or through private health coverage, which can be cost-prohibitive and can make AP less accessible for people in lower socioeconomic statuses.^16,17 Thus, it is essential to investigate alternative delivery methods of AP that may help reduce the cost of treatments to patients. Group AP is an emerging cost-effective method of treating patients.¹⁸ It is typically performed with one practitioner treating multiple patients at once all in the same room; patients are often seated in reclining chairs.^19,20 Evidence suggests that group AP clinics reach individuals of a broad socioeconomic spectrum and may allow for increased frequency of treatment.¹⁹ Despite its known affordability, the cost-effectiveness of group AP relative to individual AP is currently unknown. Cost-effectiveness analyses help to quantify the value of new interventions, informing both medical decision-making and health policy.²¹ Given that patient experiences in group AP have been reported to be on par with individual AP,^18,20 there is a potential benefit in undertaking health economic studies to determine the relative value of group AP.

Previously, a randomized noninferiority trial (1:1) was conducted by our team to determine the noninferiority of group versus individual AP, the gold standard modality of AP treatment for cancer pain.²² The group AP was found to be noninferior to individual AP for pain and superior for mood states, sleep disturbance, and quality of life.²² In the context of this trial, the current study sought to evaluate the cost–utility of group AP compared with individual AP from a patient perspective. The specific objectives of the current study were: (1) to compare pre- to post-intervention change in quality of life in cancer patients enrolled in the group versus individual AP arms and (2) to assess the cost–utility of group versus individual AP from the patient perspective.

Materials and Methods

Participants and procedure

Data from our noninferiority trial were used for the current analysis.²² Eligibility criteria for participants in the trial included: (1) anyone diagnosed with cancer; (2) age 18 years or older; (3) metastatic or nonmetastatic cancer; (4) experiencing pain with a minimum worst pain score (in the previous week) ≥3 on the 10-point Brief Pain Inventory; (5) willing to be randomized and (6) able to attend a minimum of 9 of the total 12 treatment sessions within a 6-week period. People who had received AP treatments within the previous 6 months or who had a change of cancer treatment within 6 weeks of starting the study (i.e., were not on stable treatment) were excluded from the trial. Detailed information on the trial's design, inclusion and exclusion criteria, population characteristics, and results is available elsewhere.²²

Cancer patients (n = 74) were randomized to either group AP (n = 35) or individual AP (n = 39). Individual AP was performed one-on-one, with only one participant per session and each session lasting 45 min. In contrast, group AP included about four to six participants per session, all seated comfortably in reclining chairs spaced in a large circle to receive their treatments. Each group session was scheduled for 90 min, with each participant staying for ∼45 min. AP treatments for both groups were administered twice per week for 6 weeks. The EuroQol five-dimension five-level questionnaire (EQ-5D-5L) was administered preintervention at baseline and postintervention (6 weeks).

The sample size of 62 for the noninferiority trial was calculated to observe a difference between the standard treatment and the experimental treatment, with 80% certainty that the lower limit of a one-sided 95% confidence interval (or equivalently a 90% two-sided confidence interval) was above the predetermined noninferiority limit of −1 for pain interference.^22,23

Measures

EQ-5D-5L

The EQ-5D-5L was used to assess the change in quality of life before and after the intervention. The EQ-5D-5L is an indirect-preference instrument for assessing health-related quality of life (HRQoL) and the EQ-5D index is a composite constituted of five domains.²⁴ It comprises five items measuring mobility (MO), self-care (SC), usual activities (UA), pain–discomfort (PD), and anxiety–depression (AD), which are graded on five levels according to severity: no problems (Level 1); slight; moderate; severe; and extreme problems (Level 5). There are 3,125 possible health states defined by combining one level from each dimension, ranging from 11111 (full health) to 55555 (worst health).²⁵ EQ-5D-5L health states are converted into a single index “utility” score using a scoring algorithm based on public preferences. The utility index values for the EQ-5D-5L (Canada) were calculated using the program R (Shiny App). The Canadian weights were used to convert responses into single utility indices between −1 (the poorest imaginable health state) and 1 (perfect health), with death being anchored at a value of zero. The negative values representing values as worse than dead and higher scores indicating higher health utility.

Data analysis

Change in EQ-5D-5L subscales (QoL) over time

Modeling of linear mixed effects was used to examine change in outcome across pre- and post-intervention assessments.²⁶ Group (1 = individual AP; 2 = group AP), time (categorically coded), and the Group × Time interaction were included as fixed effects. Random intercepts, as well as random slopes, were included as random effects.²⁷ Within-group effect sizes were calculated using Cohen's d statistic and presented where appropriate to represent changes within groups. Per Cohen's guidelines, d = 0.2 is considered a small effect, d = 0.5 a medium effect, and d = 0.8 a large effect.²³

Cost–utility analysis

Cost assessment

Costs associated with the group and individual AP included the acupuncturist fee per session for both arms, as well as the initial consultation fee. The cost of the treatments (from a patient perspective) was calculated by comparing the average cost of one treatment cycle (6 weeks of treatment) for one group AP participant to the cost of one treatment cycle for an individual AP participant. Because not every group session was full, attendance for each group AP session was tracked and the hourly cost of the practitioner was divided among the number of participants to calculate the actual cost per participant per session, and subsequently cost per treatment cycle. Incremental costs were calculated using the difference of the costs for 6 weeks between the group and individual AP arms. The acupuncturist fee ($50/h) was discounted for the purpose of the study, whereas the standard fee is $100/h in real-world clinical practice. As a sensitivity analysis, the total cost savings were also examined, assuming the acupuncturist fee to be $100/h.

Quality-adjusted life year and incremental quality-adjusted life year

The analysis of incremental cost-effectiveness was a cost–utility analysis. Quality-adjusted life years (QALYs) were estimated based on EQ-5D-5L scores. Cost–utility was expressed as cost per QALY gained over 6 weeks. QALYs were estimated as the area under the health utility curve over time through the use of linear interpolation between the weights of observations at baseline and postintervention (6 weeks). Asymptotic QALYs were calculated for 6 weeks using the formula [(QALY index_POST − QALY index_PRE) × time] applied to each arm. In the calculation, the value of time was substituted by 0.125 (representing 6 weeks of the entire year). In using the asymptotic curve, the authors assume that pain reduction benefits are almost immediate after treatment start and persist during the treatment period. Although some benefits may persist beyond the final treatment, the authors are unclear how long the benefit would persist; hence, the benefit is slightly underreported here by only taking into account benefit over the 6 weeks of treatment. The mean QALY values for the group and individual arms were compared using mean differences for continuous variables (independent samples t-test). Statistical analyses were conducted using IBM SPSS version 23.0 (IBM Corp, Armonk, NY). The p-value <0.05 indicates statistical significance.

Results

Participants

Participants' mean age was 54.25 years (±8.47 years) in the individual AP arm and 52.00 years (±8.61 years) in the group AP arm. Eighty-one percent of participants were females. Three fourth of the participants were married or cohabitating, and the majority (80%) were well educated, having at least some postsecondary education. Less than one third were employed full time or part-time, others were either unemployed, unable to work due to a disability, or retired. Nearly 61% of the patients had a breast cancer diagnosis. Other cancer diagnoses included gastrointestinal (18%), gynecological (9%), hematological (11%), lung (6%), and one case each of skin and head and neck cancer. No significant differences between the two arms were found in regard to clinical or sociodemographic characteristics. Table 1 shows demographic and clinical characteristics.

Table 1.

Participant Sociodemographic and Clinical Characteristics

Variable	Individual AP	Group AP	p-Value
Age (years)	54.25 (8.47)	52.00 (8.61)	0.62
Sex
Female	29	31	0.17
Male	10	4	0.17
Marital status
Married/cohabitating	26	23	0.99
Single/divorced/widowed	9	8	0.99
Education
High school	9	5	0.68
College/technical school	15	15
University	13	11
Employment
Unemployed/retired/cannot work due to disability	27	20	0.25
Employed (FT/PT)	8	11	0.25
Cancer diagnosis
Breast	19	21	0.37
Colorectal	5	4
Ovarian	2	0
Myeloma	3	0
Appendiceal	1	0
Uterine	1	3
Pancreatic	0	1
Anal	0	1
Hematological	2	2
Skin	0	1
Lung	3	1
Head and neck	1	0

AP, acupuncture; FT/PT, full time or part-time.

Changes in HRQoL (EQ5D5L) over time

Table 2 indicates a change in outcomes over time in HRQoL (EQ-5D-5L) between the group arm and the individual arm from baseline to postintervention. Participants in the group arm experienced greater relief in the PD subscale of the EQ-5D-5L measure compared with those in the individual arm over the period of 6 weeks (group × time interaction, F = 6.18; p = 0.02). The pre–post within-group effect size was also greater for the group arm (d = 0.80) compared with the individual arm (d = 0.34). There were no significant differences between the two study arms for changes in MO, SC, UA, and AD over time.

Table 2.

Linear Mixed Model Results to Determine Change in EQ-5D-5L Outcomes Over Time in Group Versus Individual Acupuncture

Outcome	Intervention	Time point	Mean (SE)	Change	Effect size	Group × time F, p-value (sig)
EQ5D5L-mobility	Individual	Pre	2.32 (0.16)	0.05	0.13	3.22 (0.08)
	Individual	Post	2.27 (0.16)	0.05	0.13	3.22 (0.08)
	Group	Pre	2.27 (0.17)	0.41	0.43
	Group	Post	1.86 (0.18)	0.41	0.43
EQ5D5L-self care	Individual	Pre	1.46 (0.11)	0.14	0.31	0.32 (0.58)
	Individual	Post	1.32 (0.09)	0.14	0.31	0.32 (0.58)
	Group	Pre	1.35 (0.11)	0.07	0.06
	Group	Post	1.28 (0.12)	0.07	0.06
EQ5D5L-usual activities	Individual	Pre	2.56 (0.16)	0.48	0.66	0.75 (0.39)
	Individual	Post	2.08 (0.16)	0.48	0.66	0.75 (0.39)
	Group	Pre	2.71 (0.17)	0.65	0.72
	Group	Post	2.06 (0.17)	0.65	0.72
EQ5D5L-pain–discomfort^* ^,a	Individual	Pre	2.97 (0.10)	0.26	0.38	6.18 (0.02) ^*
	Individual	Post	2.71 (0.13)	0.26	0.38	6.18 (0.02) ^*
	Group	Pre	3.06 (0.11)	0.75	0.80
	Group	Post	2.31 (0.15)	0.75	0.80
EQ5D5L-anxiety–depression	Individual	Pre	1.97 (0.14)	0.17	0.29	1.07 (0.31)
	Individual	Post	1.80 (0.13)	0.17	0.29	1.07 (0.31)
	Group	Pre	2.12 (0.15)	0.35	0.41
	Group	Post	1.77 (0.15)	0.35	0.41

Significant (p < 0.05).

Lower pain scores indicate less pain–discomfort.

EQ-5D-5L, EuroQol five-dimension five level questionnaire.

Cost–utility

Table 3 reveals that actual costs for the group AP ($201.25) were half the cost of the individual AP ($400) over the duration of the trial. These costs included the acupuncturist's fee for the entire duration of the trial (2 sessions per week for 6 weeks) and were based on the total time spent by the acupuncturist over the duration of the trial. The acupuncturist's fee was set at $50/h. Thus, for the individual AP, the cost of a 45-min session per participant was $37.50, and for the group AP, the cost of a 90-min session for each group with an average of four participants per group was $75, amounting to $18.75/person. The details of costs related to AP treatment in both the group and individual arms in the trial have been described in our previous study.²² The average number of sessions attended by the participants in the individual and group arms was 10 and 9.4, respectively. Table 3 also shows the pre- and post-utility index values for the EQ-5D-5L scale for both the individual and group arms. The QALY values reveal that the incremental QALY gained by the group arm (QALY group − QALY individual) was 0.013; however, the gain was not statistically significant (p = 0.07) (Table 3).

Table 3.

Cost Comparison and Quality-Adjusted Life Years for Individual and Group Arms and Incremental Quality-Adjusted Life Years: 0.02–0.007 = 0.013

Variable	Individual arm	Group arm	p-Value
Variable	Mean (SD)	Mean (SD)	p-Value
Cost per participant/session	$37.5	$18.75	—
Cost per participant for 6 weeks	$375	$176.25	—
Cost of the 30-min assessments at initial intake per participant	$25	$25	—
Total cost of the program	$400	$201.25	—
Eq5D5L utility index at Pre	Mean: 0.69 (0.19)	Mean: 0.65 (0.19)	0.52
Eq5D5L utility index at Post	Mean: 0.74 (0.15)	Mean: 0.77 (0.16)	0.42
QALY at 6 weeks	Mean: 0.007 (0.016)	Mean: 0.02 (0.017)	0.07

QALY, quality-adjusted life year.

Sensitivity analysis

The results of the sensitivity analysis for the acupuncturist fees indicated that if the fee was $100/h (closer to the actual fee), the cost of the individual and group AP would be $75 and $37.5 per person per session, respectively. The total cost over 6 weeks from the initial assessment would be $775 (average of 10 sessions) and $377.50 (average of 9.4 sessions) for the individual and group arms, respectively. Thus, in a more realistic scenario, the cost saving of the group AP would be $397.50 per person over 6 weeks.

Discussion

This is the first study to evaluate the cost–utility of group AP in relation to individual AP within a randomized noninferiority trial. The authors obtained utilities by means of the EQ-5D-5L questionnaire for different health states in cancer patients in Alberta, Canada. As expected, there was an increase in the EQ-5D-5L utility index before and after the intervention across both arms. However, there was no significant difference in the pre- and post-intervention values of utility between the two arms, indicating that patients in both the group and individual AP arms experienced an improvement in health states, but the change was similar across the two treatment arms. The average utility at preintervention was 0.69 (±0.19) versus 0.65 (±0.19) (p = 0.52), whereas the average utility at postintervention was 0.74 (±0.15) versus 0.77 (±0.16) (p = 0.42) for the individual and group arms, respectively. This indicates that irrespective of the treatment modality, cancer patients receiving AP treatment twice a week for 6 weeks experienced an improvement in HRQoL states of MO, SC, UA, PD, and AD. This finding mirrors our primary outcomes showing similar improvements across other measures of sleep, distress, and fatigue between groups.²² The pre–post change in the PD subscale of EQ-5D-5L over a period of 6 weeks was larger in participants in the group AP arm compared with the individual AP arm. This is significant as it shows not only that group delivery of AP to cancer survivors with pain is as effective as traditional individual delivery, it may be even more effective, at much lower cost.

In regard to cost–utility, the incremental QALYs gained by those in the group arm was 0.013. However, this gain was not statistically significant (p = 0.07), indicating that QALYs gained were also similar for both arms. Furthermore, there was a cost saving of $198.75 per person over a 6-week period for the group arm compared with the individual arm. In summary, the group treatment was dominant over individual treatment since it was equal in efficacy and much less expensive compared with individual treatment. These findings, in addition to the favorable effects of group AP on pain interference and severity, mood states, sleep quality, fatigue, and perceived social support, as reported previously,²² make the group AP the preferred choice of treatment for cancer survivors experiencing pain.

The findings of this study regarding the improvement of PD and overall HRQoL are consistent with past studies focusing on the use of AP in cancer patients.^28,29 In their systematic review, He et al.³⁰ found moderate evidence that AP and/or acupressure was significantly associated with lower pain intensity in cancer patients compared with sham control conditions. Although none of the studies included in this review had used the group AP format, it highlights the role of AP in relieving pain. Furthermore, although there is no formal threshold for what could be considered good cost-effectiveness for group AP in relation to individual AP, the World Health Organization (WHO) argues that a threshold should simply be seen as an indication of poor, good, or very good value for money.³¹ In this study, for cost savings of ∼$200 per person over a 6-week period for a 0.013 incremental QALY gain, the group AP can be considered much more cost-effective.

The results of the sensitivity analysis showed that if the cost was calculated based on a standard acupuncturist fee, the delivery of AP in the group arm would lead to a saving of ∼$400 over a period of 6 weeks. Assuming that patients want to continue AP beyond 6 weeks, the savings would grow over time. With increasingly high number of cancer patients seeking AP for cancer-related pain,^13,14,16 and with patients requiring 6–12 sessions and potentially further maintenance sessions, group AP could help save ∼$400–$800 or more per patient per year compared with individual AP. In countries such as the United States where the cost of opioids increases by 5%–10% per year,³² significantly outpacing inflation, the cost of pain medication can be burdensome to patients with cancer.³³ Therefore, AP can play a crucial role in providing effective pain relief with lower cost. Future research should examine the cost of pain treatment with pain medications alone, pain medications and group AP, and pain medications and individual AP.

The authors did not consider the cost of health care from the health system perspective. However, if these costs are taken into account, the savings from group AP, which potentially requires one room for four to six patients, will be much higher compared with individual AP, which requires one room for each patient. This presupposes that governments are willing to fund AP at the individual patient level. In countries such as Canada, where universal health care is managed by each of the provincial governments, if the province is not willing to fund individual AP treatments, then the group represents a less expensive alternative.

Additionally, it would still be an incremental cost with the potential cost offsets related to reduction in pain medications, fewer medication-related side effects, and potentially fewer trips to other medical professionals. It is unclear if this would prove to be cost-effective, but it is unlikely to be a dominant scenario. It may prove useful to assess these costs as a follow-up research project if provincial governments are considering coverage for AP in the management of cancer pain. Evidence suggests that 33%–42% of cancer patients experiencing pain receive inadequate pain medications primarily due to their concerns about opioid addiction and the adverse effects of drugs.^1,3,34,35 The use of AP as a complementary therapy in such patients can result in the reduced use of analgesic medications.³⁰ The majority of patients seek AP for pain-related conditions as it is considered safe and effective as adjunctive treatment for managing cancer-related symptoms.^15,36

–39 A decrease in the use of pain medications would also diminish the side effects associated with medication.

The study has a number of strengths. The trial was pragmatic, and the intervention was delivered at a tertiary care hospital, where participants visited for regular cancer care. The authors used the EQ-5D-5L for assessing HRQoL. The advantage of using this measure is that it allows HRQoL determination across multiple dimensions of health, which include both physical and mental health-related HRQoL.

Limitations

The study also has limitations. First, the majority of the patients had a breast cancer diagnosis, which may limit the generalizability of the findings to different cancer types. Second, the authors did not follow the patients beyond the 6-week intervention period, and hence, the calculation of QALY was asymptotic based on the assumption that the peak effect would be observed at the end of the 6 weeks and remain relatively constant over the remaining 46 weeks. The longer any observed benefit is maintained post-treatment, the more likely the intervention is a cost-effective use of resources. It would be ideal, although usually impractical, to measure any benefits accrued over the lifetime of the participant. Third, as a single trial with a small sample size, it may not provide sufficient evidence on which to base a decision on cost-effectiveness,⁴⁰ more trials need to be conducted to confirm the reliability of the findings. Finally, since all the outcomes were patient-reported, there is a risk of patient recall bias.

Conclusions

The study concludes that group AP is superior to conventional individual AP from a patient perspective. The findings have a strong implication for cancer care in all types of health care systems where AP is not a part of usual care and is not covered by universal health coverage. Participants who cannot afford to pay for private insurance or directly to the health care provider may find group AP useful as it costs less without compromising health benefits. The results of this study can help to guide clinicians and health policymakers involved in decision-making processes about resource allocation strategies for AP.

Ethics Approval and Consent to Participate

Health Research Ethics Board of Alberta (HREBA)—Cancer Committee (CC) University of Calgary (Ethics ID HREBA.CC-17-0237) approved the study. Written consent was obtained from study participants.

Availability of Data and Materials

The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Footnotes

Authors' Contributions

D.V.O.: Current study design, data analysis and interpretation, article writing. C.J.L.: Data interpretation, article writing. E.N.R.: Study design, screening and recruitment, data collection. J.L.: Study design, performed the AP intervention. K.-A.L.P.: Screening and recruitment, data collection and entry. L.E.C.: PI on the noninferiority trial, study design, article writing. D.V.O., C.J.L., E.N.R., J.L., K.-A.L.P., and L.E.C.: Final approval of the article.

Acknowledgments

The authors would like to thank all the patient participants for their involvement in the study. Dr. Oberoi is supported by a joint Charbonneau Cancer Institute-Cumming School of Medicine Postdoctoral Fellowship (2018–2020). Reed held a summer studentship from the Alberta Cancer Foundation during the time the study was conducted. Dr. Carlson holds the Enbridge Research Chair in Psychosocial Oncology, co-funded by the Canadian Cancer Society Alberta/NWT Division and the Alberta Cancer Foundation. Dr. Carlson also holds a CIHR SPOR Mentorship Chair in Innovative Clinical Trials, which funds the TRACTION (Training in Research and Clinical Trials in Integrative Oncology) Program.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This study was supported by the Enbridge Research Chair in Psychosocial Oncology, co-funded by the Canadian Cancer Society Alberta/NWT Division and the Alberta Cancer Foundation, held by Dr. Carlson. The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the article.

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