Last week, ACC’s spending on alternative therapies was in the media spotlight. There were pieces on both TV3’s Story and Stuff asking the question of whether or not this spending is justified.
This was prompted by some new information that’s been released by ACC under the Official Information Act, regarding their funding of acupuncture treatments.
ACC reports spending over $25 million per year on acupuncture, even though ACC’s reviews of the evidence for acupuncture have been largely inconclusive or negative. There were only three types of injury for which they have concluded acupuncture may be effective:
Frozen Shoulder There is some evidence that exercise and acupuncture, compared with exercise alone, may lead to better outcomes.
The evidence for the effectiveness of acupuncture is most convincing for the treatment of chronic neck and shoulder pain. In terms of other injuries, the evidence is either inconclusive or insufficient.
Until recently, the only available breakdown of ACC’s spending on acupuncture treatments was categorised by “injury diagnosis”. Unfortunately, this breakdown is not very useful because it lumps 94% of acupuncture spending into a single treatment category:
Earlier this year, I met with someone from ACC to discuss what data is available that might help me answer the question of whether or not ACC’s funding of acupuncture is supported by the conclusions of their evidence-based reviews. They suggested that I ask what the top read codes are that are used for acupuncture treatment in ACC claims.
In ACC’s terminology, a read code is a five character code that denotes a specific injury type. For example, “S572.” denotes a lumbar sprain, whereas “TE532” means a toxic reaction to a bee sting.
Following this meeting, I sent another Official Information Act request to ACC. I asked for the number of accepted claims and cost of treatment of acupuncture in 2014/15 categorised by read code, and for any significant confounding factors that would make the data difficult to interpret. That was something that had been discussed at my meeting with ACC earlier, so I knew the best I was going to be able to get was an estimate, and wanted to make sure I knew just what the information I’d be given would and would not mean.
To answer the question of confounding factors, ACC explained in their response that they had categorised claims by their primary read code, and that this information isn’t able to tell me exactly how acupuncture was used in individual claims:
The read code information provided in this response records the primary read code of every claim that has received a payment for acupuncture treatment. As you [are] aware, there can be more than one read code under a single claim.
The read code information alone does not indicate how acupuncture was used in individual claims, because it is not possible to determine whether acupuncture was used in relation to the primary read code or some other read code on the claim. This would only be possible by reviewing individual claims. This is also the case with the primary body site and primary diagnosis information provided. Please take this into account when considering the data provided.
The response also had a pleasant surprise, in that ACC had supplied some extra data I hadn’t asked for, in case it would assist me. This contrasts somewhat with some of the frustration I’ve felt in the past with delayed and denied requests, but I’m very happy with how they responded this time.
The extra information they provided is a breakdown of acupuncture spending by primary injury site. Unlike the injury type breakdown I’d been provided in the past, this could be very helpful in determining how much of ACC’s funding of acupuncture treatments is aligned with the findings of their own reviews of the evidence.
Since their reviews only found positive conclusions for two injury sites – neck and shoulder – it seems like it should be a reasonable first estimate to look at the proportion of ACC’s spending on just these injury sites, allowing for the charitable assumption that these were all treating chronic neck or shoulder pain, or frozen shoulder. Allowing for some amount of error because of the caveats ACC mentioned, ideally this would come pretty close to 100%.
*Small numbers were reported as <4 or <$500 in order to protect privacy
Although shoulder and neck are in the top three primary injury sites for acupuncture, together they made up just 25% of the cost of acupuncture claims to ACC. This leaves just under $20 million for claims involving other primary injury sites.
I hadn’t expected to see such a strong trend toward a single injury site that was neither shoulder nor neck, but there were more claims with the lower back as the primary injury site than there were for neck and shoulder combined.
Looking at the data for individual read codes, I found that 33% of all ACC’s spending on claims involving acupuncture had a primary read code of “S572.”, which indicates a lumbar sprain.
Because of the caveats mentioned earlier, it’s likely that not all of the $8,652,237 spent on these 20,409 claims was for acupuncture used to treat a lumbar sprain. But it certainly indicates that ACC spends a large amount of money on ACC for lumbar sprain – large enough to be measured in the millions.
ACC has evaluated the evidence for acupuncture used to treat lower back pain. Its 2004 New Zealand Acute Low Back Pain Guide* categorised acupuncture as having “Evidence of no improvement in clinical outcomes”.
*ACC’s website notes that “due to the age of this guideline, some sections may have been superseded by more recent evidence”, although as far as I can tell they haven’t published an updated guideline.
Their more recent (2011) review on acupuncture for musculoskeletal pain concluded that:
The evidence for the use of acupuncture in (sub)acute LBP is inconclusive
There is limited evidence to support the use of acupuncture for pain relief in chronic LBP in the short term (up to 3 months)
The evidence is inconclusive for the use of acupuncture for long term (beyond 3 months) pain relief in chronic LBP
There is no evidence to recommend the use of acupuncture for lumbar disc herniation related radiculopathy (LDHR)
This is hardly the sort of ringing endorsement that I’d expect to back up the spending of millions of dollars of public money each year on a treatment for lower back pain.
Until recently, the National Health Service (NHS) in the UK would pay for acupuncture to treat lower back pain. But the Guardian reported in March that acupuncture for lower back pain is no longer recommended for NHS patients. The latest draft guidelines for lower back pain, which will replace the previous guidelines from 2009, involved a thorough review of the evidence and recommended not offering acupuncture at all for treating lower back pain. Its summary for acupuncture notes that:
comparison with sham acupuncture showed no consistent clinically important effect, leading to the conclusion that the effects of acupuncture were probably the result of non-specific contextual effects.
“Non-specific contextual effects” is just a more descriptive way of saying “placebo effect”.
In the last year, the New Zealand government has been under intense criticism for spending $26 million over three years on a referendum for changing the flag. More recently, the importance of funding evidence-based treatment has been emphasised in the media when reporting on Pharmac’s decision not to fund the effective, yet extraordinarily expensive, melanoma drug pembrolizumab (branded as Keytruda), estimated to cost $30 million annually.
In this context, it seems increasingly bizarre that ACC continues to spend $25 million or more each year on a treatment that they themselves have found is not supported by evidence for at least three quarters of the injuries it’s used to treat.
To summarise, in 2014 a couple of Official Information Act (OIA) requests to ACC uncovered information about how much they had spent on acupuncture treatments over the past decade, as well as a more detailed breakdown of how much was spent on acupuncture used for different categories of injury (the detailed breakdown also included data for 2013/2014).
As you can see from the chart below, their projections turned out to be rather inaccurate, and ACC spending on acupuncture has been absolutely booming:
It was with this information that I wrote my previous two posts on this topic. Here are the important parts of those reviews’ conclusions:
The evidence for the effectiveness of acupuncture is most convincing for the treatment of chronic neck and shoulder pain. In terms of other injuries, the evidence is either inconclusive or insufficient.
There is limited good quality evidence to conclusively determine acupuncture’s efficacy in treatment of mental health conditions such as Major Depressive Disorder, Dysthymia, Anxiety Disorder, Borderline Personality Disorder and Post Traumatic Stress Disorder.
When I went to write on this topic again last year during “Acupuncture Awareness Week”, I found two more ACC literature reviews on the efficacy of acupuncture (as well as other treatments) on the ACC website:
On the topic of acupuncture, these reviews concluded that:
The evidence is either weak or absent for: … acupuncture
current evidence does not support the use of acupuncture to treat people with [Traumatic Brain Injury].
Feeling rather frustrated that ACC’s response to my earlier request (which arrived less than 2 weeks before last year’s September election) was apparently false, I sent a more specific followup:
I would like to reiterate my request to be provided with copies of or links to all literature reviews regarding the effectiveness of acupuncture for any condition undertaken by ACC. For the sake of clarity, I would like to be explicit that this includes both reviews that looked at several treatment options including acupuncture, and reviews that were commissioned by ACC as well as those directly undertaken by ACC.
I hope anyone reading this would agree that this followup should absolutely not have been necessary, and all the information I was requesting here should have been provided in ACC’s response to my original request before they’d be breaking the law.
However, when ACC finally acknowledged my request over a week after having received it, they maintained that “the information provided to [me] on 3 September 2014 was complete” and that this was therefore a new, separate OIA request. Because of the break over summer, this gave them until the 20th of January to respond to my request.
At 4 o’clock in the afternoon on the 20th of January, I heard back from ACC with an answer that essentially felt like “find the information yourself, it’s online”. Instead of providing me with copies of or links to any reviews, they told me the name of one review commissioned by ACC and that it could be found online, and provided me with 2 links to pages on their website that listed all of their reviews.
Interestingly, although I don’t believe the 2011 review has been released except in response to an OIA request, it was not mentioned in ACC’s response and they told me that:
ACC does not hold any other information that has not been published.
Having taken some time to go through all the reviews found on the pages I was linked to in order to find all those which mention acupuncture, I came up with the following list. As well as a link to the review and its title and date where I could find one, I am quoting the relevant conclusions below.
There is limited good quality evidence to conclusively determine acupuncture’s efficacy in treatment of mental health conditions such as Major Depressive Disorder, Dysthymia, Anxiety Disorder, Borderline Personality Disorder and Post Traumatic Stress Disorder.
There is limited and heterogeneous evidence of effectiveness of acupuncture in depression… The evidence base [for anxiety] is small and varies greatly in terms of methodological rigour and comparability and the published literature is limited to very few good quality RCTs… There is limited evidence about the effectiveness of acupuncture in PTSD
Unknown effectiveness (conflicting evidence of efficacy or absence of evidence; methodological concerns with research/insufficient data to date):… Acupuncture
While acupuncture and ginkgo biloba have respectively been demonstrated in two small, separate randomised clinical trials to provide statistically significant effects on the frequency of RP attacks, use of these therapies is not recommended in these guidelines, on account of the absence of any further followup studies investigating these interventions.
New Zealand Acute Low Back Pain Guide (2004; apparently superceded by more recent evidence but this appears to be ACC’s latest guide on this topic?)
No improvement Evidence of no improvement in clinical outcomes… Acupuncture
Evidence on the use of acupuncture for post-TBI symptoms is scarce and inconsistent. Therefore, current evidence does not support the use of acupuncture to treat people with TBI.
No recommendations can be made about the use of acupuncture, chiropractic, osteopathy or other complementary therapies for the treatment of soft tissue knee injuries due to a lack of good quality evidence.
Given the very small number of eligible RCTs identified, and their heterogeneity, it is not possible for this review to reach any strong conclusions about the effectiveness of acupuncture for the treatment and rehabilitation of musculoskeletal injuries.
The evidence for the effectiveness of acupuncture is most convincing for the treatment of chronic neck and shoulder pain. In terms of other injuries, the evidence is either inconclusive or insufficient.
Although they have told me so incorrectly in the past, I have ACC’s word that these are all the ACC literature reviews that evaluate acupuncture. As you can see, they are inconclusive or negative for all but a few specific conditions: Frozen shoulder, chronic neck pain, chronic shoulder pain.
In 2014 ACC spent $30,000 on acupuncture to treat burns, $59,000 on acupuncture for concussion and brain injury, and $591,000 on acupuncture for fracture and dislocation. They apparently spent $22,592,000 on acupuncture for soft tissue injuries, but I find it highly unlikely that all of this money was used to treat frozen shoulder, chronic neck pain, and chronic shoulder pain.
ACC’s expenditure on acupuncture shows no sign of slowing. It grew 17% from 2011/12 to 2012/13, then a further 17% from 2012/13 to 2013/14, leaving the expenditure for 2013/14 at over $24,000,000. It’s certainly not a large part of ACC’s total expenditure, but it’s no small sum of money.
ACC is publicly funded. Publicly funded healthcare should be based on rigorous evidence. ACC does not appear to have evidence that would allow them to conclude that acupuncture is an effective treatment for any more than these conditions. It is well past time for ACC to re-evaluate their expenditure on acupuncture. It should only be funded when used to treat conditions in a way that is supported by rigorous evidence, and that is certainly not the case currently.
I will end this post the same way as I have ended my previous posts on this topic, with my recommendations for how ACC should deal with this issue:
I think ACC needs to review its funding scheme for acupuncture. I think their approach to this should start with reviewing their Acupuncture Treatment Profiles document, ensuring that the only treatments contained within it are those supported by rigorous evidence, and purging pseudoscientific claims from it. If they find they need to undertake further reviews of the evidence for the use of acupuncture for particular indications, then they should do that before approving funding for it.
I think ACC should then only agree to pay for acupuncture treatments that are aligned with their Treatment Profiles document, which they should commit to reviewing at regular intervals to keep it in line with the latest evidence (I’m not sure what time interval would be most appropriate, and I understand that there is a cost involved in that work).
I’m not sure, but it’s possible some changes to legislation may be required before this becomes a reality, but if that’s the case those changes should happen. A government body should not be bound by law to fund healthcare that is not supported by evidence.
There’s one last thing I’d also like to see, although I really feel like this is a long shot. I think ACC should take an active role in discouraging healthcare practice based on the “pre-scientific notions” described in their 2011 review. I think they should do this by distancing themselves from those acupuncturists who promote it and who base their practice on it, by refusing to grant them status as registered ACC practitioners if they are found to rely on it.
In 2011, ACC’s research team conducted a literature review of the efficacy of acupuncture in the management of musculoskeletal pain. It found the most convincing evidence for the effectiveness of acupuncture related to the treatment of chronic neck pain and the improvement of pain and mobility in chronic shoulder pain. In terms of other injuries, evidence of the benefits of acupuncture was either inconclusive or insufficient.
I have been unable to find this particular review by searching on the ACC website, although I have found other reports such as the “Effectiveness of acupuncture in selected mental health conditions” brief report from earlier this year.
Also, if ACC has any guidelines for carrying out these reviews, could you please provide me with a copy of or link to these guidelines.
There is limited good quality evidence to conclusively determine acupuncture’s efficacy in treatment of mental health conditions such as Major Depressive Disorder, Dysthymia, Anxiety Disorder, Borderline Personality Disorder and Post Traumatic Stress Disorder.
Here’s what ACC said in response to my OIA request yesterday:
There are only two ACC literature reviews on the efficacy of acupuncture. These are:
The efficacy of acupuncture in the management of musculoskeletal pain.
I understand from your email of 25 August 2014 that you have accessed a copy of this report and therefore do not require another copy.
Effectiveness of acupuncture in selected mental health conditions — Brief report 2014.
As you have identified, this is available on the ACC website.
In regard to ACC guidelines on literature reviews, ACC follows standard practice when undertaking literature reviews, and there are no ACC specific guidelines on this practice.
After my previous post on this topic, I was contacted by Ross Mason who told me about a similar OIA request he had made some years ago. One interesting thing I read in their response to him, which was written by the same person as their response to me, was this (bolded emphasis mine):
2. Evidence of the efficacy of the use of CAM treatments/programmes;
Schedule 1 Part 1 sections 1 & 2 of the [Accident Compensation] Act detail ACC’s liability to pay for the cost of treatment. These provisions in part include the requirement that the treatment is necessary and appropriate and of the quality required for the purpose. ACC has always required that new treatments for which payment is requested are supported by evidence of effectiveness. However it must be noted that there are many treatments that treatment providers utilise that do now have a well established evidence base.
If requested to fund CAM, ACC would require that evidence be provided for the treatments [sic] efficacy. ACC evaluation process of the evidence is detailed on the ACC website in the “For Providers, Clinical Best Practice” section – http://www.acc.co.nz/for-providers/clinical-best-practice/index.htm.
The first link, to the “Evidence based healthcare reports” page, seems to provide a little more detail on what was described as “standard practice” in response to my request:
Evidence based reviews
These reports assess the effectiveness and safety of health interventions. They are developed according to a robust methodology similar to that used by the Centre for Evidence Based Medicine (external link) and the Scottish Intercollegiate Guidelines Network (external link). This includes systematic searches of the literature, critical appraisal of existing research evidence and peer review by clinical experts.
ACC has funded acupuncture treatments for over a decade, spending over $24 million on it last year alone.
In August 2011, ACC reviewed the evidence regarding the efficacy of acupuncture for musculoskeletal pain and found that (emphasis mine):
The evidence for the effectiveness of acupuncture is most convincing for the treatment of chronic neck and shoulder pain. In terms of other injuries, the evidence is either inconclusive or insufficient.
In March 2014, ACC published a brief report on the effectiveness of acupuncture in selected mental health conditions didn’t find enough good quality evidence to provide any recommendation.
No other review of the evidence for acupuncture has been undertaken by ACC. Despite this, over the last year ACC spent significant amounts of public money on acupuncture treatments for other medical issues such as burns ($30,002), lacerations and puncture wounds ($309,458), and fractures and dislocations ($591,613).
In the past year, they spent $22,592,552 on acupuncture for soft tissue injuries. Unfortunately, their recent response to another OIA request shows that they haven’t been keeping track of which body parts were treated, so we’ve been unable to determine how much of this substantial amount of money was spent on treatments that ACC’s own findings say are not supported by evidence.
As far as I’ve been able to tell, ACC’s funding scheme for acupuncture simply isn’t consistent with the evidential requirements they claim to require, and is instead largely based on the pre-scientific notions (to quote the author of their 2011 review) detailed in their Acupuncture Treatment Profiles document. When these issues were raised with the previous ACC minister Nick Smith in 2009 he promised a review of their effectiveness would be undertaken, but in the 5 years since then no such review has taken place. This latest response of theirs has only made me feel even more strongly about my recommendations for change:
I think ACC needs to review its funding scheme for acupuncture. I think their approach to this should start with reviewing their Acupuncture Treatment Profiles document, ensuring that the only treatments contained within it are those supported by rigorous evidence, and purging pseudoscientific claims from it. If they find they need to undertake further reviews of the evidence for the use of acupuncture for particular indications, then they should do that before approving funding for it.
I think ACC should then only agree to pay for acupuncture treatments that are aligned with their Treatment Profiles document, which they should commit to reviewing at regular intervals to keep it in line with the latest evidence (I’m not sure what time interval would be most appropriate, and I understand that there is a cost involved in that work).
I’m not sure, but it’s possible some changes to legislation may be required before this becomes a reality, but if that’s the case those changes should happen. A government body should not be bound by law to fund healthcare that is not supported by evidence.
There’s one last thing I’d also like to see, although I really feel like this is a long shot. I think ACC should take an active role in discouraging healthcare practice based on the “pre-scientific notions” described in their 2011 review. I think they should do this by distancing themselves from those acupuncturists who promote it and who base their practice on it, by refusing to grant them status as registered ACC practitioners if they are found to rely on it.
Over the past year or so, various Official Information Act (OIA) requests have been made via the website fyi.org.nz, which allows for these requests and their responses to be made public. I have written previously about the results of some of these requests regarding ACC and Alternative Medicine. I’ve also shared some more information on Twitter, which Thomas Lumley has documented on the StatsChat blog: Sticking it to ACC
Following my previous post on this matter I also wrote to the ACC Minister, Judith Collins, in May to outline my concerns. Here’s what I said in my email:
Dear Ms Collins,
My name is Mark Hanna. I’m a consumer advocate from Auckland with a particular interest in alternative medicine. Over the past year and a half I’ve been actively trying to reduce the amount of misinformation regarding alternative medicine so often seen in advertisements, mainly by lodging complaints with the Advertising Standards Authority.
Last year, prompted by an earlier Official Information Act request, two friends of mine submitted OIA requests of their own to the Accident Compensation Corporation inquiring as to how much funding it had provided to “alternative therapies”:
I’m also aware, largely due to its mention in the recent article, and also due to this article from 2009, that in 2009 then-ACC Minister Nick Smith said the ACC would review the effectiveness of these treatments. Unfortunately, it seems no such review has been conducted.
Piecing together the information released by the ACC regarding their funding of acupuncture, I believe it paints a rather disturbing picture. I have attached a chart constructed from the data released by the ACC in response to your 2004 questions, and their updated expenditure data released earlier this month.
Now, of course, this wouldn’t be a problem if the ACC’s funding of acupuncture were due to a strong evidence base in favour of its effectiveness and safety. Unfortunately, this does not seem to be the case.
The earlier OIA request I mentioned asked the ACC how they measure the effectiveness of treatments that they fund. Their answer included the statement that:
With respect to processes and requirements for measuring effectiveness, Treatment Profiles have been developed for 150 common injury types. Treatment Profiles are guides to the treatment and rehabilitation services ACC expects a practitioner to provide to a client for a particular injury. They describe current ‘good practice’ and what outcomes should be achieved.
However, viewing the ACC’s Acupuncture Treatment Profiles document, I find instead that it is based on statements such as these:
“Acupuncture… Relieves pain by treating stagnation of Qi and Blood in the affected areas and channels”
“Qi is the vital force of life which… Is the material substrate of the Universe”
“Brain… Is considered to be the same in substance as marrow”
“the Kidney produces marrow”
That is only a small selection of the many statements in that document that are clearly – even blatantly – no more than pseudoscience at best. They certainly do not give the impression of science-based decision making.
In light of all this, I believe it is high time the ACC conducted a rigorous review of the evidence regarding acupuncture so as to cease funding treatment options that do not appear to be effective or science-based.
As current ACC Minister, I hope you will be able to help facilitate what seems to me like a long overdue review of the effectiveness of acupuncture and related practices as they are funded by the ACC.
Sincerely,
Mark Hanna
Here’s the chart I attached to that email:
I heard back from Ms Collins on the 18th of June, you can view her response here:
In her response, she described review ACC undertook of some of the evidence regarding acupuncture in 2011:
In 2011, ACC’s research team also conducted a literature review of the efficacy of acupuncture in the management of musculoskeletal pain. It found the most convincing evidence for the effectiveness of acupuncture related to the treatment of chronic neck pain and the improvement of pain and mobility in chronic shoulder pain. Evidence on the effectiveness of acupuncture is not dissimilar to other physical therapies such as physiotherapy, chiropractic and osteopathy.
The vast majority of the spending (around 94% for each of the last 2 years) was for soft tissue injuries. However, without a more detailed breakdown we don’t yet know how many of this was supported by ACC’s findings regarding the evidence for acupuncture.
Although the amount of money is piddling in comparison, I have to admit I find it rather concerning to see that, over the past decade, ACC has spend $9,000 on acupuncture for deafness.
EDIT 2014/08/30
In a discussion of this post on Facebook, Jonathan Grady raised a good point about what this might have involved. It’s still just speculation, but I thought it was worth mentioning here:
Well, I know of no evidence that acupuncture is useful in the treatment of hearing impairment per se. There’s no plausible mechanism at work. But it could well, in some instances, be used plausibly to treat tinnitus, as tinnitus has a high component of subjective influences such as mood and levels of physiological and psychological arousal (similar to perceptions of chronic pain and of “phantom limb” syndrome). Placebos have some good efficacy in the treatment of tinnitus and, as we all know, acupuncture is really not much more than a placebo treatment. But it certainly won’t help you hear any better…
I currently have an outstanding OIA request with ACC, asking for their 2011 review as well as any others they’ve conducted regarding acupuncture, and any guidelines they have for conducting these reviews.
Although my request asked for “copies of or links to all literature reviews regarding the effectiveness of acupuncture for any condition undertaken by ACC”, in their initial response to my request they only identified that I had asked for “A copy of The efficacy of acupuncture in the management of musculoskeletal pain conducted by ACC’s research team”.
I’m still waiting to hear back regarding if this means it’s the only such review, or if there are others as well. However, I have found other reports on the ACC website, like this one on the Effectiveness of acupuncture in selected mental health conditions, so I suspect there should be more reviews than just the 2011 one.
Yesterday, in response to a separate request from Kevin McCready, ACC has released this 2011 review. Although the names and qualifications of the author or authors were also requested, ACC denied this part of McCready’s request and removed that information from the report:
ACC declines to provide the names and qualifications of the staff members who compiled the literature review as there is a need to protect people’s privacy. We have also been unable to identify why the release of this information would be in the public interest.
There is insufficient evidence to make a recommendation for the use of acupuncture in the management of acute neck, back or shoulder pain
There is emerging evidence that acupuncture may enhance/facilitate other conventional therapies (including physiotherapy & exercise-based therapies)
There is a paucity of research for the optimal dosage of acupuncture treatment for treating shoulder, knee, neck and lower back pain
Studies comparing effective conservative treatments (including simple analgesics, physical therapy, exercise, heat & cold therapy) for (sub) acute and chronic non-specific low back pain (LBP) have been largely inconclusive
Lower back
The evidence for the use of acupuncture in (sub)acute LBP is inconclusive
There is limited evidence to support the use of acupuncture for pain relief in chronic LBP in the short term (up to 3 months)
The evidence is inconclusive for the use of acupuncture for long term (beyond 3 months) pain relief in chronic LBP
There is no evidence to recommend the use of acupuncture for lumbar disc herniation related radiculopathy (LDHR)
Neck
There is good evidence that acupuncture is effective for short term pain relief in the treatment of chronic neck pain
There is moderate evidence that real acupuncture is more effective than sham acupuncture for the treatment of chronic neck pain
There is limited evidence that acupuncture has a long term effect on chronic neck pain
Shoulder
There is good evidence from one pragmatic trial that acupuncture improves pain and mobility in chronic shoulder pain
There is limited evidence for the efficacy of acupuncture for frozen shoulder
There is contradictory evidence for the efficacy of acupuncture for subacromial impingement syndrome
Knee
There is no evidence to recommend the use of acupuncture for injury-related knee pain
Ankle
There is no evidence to recommend the use of acupuncture for ankle pain
Regarding the evidence found for neck and shoulder pain, it seems important to note a couple of caveats:
The “good” evidence for shoulder pain was from a single trial: Molsberger et al. 2010. This trial had a decent sample size of 424, and compared Chinese acupuncture to sham acupuncture.
The abstract doesn’t specify any details of the sham treatment, but the full paper describes it as involving the same number of needles and number and frequency of treatments, but the needles were placed at non-acupuncture points and inserted less than 5 mm (compared with 1-2 cm in the acupuncture group). I was glad to see one of the inclusion criteria was that participants be naïve to acupuncture, so they could be effectively blinded to this.
The full paper makes it clear that “Treatment assignment… was known to the acupuncturist” so this study wasn’t double-blinded.
The report also notes that its conclusions contrast with an earlier Cochrane review on Acupuncture for shoulder pain, which found that:
There is little evidence to support or refute the use of acupuncture for shoulder pain
The Cochrane review was carried out in 2005, though, prior to some of the studies examined in the ACC review such as Molsberger et al 2010.
It’s surprisingly hard to find a stock photo of acupuncture involving gloves
While the overall evidence for neck pain was described as “good”, when compared with sham acupuncture (which is the most appropriate control if you want to account for the elaborate placebo effect of acupuncture) the evidence was not so strong. It’s not clear what the sham protocol was, or if it allowed for the blinding of both participants and practitioners.
It seems Judith Collins’ description of the review’s conclusions was taken practically verbatim from its “Summary Message”, although she also seems to have opted to remove the sentence regarding the evidence for injuries other than those involving chronic neck and shoulder pain, which I’ve highlighted below:
The evidence for the effectiveness of acupuncture is most convincing for the treatment of chronic neck and shoulder pain. In terms of other injuries, the evidence is either inconclusive or insufficient. The state of the evidence of the effectiveness of acupuncture is not dissimilar to other physical therapies such as physiotherapy, chiropractic and osteopathy.
For a more direct comparison, here’s her wording again:
In 2011, ACC’s research team also conducted a literature review of the efficacy of acupuncture in the management of musculoskeletal pain. It found the most convincing evidence for the effectiveness of acupuncture related to the treatment of chronic neck pain and the improvement of pain and mobility in chronic shoulder pain. Evidence on the effectiveness of acupuncture is not dissimilar to other physical therapies such as physiotherapy, chiropractic and osteopathy.
Despite the findings of this report, ACC still seems to be spending a lot of money on treatments that their own review concludes are not supported by evidence. It’s hard to quantify exactly how much of their expenditure on acupuncture – over $24,000,000 over the 2013/14 financial year – went toward these treatments, but Daniel Ryan (also from the Society for Science Based Healthcare) has submitted another OIA request asking for a further breakdown of spending by body part.
In their response to Kevin McCready’s request, however, they have said that:
ACC funds acupuncture for conditions where prescribed by the client’s medical professional. This includes conditions other than musculoskeletal pain, and for non-chronic pain.
I’m trying to give them the benefit of the doubt, but from this it sounds like their review of the evidence may play no part in the decision of whether or not to fund acupuncture treatment for any particular condition.
Instead, it appears ACC will fund any acupuncture treatment so long as the patient was:
referred for acupuncture by a health professional who is covered by the Health Practitioners Competence Assurance (HPCA) Act.
Perhaps this explains ACC’s worrying funding of such treatments as acupuncture for deafness, but I certainly don’t think it excuses it.
Although the report makes an “Important Note” at the top that “The content [of this document] does not necessarily represent the official view of ACC or represent ACC policy”, I did find one particular section in the background section quite interesting. First off, TCM acupuncture is described as:
TCM acupuncture involves inserting needles into traditional meridian points with the intention on [sic] influencing energy flow within that meridian
As far as I’m aware, that’s a fairly accurate description of how modern acupuncturists tend to claim their treatments work. For example, the New Zealand Register of Acupuncturists’ explanation of How Acupuncture Works claims that:
Any disruption or blockage of the flow of Qi along the meridians will in time affect the associated organ, resulting, for example, in decreased function or pain. Acupuncture aims to correct this flow of Qi, and thereby restore the balance within the body
This explanation also seems to be reflected in ACC’s Acupuncture Treatment Profiles document. However, the reviewer then went on to say that:
many physicians currently practicing acupuncture reject such pre-scientific notions described above
I think that description of acupuncturists’ claims to be able to manipulate qi flow with their needles as “pre-scientific notions” is absolutely spot on. The existence of qi and meridians is not supported by any evidence, and when this practice was developed it was based more on philosophy than evidence. In that way, it’s similar to extinct medical philosophies such as the “Western” medical philosophy of humorism.
One aspect of acupuncture that I find illustrates quite well the fact that its development was not supported by evidence is that horses are said to have a gall bladder meridian. This gall bladder meridian has even been the subject of published papers in journals such as the “Journal of Acupuncture and Meridian Studies”. What’s so odd about that, though? Horses don’t have a gall bladder.
Statements such as many of those found in ACC’s Acupuncture Treatment Profiles, which was “developed by the New Zealand Register of Acupuncturists Inc. in consultation with the New Zealand Acupuncture Standards Authority in a joint initiative with ACC”, are pretty self-evidently pseudoscientific. For example:
“Qi is the vital force of life which… Is the material substrate of the Universe”
If I want to know about the “vital force of life” or the “material substrate of the Universe”, I’ll ask a biologist and a physicist, respectively. So I asked a biologist and a physicist what they thought of these claims regarding “Qi”. Here’s what they had to say:
From my perspective as a biologist, that quote about Qi bears a lot more relation to the old and discredited concept of ‘vitalism’ than it does to modern biology. There is no evidence Qi exists, let alone that the lines along which Qi is supposed to flow through the body exist (and indeed, different ‘schools’ of acupuncture seem to deal in different ‘meridians’ – they can’t all be right!)
Alison Campbell, Senior biological sciences lecturer at the University of Waikato
I think it is self-evident that modern physics does not hold that qi is the “material substrate of the universe”; I would just say that qi is not something you find in physics textbooks; going beyond that might be beating a dead horse.
Richard Easther, Professor and Head of Department of Physics at the University of Auckland
(Alison and Richard often have interesting things to say. If you’d like to follow them, Alison blogs at Bioblog, and Richard at Excursionset.com. You can also follow him on Twitter @REasther.)
Now you have some insight into what I consider to be the problems with ACC’s funding of acupuncture. I’ve had people suggest to me, though, that some people do seem to benefit from acupuncture, so perhaps I shouldn’t be so interested in removing it from ACC.
Before I respond to that, I want to make one thing clear. I am not and will not argue for preventing people who want acupuncture from having acupuncture. Patient autonomy is an immensely important aspect of healthcare, and people have the right to make their own healthcare choices.
My primary motivation, as with all my involvement in dealing with dodgy healthcare claims, is echoed in the mission statement of the Society for Science Based Healthcare:
We believe that a strong basis in rigorous science is a necessary prerequisite for providing safe and effective healthcare. Decisions regarding public funding of healthcare in New Zealand should therefore be science based. We support public health measures that have a clear basis in science and evidence, and oppose those that do not.
We will work to counter misinformation about health issues propagated by individuals and organisations in New Zealand.
Consumers have the right to make an informed decision about their healthcare, and should not have to worry about being misled by unsubstantiated claims.
People have the right to make their healthcare choices, but they should not be misinformed by claims like “this needle will unblock qi flow through your meridians”.
Also, and this is more relevant to the case at hand, a treatment that is not supported by rigorous evidence is at best an experimental treatment. Generally the only ethically appropriate situation for an experimental treatment to be used is in a well-designed clinical trial, although in certain cases an argument can also be made for compassionate use exceptions.
However, this is not what is being funded. ACC is funding acupuncture for indications for which there is either insufficient evidence, no evidence, or negative evidence, and it is funding it in a clinical setting.
Furthermore, the ACC registered acupuncturists that benefit from this framework are generally proponents of the “pre-scientific notions” of qi flow and meridians. Whether they intend to or not, I think ACC is effectively promoting this via their association with these practitioners, and through official documents such as the Acupuncture Treatment Profiles. I also think this promotion is likely to do harm to the public understanding of science, particularly medical science.
ACC funding implies governmental approval, and many more obviously ineffective services such as “energy therapies” make similar justifications to acupuncturists. If consumers are led to believe that practitioners who base their practice on “pre-scientific notions” like qi flow are reliable and trustworthy, it seems reasonable to me to expect that they will think the same of practitioners who base their practice on other concepts such as aura healing.
So, what do I think should be done? I think ACC needs to review its funding scheme for acupuncture. I think their approach to this should start with reviewing their Acupuncture Treatment Profiles document, ensuring that the only treatments contained within it are those supported by rigorous evidence, and purging pseudoscientific claims from it. If they find they need to undertake further reviews of the evidence for the use of acupuncture for particular indications, then they should do that before approving funding for it.
I think ACC should then only agree to pay for acupuncture treatments that are aligned with their Treatment Profiles document, which they should commit to reviewing at regular intervals to keep it in line with the latest evidence (I’m not sure what time interval would be most appropriate, and I understand that there is a cost involved in that work).
I’m not sure, but it’s possible some changes to legislation may be required before this becomes a reality, but if that’s the case those changes should happen. A government body should not be bound by law to fund healthcare that is not supported by evidence.
There’s one last thing I’d also like to see, although I really feel like this is a long shot. I think ACC should take an active role in discouraging healthcare practice based on the “pre-scientific notions” described in their 2011 review. I think they should do this by distancing themselves from those acupuncturists who promote it and who base their practice on it, by refusing to grant them status as registered ACC practitioners if they are found to rely on it.
The Accident Compensation Corporation (ACC) is part of the healthcare system in New Zealand. To quote themselves on their purpose, they provide “comprehensive, no-fault personal injury cover for all New Zealand residents and visitors to New Zealand”. To put it simply, if you hurt yourself in an accident in New Zealand, ACC will likely pay for all treatment you require to recover from that injury.
They are not strictly part of the government, but they are a Crown organisation set up via the Accident Compensation Act 2001, and they are controlled directly by the government through an ACC minister. At the time of writing, the current ACC minister is Judith Collins. The ACC is funded publicly through various avenues, including levies on people’s earnings.
Recently, the current chair of the New Zealand Skeptics, Gold, submitted an Official Information Act (OIA) request (using the great service FYI, which makes these requests public) to the ACC asking:
Please can you tell me, for each of the last 10 years, how much the
ACC has paid out for each of the following services:
Acupuncture
Chiropactic
Osteopathy
Naturopathy
On the 20th of May 2014, the ACC responded to Gold’s OIA request with this information:
The following table shows the total amount (in dollars, excl GST) ACC has paid under Regulations for Osteopathic, Acupuncture and Chiropractic services for the last 10 years.
Financial Year
$ cost
Osteopathy
Acupuncture
Chiropractic
Total
2003/04
6,210,642
4,424,458
8,056,875
18,691,975
2004/05
6,767,849
5,452,119
8,007,011
20,226,979
2005/06
7,237,766
5,954,239
7,947,342
21,139,347
2006/07
8,038,676
7,616,042
8,734,453
24,389,171
2007/08
10,082,351
12,392,494
12,007,580
34,482,415
2008/09
10,945,880
15,761,415
13,173,902
39,881,197
2009/10
10,470,269
15,605,042
11,804,095
37,879,406
2010/11
9,802,401
16,225,902
10,832,912
36,861,215
2011/12
10,029,446
16,958,808
11,654,292
38,642,546
2012/13
10,964,806
19,961,329
12,312,832
43,238,967
…
Naturopath is not an ACC funded service; therefore your request for this information is declined under section 18(e) of the Act, as the document alleged to contain the information requested does not exist or cannot be found.
Here’s that information on a chart, excluding the totals. As you can see, spending on acupuncture in particular has increased dramatically over the last decade:
ACC spending on alternative therapies per financial year from 2003/04 to 2012/13
This OIA request was a follow-up to an earlier request from Mark Honeychurch regarding essentially the same information. The response to Gold’s request included a new column for 2012/13, as well as the “Total” column although that isn’t strictly new information. Also, the information from Gold’s request seems to have been a catalyst for an article published on the 24th of May 2014 on stuff.co.nz: Big Bill for Alternative Health.
This article did a little more digging, asking questions of doctors, acupuncturists, and the ACC. I highly recommend you read it. The most interesting part to me was this:
In 2009, then-ACC Minister Nick Smith questioned the ballooning ACC bill for complementary treatments and said their effectiveness would be reviewed.
Since then, the cost has risen another $5m but ACC said no review ever took place.
ACC Minister Judith Collins did not answer questions about the review.
It is not mentioned in this article, but I have known for some time that the ACC has a document published on their website entitled Acupuncture Treatment Profiles. The document describes itself as:
a valuable guide in the application of protocols that are included within a Traditional Chinese Medical (TCM) diagnosis, providing important information that assists an acupuncturist’s treatment strategy.
This appears to be an official ACC document, to be used by ACC-registered acupuncturists to determine appropriate methods of diagnosis and treatment that are approved for ACC funding. However, having a look through it one can’t help but notice egregiously wrong and pseudoscientific statements such as the following:
Acupuncture… Relieves pain by treating stagnation of Qi and Blood in the affected areas and channels
Qi is the vital force of life which… Is the material substrate of the Universe
Brain… Is considered to be the same in substance as marrow
the Kidney produces marrow
I shudder at the thought that the ACC levies I pay are partly used to fund this. It seems to me that it’s high time the ACC carried out a review of the evidence behind these therapies that it funds, so problems like this can be rooted out and dealt with. Publicly funded healthcare should be based on science, after all.
Honest Universe 