Acupuncture for postoperative pain : a systematic review, a randomized controlled trial and a health economics analysis

Abstract

Postoperative pain makes patients suffer and leads to a number of health and health economics consequences. Although acupuncture is well known for use in pain management, it is not available to perioperative inpatients in Hong Kong (HK). Therefore, this project was conducted to assess the possibility of adopting perioperative acupuncture in HK. This project comprises three studies: 1) a systematic review to summarize previous knowledge on acupuncture in postoperative pain control, 2) a clinical trial to evaluate the efficacy of acupuncture in postoperative pain management in HK, and 3) a health economics analysis to explore the economic value of acupuncture. First, a systematic review was performed to evaluate the evidence on the efficacy of acupuncture in controlling pain after all types of surgeries. Twenty-eight randomized sham-controlled trials were identified, of which 23 were included in the meta-analysis. Acupuncture was found to be superior to sham acupuncture in reducing postoperative pain and analgesic consumption at around 8h, 24h and 72h after surgery. However, heterogeneities exist in the choice of analgesics and outcome assessment time, weakening the strength of the results. In addition, of all the identified studies, only 1 small-scale study (n=27) was conducted in HK. Therefore, the applicability of using acupuncture in HK postoperative pain control remains unclear. A randomized, patient-and-assessor-blind, sham-controlled trial was therefore performed to examine the safety, feasibility, efficacy and health economics effectiveness of applying acupuncture in reducing postoperative pain in HK. Seventy-two laparotomy patients were recruited. They were randomly and evenly allocated to either an acupuncture group or a sham acupuncture group. A semi-standardized acupuncture protocol was adopted in the perioperative period (preoperatively: 1 session; postoperatively: up to 6 sessions). For the sham acupuncture treatment, the only difference from the true acupuncture group was the use of non-invasive needles on non-acupoints. No statistically significant difference was found between the 2 groups on the pre-defined primary outcome of area under the curve of pain at rest over the 5 days after the surgery. However, as many data were missing, post-hoc direct comparison was performed on the pain scores at 3 time points with high availability of data. The acupuncture group reported a statistically significantly lower pain score at 22h after surgery when compared with the sham group. A further health economics evaluation was conducted using the data collected from the aforementioned clinical trial by assuming the cost of sham acupuncture to be zero. The health outcome was measured using the Short-Form 6-Dimension (SF-6D) questionnaire and the EuroQol 5-Dimension 5-Level (EQ-5D-5L) questionnaire from baseline to postoperative day 5. Direct cost from the health care provider perspective was calculated. The mean total cost of the acupuncture group was numerically lower than the sham acupuncture group. However, the mean quality adjusted life years (QALY) was similar in the 2 groups. In conclusion, the results of the current studies suggest the potential efficacy and cost-saving value of acupuncture in perioperative care in HK.