Journal Name: British Medical Journal
Article title: Evidence on acupuncture therapies is underused in clinical practice and health policy
• A large number of systematic reviews of acupuncture exist which are overall methodologically rigorous
• Clinical practice and health policy underuse beneficial acupuncture therapies for which rigorous systematic reviews have documented high or moderate certainty evidence
• Acupuncture funding and research need to focus on conditions for which acupuncture therapies have had substantial beneficial effects but for which evidence is of low certainty
• A coordinated multistakeholder effort to generate acupuncture evidence and support its implementation will enable a more evidence based approach to practice and research
Evidence based acupuncture therapies are underused
A recent overview of acupuncture systematic reviews found that of 77 diseases investigated,
acupuncture showed a moderate or large effect with moderate or high certainty evidence in eight diseases or conditions: improvement in functional communication of patients with post-stroke aphasia; relief of neck and shoulder pain; relief of myofascial pain; relief of fibromyalgia related pain; relief of non-specific lower back pain; increased lactation success rate within 24 hours of delivery; reduction in the severity of vascular dementia symptoms; and improvement of allergic rhinitis nasal symptoms.
However, instead of endorsement in health policies and wide use in clinical practice, only a few healthcare systems incorporated acupuncture into clinical practice guidelines and national health coverage for these conditions.
For example, acupuncture is underused in practice for treatment of post-stroke aphasia. The US National Aphasia Association estimated that 2 million people in the country and 250 000 people in the UK suffered from post-stroke aphasia in 2016. Up to 38% of stroke patients suffer from aphasia. Post-stroke aphasia affects patients’ ability to express or understand language and disrupts their socialisation and work. Patients most often receive speech and language rehabilitation, neuromodulation, and pharmacological therapy (eg, bromocriptine, piracetam, and donepezil). Of these three treatments, only language rehabilitation shows a clear benefit for post-stroke aphasia. Additional treatment methods are needed.
A high quality systematic review, as assessed by AMSTAR 2, of eight trials including 481 patients that compared acupuncture to language rehabilitation found a large difference in improvement in the functional communication of post-stroke aphasia patients in favour of acupuncture (standardised mean difference 1.01, 95% confidence interval 0.81 to 1.2, moderate certainty). This difference corresponds to an over 20% improvement (56 in an instrument from 0 to 250) on the Chinese functional communication scale. In the absence of an anchor based minimal important difference (the smallest difference that informed patients or proxies perceive as important, either beneficial or harmful, and can lead to a change in patient management) for the Chinese functional communication scale, we calculated the distribution based minimal important difference (0.5 standard deviations of the Chinese functional communication profile). Even the lower boundary of the 95% confidence interval (44.8) exceeded the minimal important difference (28.0).
A cumulative meta-analysis (fig 2) showed that by 2015, acupuncture had already demonstrated a likely improvement in functional communication in post-stroke aphasia patients (standardised mean difference 0.95, 95% confidence interval 0.74 to 1.17), corresponding to 52.5 of the Chinese functional communication profile scales (0–250), moderate certainty). The 95% confidence interval becomes narrower and the effect slightly larger when adding more randomised controlled trials after 2015. Thus, by 2015 compelling evidence had accumulated that acupuncture provided important improvement, relative to the best existing therapy, in functional communication in post-stroke aphasia. To date, however, only one Chinese clinical practice guideline has recommended acupuncture therapies for treatment of post-stroke aphasia. In the US alone, 10 million patients with post-stroke aphasia could have benefited from acupuncture treatment.
Cumulative meta-analysis of the use of acupuncture compared with language rehabilitation for functional communication in patients with post-stroke aphasia
Moreover, insurance does not cover some beneficial acupuncture therapies. Of the eight diseases and conditions identified earlier, the main national insurers in Western countries only cover pain related conditions. In the US, at the end of 2020, Medicare started covering acupuncture treatment for chronic lower back pain. In Australia, Medicare covers back pain and shoulder pain. In UK, the National Institute for Health and Care Excellence provides limited recommendations, indicating that most fully informed patients would choose to use acupuncture as a treatment option for chronic tension-type headaches, migraines, and chronic pain. Nevertheless, no national insurance reimburses acupuncture treatment.
Summary recommendations to increase use of acupuncture systematic reviews
Incorporate acupuncture evidence into decision making within health systems
Given the many systematic review summarising acupuncture evidence identified in The BMJ acupuncture collection, international, regional, and national organisations and health systems should initiate, support, and develop more acupuncture evidence informed decision making.
Build a joint research production effort
Knowledge users, funding agencies, and researchers should set joint research agendas to accelerate the generation, updating, evaluation, and release of evidence to provide a basis for the application of acupuncture.
Digitize and disseminate evidence on acupuncture to facilitate access
A digitized repository should be created with evidence matrices that map systematic reviews of acupuncture and disseminate (eg, through social media, subscriptions, and emails) tailored messages derived from systematic reviews to help patients, clinicians, and policy makers access evidence on acupuncture.
Enable the use of existing evidence in health system decision making
Linkages and exchange between researchers, clinicians, and policy makers should be encouraged to help expand the use of existing acupuncture evidence, especially in areas in which acupuncture therapy shows moderate or large effects supported by moderate or high certainty evidence. The GRADE evidence to decision framework enables transparent and structured evidence informed health system decisions.
Align knowledge gaps and research with funding priorities
Researchers and granting agencies should focus on areas where acupuncture has shown large effects supported with low or very low certainty evidence (areas of high potential) and avoid research and funding in areas where moderate or high certainty evidence has proven the benefit of interventions.
This is an analysis paper published at British Medical Journal, one of the world's oldest general medical journals. Hopefully, the unfair policies will be changed soon!.
Evidence on acupuncture therapies is underused in clinical practice and health policy