Model-based economic evaluation of pharmacopuncture for chronic low back pain: a 3-year Markov analysis

Background: Chronic low back pain (cLBP) is the leading cause of disability worldwide and a major driver of healthcare costs. Excessive reliance on pharmacological treatments raises sustainability and safety concerns, highlighting the need for effective non-pharmacological alternatives. Pharmacopuncture (PPT), also known as herbal acupuncture or acupoint injection therapy, is widely practiced in some Asian countries (e.g., Korea and China) but remains uninsured in most health systems and largely excluded from international guidelines despite its clinical adoption. Evidence on its long-term cost-effectiveness compared with standard physiotherapy (PT) is limited. Objective: To evaluate the cost-utility of PPT versus PT for patients with cLBP using a Markov model designed in accordance with international pharmacoeconomic guidelines and standard government requirements for cost-effectiveness analysis. Methods: A three-state Markov model (mild, moderate, severe pain) projected outcomes over 3 years with 3-month cycles. Clinical inputs were derived from a multicenter pragmatic RCT. Costs were estimated from healthcare system, restricted societal, and full societal perspectives, incorporating medical, non-medical, and productivity loss costs estimated using national health databases. Quality-adjusted life years (QALYs) were calculated using EQ-5D-5L data. Incremental cost-effectiveness ratios (ICERs) were benchmarked against the Korean willingness-to-pay (WTP) threshold. Deterministic and probabilistic sensitivity analyses assessed robustness. Results: Over 3 years, PPT was less costly and more effective than PT. From the healthcare perspective, PPT reduced costs ($1,304 vs. $1,385) while yielding higher QALYs (2.30 vs. 2.23), resulting in dominance (ICER = -$1,145 per QALY). From the societal perspective, including productivity, PPT further strengthened its dominance ($25,760 vs. $31,962). Probabilistic sensitivity analysis showed a 97.7% (healthcare) and 99.4% (societal) probability of cost-effectiveness at the WTP threshold. Results were robust across sensitivity scenarios. Conclusion: This is the first model-based economic evaluation of pharmacopuncture for cLBP. Findings indicate that PPT can deliver higher QALYs at lower costs compared with PT, underscoring its potential as a high-value non-pharmacological alternative. This aligns with WHO priorities for evidence-based integration of traditional medicine, supports policy discussions on equitable coverage, and informs sustainable chronic pain management strategies across health systems.