Review for 10.1186/1471-230X-12-149 (2012)

Reviewer's report
Title:Cost-effectiveness of acupuncture for irritable bowel syndrome: findings
from an economic evaluation conducted alongside a pragmatic randomised
controlled trial in primary care.
Version: 2Date:19 July 2012
Reviewer: Thomas Reinhold
Reviewer's report:
The study investigates the economic usefulness of additional acupuncture in
patients suffering from irritable bowel syndrome from UK NHS perspective.
Overall, the paper seems to be from interest for readers and the main
analysis-steps are comprehensible. Nevertheless, some points of discussion are
remaining in my opinion.
Major Compulsory Revisions
1) Methods: Why the study did not include costs of medications used for treating
or handling IBS? Beside contacts to the healthcare system, drug costs usually
have a large impact in total costs in healthcare – especially in chronic disorders.
In my meaning this could be a large potential limitation in this study and should
be discussed.
2) Results: On page 8 you stated “The complete case analysis, based on all
costs (IBS and non IBS related) demonstrated that acupuncture results in a
QALY gain at 12 months of 0.0035 (BCA 95% CI: -0.0395 to 0.0465) for
unadjusted and 0.0033 (BCA 95% CI: -0.0398 to 0.0462) adjusted for baseline
costs (see Table 5).” – However I was able to find only the QALY difference of
0.0033 in this table. The unadjusted result should be 0.7534 – 0.7365 = 0.0169
QALYs gained and not 0.0035. I was not able to follow your calculation.
In addition you wrote in the same text on page 8 that the QALYs are adjusted for
costs. In table 5 you mentioned marked by using“#”, “The difference in QALYs is
always adjusted for baseline EQ-5D scores”. So it remains unclear on what kind
of values the adjustment was based on.
3) Discussion: When looking on the QALY-differences of the total group, that are
not significant, the usefulness of conducting a cost-utility analysis could be
discussed. Isn’t it a target for a cost-minimization-analysis?
4) Discussion: The discussion has in its present form is very short and should at
least expand to more potential limitations of this trial (e.g. missing drug costs).
But maybe the discussion made in the effectiveness paper will add some
information.
Minor Essential Revisions
5) Methods: How the IBS-related costs were extracted from the overall costs?
Was it based on ICD-codes, resource utilization pattern, expert opinions…?
6) Results, Table 3: Why the mean costs differences in the complete data
analysis are not adjusted for baseline costs? In the methods section of the
manuscript you wrote “Cost data are presented unadjusted and adjusted for
baseline costs…”? (Throughout the manuscript, I could not find any adjusted
costs, only adjusted cost-differences)
7) Results: Table 4 indicates that the Baseline-utilities are adjusted on baseline
EQ-5 D scores. I would assume that this only counts for utility-values at month 3
to 12, not for baseline, or not? Please precise the information in this table.
8) Results: On page 8 you wrote “At month 12, utility scores for the acupuncture
patients were marginally better than those for the usual care group.” I think this
was a typing error, because the values for the controls were better compared to
patient receiving acupuncture at this time point (see table 4).
9) Results: The heading “cost-effectiveness-analysis” is fat marked, indicating
that this should be a separate bullet and not a part of the results section.
10) Results, Table 5: The “#” has no reference to a “#” in the table.
Discretionary Revisions
11) Methods: Some information on the kind of acupuncture used, patient’s
recruitment, inclusion and exclusion criteria and the randomization process
should be explained more detailed in the paper. However I would assume that
these information’s are stated in the additional submitted effectiveness paper of
this study. If not, it should be mentioned in the present manuscript.
12) Methods: Please provide information when (year) the study project was
conducted.
13) Results: The information on the number of patients in table 5 seems not to be
precise. It would be useful to get information on the number of participants in the
subgroups. Maybe you could present the results like you did it in table 4.
14) Results: I assume that the effectiveness paper will provide detailed
information on baseline characteristics of the randomized patients, but it would
be useful to include a verbal statement whether the baseline characteristics are
well balanced or not (e.g. socioeconomic parameters, age…). And if not, I would
recommend adjusting costs as well as effects on these differences.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests