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Expert Rev Pharmacoecon Outcomes Res. 2024 Jan;24(1):117-142.

Overview and quality assessment of health economic evaluations for homeopathic therapy: an updated systematic review

Thomas Ostermann 1, Julia Burkart 2, Sabine De Jaegere 2, Christa Raak 3, Steven Simoens 4

1 Department of Psychology and Psychotherapy, Witten/Herdecke University, Witten, Germany.
2 Medical Scientific Services/Medical Affairs, Deutsche Homöopathie-Union DHU-Arzneimittel GmbH & Co. KG, Karlsruhe, Germany.
3 Institute of Integrative Medicine, Witten/Herdecke University, Herdecke, Germany.
4 Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.

Abstract

Introduction: Likewise other medical interventions, economic evaluations of homeopathy contribute to the evidence base of therapeutic concepts and are needed for socioeconomic decision-making. A 2013 review was updated and extended to gain a current overview.

Methods: A systematic literature search of the terms 'cost' and 'homeopathy' from January 2012 to July 2022 was performed in electronic databases. Two independent reviewers checked records, extracted data, and assessed study quality using the Consensus on Health Economic Criteria (CHEC) list.

Results: Six studies were added to 15 from the previous review. Synthesizing both health outcomes and costs showed homeopathic treatment being at least equally effective for less or similar costs than control in 14 of 21 studies. Three found improved outcomes at higher costs, two of which showed cost-effectiveness for homeopathy by incremental analysis. One found similar results and three similar outcomes at higher costs for homeopathy. CHEC values ranged between two and 16, with studies before 2009 having lower values (Mean ± SD: 6.7 ± 3.4) than newer studies (9.4 ± 4.3).

Conclusion: Although results of the CHEC assessment show a positive chronological development, the favorable cost-effectiveness of homeopathic treatments seen in a small number of high-quality studies is undercut by too many examples of methodologically poor research.

Plain language summary

To help make decisions about homeopathy in healthcare, it is important, as with other medical treatments, to look at whether this treatment is effective in relation to its costs; in other words, to see if it is cost-effective. The aim of the current work was to update the picture of scientific studies available on this topic until 2012. To this purpose, two different researchers screened electronic literature databases for studies between January 2012 and July 2022 which assessed both the costs and the effects of a homeopathic treatment. They did this according to strict rules to make sure that no important study was missed. They reviewed the search results, gathered information from the studies, and assessed the quality of the studies using a set of criteria. They detected six additional new studies to the 15 already known from the previous work. Overall, they found that in 14 out of 21 studies, homeopathic treatment was at least equally effective for less or similar costs. For the remaining seven studies, costs were equal or higher for homeopathy. Of these seven, two were shown to be advantageous for homeopathy: indeed, specific economic analyses demonstrated that the benefit of the homeopathic treatment compensated for the higher costs. For the remaining five studies, the higher or equal costs of homeopathic treatment were not compensated by a better effect. The quality of the studies varied, with older studies generally being of lower quality compared to newer ones. The authors concluded that although the quality of research on homeopathy’s cost-effectiveness has improved over time, and some high-quality studies show that it can be a cost-effective option, there are still many poorly conducted studies which make it difficult to offer a definitive statement. In other words, while there is some evidence that homeopathy can be effective in relation to its costs, there are still many studies that are not very reliable, which means that interested parties need to be cautious about drawing conclusions.

Free full text:
https://www.tandfonline.com/doi/full/10.1080/14737167.2023.2266136

Excerpts:

"In many countries the use of homeopathy is rather common in the general population. A systematic review of the 12-month prevalence of homeopathy use based on survey data from 11 countries (U.S.A., UK, Australia, Israel, Canada, Switzerland, Norway, Germany, South Korea, Japan, Singapore) demonstrated that each year a small but significant proportion (median 3.9%, range 0.7–9.8%) of the general population consults homeopaths or purchases over-the-counter (OTC) homeopathic medicines [Citation1]. Among 1,323 parents who visited the pediatric departments of two hospitals in Germany in 2015 and 2016, 40% stated that they were already using therapies of complementary and integrative medicine (CIM) for their children. Homeopathy was the most frequently mentioned CIM therapy with almost 60% of parents confirming its use, followed by osteopathy and phytotherapy."

"An economic analysis of the data of the nation-wide EPI3 survey conducted in France in 2007 and 2008 [Citation4] showed that the social-security expenses for treatments by homeopathic general practitioners (GPs) were about 35% lower than for conventional GPs, while supplementary health insurance and out-of-pocket costs were slightly higher for treatments by homeopathic GPs due to higher consultation costs. The authors concluded that the management of patients by GPs certified in homeopathy may be less expensive from a global perspective and may be advantageous from the public health’s point of view...From the perspective of the Swiss health system the analysis showed 15.4% lower costs for physicians certified in homeopathy compared to physicians applying conventional medicine [Citation5]. In a small-scale study performed in a real-world setting in UK, more than 90% of 84 evaluable patients treated with homeopathic preparations had lower pharmacy costs than they would have had using conventional medicinal products for the same conditions [Citation6]."

"Overall, each euro spent by consumers on self-medication according to this analysis translates into net savings of 17 euros in resources otherwise needed for the statutory health insurance sector and the national economy [Citation7]. In line with these findings, it is assumed that homeopathic treatment via OTC medications contributes to patient care and relieves the burden on the health care system by conserving scarce resources of health-care professionals as well as money. It may thus be beneficial from a health economic perspective.

"Two analyses of data of German health insurance companies came to partly conflicting results. One of them found a reduction in morbidity as well as in the utilization of health insurance resources by patients who took homeopathy in almost all indications studied [Citation8]. Another data analysis compared the health care costs for patients subscribed to the German Integrated Care Contract ‘Homeopathy’ (ICCH) with the costs for those receiving standard care. Health claims data of 44,550 patients from a large statutory health insurance company were analyzed from both the societal perspective and from the statutory health insurance perspective, and both showed higher costs in the homeopathy group as compared to propensity score-matched controls over 18 months [Citation9], which also remained higher after 33 months [Citation10] despite a convergence tendency. While these studies [Citation9,Citation10] compared only costs but not treatment effects, information on cost-effectiveness was not provided.

"Homeopathic treatment has been shown to have additional patient-relevant benefits. A recent review [Citation11] suggests that the prophylactic and therapeutic use of CIM, including homeopathic medicines, may be an important contribution to reducing the widespread overuse of antibiotics in a variety of conditions. In the EPI3 survey patients with upper respiratory tract infections who consulted a certified homeopathic GP were significantly less likely to use antibiotic, antipyretic, and non-steroidal anti-inflammatory drugs than those treated by a conventional GP even though their clinical outcomes were similar [Citation12]. In the same survey, patients with anxiety or depression consulting a certified homeopathic GP were significantly less likely to use psychotropic drugs than those treated by a conventional GP, whereas there was a tendency toward better outcomes in the homeopathy group [Citation13]."

"Viksveen et al [Citation17] retrieved and assessed 15 economic evaluations of homeopathy in a comprehensive literature search about economic evaluations of homeopathy covering the period until April 2012. Eight found improvements in patients’ health with homeopathy together with cost savings. Five studies found that improvements in homeopathy patients were at least as good as in control group patients at similar costs. Two studies found improvements similar to conventional treatment at higher costs. Although the authors identified evidence of the costs and potential benefits of homeopathy, they concluded that the overall evidence for cost-effectiveness still seemed uncertain and was limited by the substantial heterogeneity of results and methodological issues."

"Figure 2 shows that among the 21 identified studies, 14 studies (66.7%) reported more favorable clinical outcomes in the homeopathy group than in the control group; seven (33.3%) observed similar treatment effects. Regarding economic outcomes, 11 studies (52.4%) found that the costs for sole or adjuvant homeopathic treatment were lower than for the comparator. Four studies (19.0%) reported similar costs for both treatments; six (28.6%) described increased costs with homeopathy."

"In the 21 reviewed studies, we found a great diversity of therapeutic indications, treatments, methodological approaches, and reported outcomes, which meant that an overall summary and evaluation was not obvious. It appears, however, that most of the studies indicated either an improvement of health outcomes under homeopathic treatment, a reduction of costs, or both and thus favored homeopathic treatment over control treatment. Lower proportions of investigations clearly favoring homeopathic treatment were found among studies meeting at least 60% of the applicable CHEC quality criteria, even though four out of the six studies with a CHEC score above 60% ascertained a positive effect of homeopathic treatment (adjuvant or alone) on clinical outcomes [Citation20,Citation22,Citation29,Citation35]. Of these one also showed lower costs for homeopathy [Citation29] and two showed homeopathic treatment to be cost-effective by incremental analysis [Citation20,Citation22]."

"Also, it cannot be ruled out that economic evaluations which report that homeopathy is not cost-effective are less likely to be published. This problem, also known as publication bias, affects all areas of medical research and is one of the elements which can distort evidence by overestimating the benefits of a treatment [Citation51]."

"In addition to the systematic review of Viksveen et al [Citation17], our systematic review identified six further studies that contribute to the overall evidence on cost-effectiveness of homeopathy. In 14 out of 21 studies, homeopathic treatment favored control treatment in a synthesis of costs and effectiveness. For two studies showing better health outcomes but at higher costs, additional incremental analysis indicated cost-effectiveness of homeopathic treatment."

"Although most recent studies yield promising data about the benefit of homeopathy for the public health system, the conclusion drawn by Viksveen et al ten years ago is still applicable today: based on the existing evidence, no firm conclusion about the cost-effectiveness of homeopathy can be drawn. Further high-quality cost-effectiveness studies are needed so that more robust statements may be made."

"Ten years after the work of Viksveen et al [Citation17], the favorable cost-effectiveness assessment of homeopathic treatments from a small number of existing high-quality studies continues to be undercut by too many examples of methodologically limited research. Thus, the lessons to be learned from the data and the recommendations for further research into the cost-effectiveness of homeopathic treatments remain essentially the same: the use of properly planned randomized controlled trials would greatly improve the internal validity of the data."

"Declaration of interest
J Burkart and S De Jaegere are employees of Deutsche Homöopathie-Union DHU-Arzneimittel GmbH & Co. KG Karlsruhe, Germany. The other authors received honoraria of Deutsche Homöopathie-Union DHU-Arzneimittel GmbH & Co. KG Karlsruhe, Germany."

"Funding
This manuscript was funded by Deutsche Homöopathie-Union DHU-Arzneimittel GmbH & Co. KG Karlsruhe, Germany."

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Comments:

As might be expected from the affiliations of the authors and the funding source, there is no discussion of the scientific implausibility of homeopathy.

While it is possible that use of homeopathic remedies for mild or self-limiting conditions might result in a cost savings compared to seeking medical care, it is impossible for it to be more effective than genuine medical treatments considering that there are no active ingredients.

Edzard Ernst has just published a column about a different article on the cost-effectiveness of homeopathy:
https://edzardernst.com/2024/05/is-homeopathy-cost-effective-a-new-economic-evaluation-of-homeopathy/