December 2000 · Vol. 49, No. 12
The Use of Complementary and Alternative Medicine by Primary Care Patients
A SURF*NET Study
Martin L. Kabongo, MD, PhD
the Surf*Net Study Group San Diego,
Submitted, revised, July 28, 2000.
From the Department of Family and Preventive Medicine, University of California, San Diego, and the San Diego Unified Practice Research in Family Medicine Network. This material was presented at the annual meeting of the North American Primary Care Research Group, San Diego, California, November 11, 1999. Reprint requests should be addressed to Lawrence A. Palinkas, PhD, Department of Family and Preventive Medicine, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0807. E-mail: email@example.com.
BACKGROUND: Despite the increased use and acceptance of complementary and alternative medicine (CAM) practices and practitioners by patients and health care providers, there is relatively little information available concerning the reasons for use or its effect on patient health status and well-being.
METHODS: We conducted a survey of 542 patients attending 16 family practice clinics that belong to a community-based research network in San Diego, California, to determine patients’ reasons for using CAM therapies in conjunction with a visit to a family physician and the impact of these therapies on their health and well-being.
RESULTS: Approximately 21% of the patients reported using one or more forms of CAM therapy in conjunction with the most important health problem underlying their visit to the physician. The most common forms of therapy were visiting chiropractors (34.5% of CAM users), herbal remedies and supplements (26.7%), and massage therapy (17.2%). Recommendations from friends or coworkers, a desire to avoid the side effects of conventional treatments, or failure of conventional treatments to cure a problem were the most frequently cited reasons for using these therapies. Use of practitioner-based therapies was significantly and independently associated with poor perceived health status, poor emotional functioning, and a musculoskeletal disorder, usually low back pain. Use of self-care–based therapies was associated with high education and poor perceived general health compared with a year ago. Use of traditional folk remedies was associated with Hispanic ethnicity.
CONCLUSIONS: Sociodemographic characteristics and clinical conditions that predict use of CAM therapies by primary care patients in conjunction with a current health problem vary with the type of therapy used.
primary health care. (J Fam Pract 2000; 49:1121-1130)
Within the past 5 years several studies have pointed to the widespread use of complementary and alternative medicine (CAM) in the United States. In a study conducted in 1991,1 1 in 3 respondents in a national sample of adults reported using at least one unconventional therapy in the past year. By 1997 that number had risen to more than 4 in 10.2 Similar studies conducted in Europe3 and Canada4 have reported utilization rates between 18% and 75%. Although several studies have found substantial use among patients attending specialty clinics,5-7 between 28% and 50% of family practice patients have been found to have used some form of CAM.8-10 In response to its widespread use, CAM has gained increasing acceptance among family physicians and other primary care physicians and in schools of medicine where more courses are being taught on the subject.11
Despite this increased use and acceptance by patients and health care providers, there is relatively little information available concerning the reasons for use of the various forms of therapies and treatments considered alternative or complementary. Recent surveys of the extent of use of these treatments provide little insight into why certain patients are more likely to use CAM therapies in general or specific therapies, such as chiropractic, message, herbal therapy, acupuncture, and homeopathy. Small studies of specific groups of patients suggest that use of these therapies is associated with the disease and with patient characteristics such as education and level of dissatisfaction with the primary care provider,9-10 but the extent to which these findings are generalizable to all primary care patients remains unclear.
A second limitation to our understanding of the use of CAM therapies by primary care patients is that the effectiveness of these therapies has not been subjected to rigorous examination. Their use by the general public appears to be based on anecdotal evidence, primarily personal experience or the experiences of others. Although there is a consensus within the medical establishment that most of these therapies are harmless,12 there is increasing evidence of the adverse consequences related to their use and misuse.13 However, much of this evidence is also anecdotal, based on case reports and not on large population-based studies.
Our objective was to address these 2 deficiencies in the understanding of the likelihood of use and the effectiveness of CAM therapies by conducting a large survey of a diverse population of patients attending family practice clinics in several different settings throughout the San Diego area, making use of a recently formed network of family physicians committed to community-based primary care research. Our goal for this survey was to examine the characteristics of primary care patients who use CAM therapies, determine whether these characteristics are significantly different for patients who have not used these therapies, and determine whether use of CAM therapies is associated with clinical condition, functional status, and quality of life.
Our subjects included 541 patients aged 18 years and older visiting 16 family practice clinics in the San Diego area during a 3-month period (June 1999-August 1999). Each of these practices was a member the recently formed San Diego Unified Research in Family Medicine Network (SURF*NET). In this practice-based research initiative, community physicians, faculty and educators of academic family medicine programs combine research and clinical practice to develop a vital body of knowledge in the discipline of family medicine. The 16 clinics participating in the study represented more than 40 family physicians who were SURF*NET members and a patient population of more than 30,000, covering a broad and representative cross-section of the San Diego community.
To participate in the study patients had to identify a specific health complaint as the reason for a clinic visit. Individuals who made a visit for a general physical examination or to transport a pediatric patient were excluded. Our study participants represented 89% of all patients who met eligibility criteria and were invited to participate. Participants and nonparticipants exhibited no significant differences with respect to age, sex, ethnicity, or insurance status.
Patients were asked to complete a questionnaire administered by a survey worker in the waiting room before the scheduled visit with a family physician. The survey instrument included questions about the social and demographic characteristics of the patient, including age, sex, marital status, ethnicity, place of birth, level of acculturation, education, and 1998 household income. Level of acculturation was assessed on the basis of a 5-item scale used in previous studies of patient populations.14 Patients were then grouped into acculturation categories: low, medium, and high. They were also grouped into categories based on their level of education (no college, some college, and college graduate), the method of payment for the clinic visit (cash, Medi-Cal/Medicare, and health maintenance organization or health insurance), and median 1998 household income (<$50,000 or Ž$50,000).
The Medical Outcomes Study Short Form (SF-36)15 was used to assess a patient’s current health status and quality of well-being. The patients were evaluated on the basis of physical and social functioning, physical and emotional role functioning, mental health, energy or fatigue, pain, general perceived health compared with others the same age, and general health compared with a year ago.
Finally, each patient was asked to describe the most important or significant health problems experienced during the past year and whether any of these problems had precipitated the current clinic visit. Health problems were then coded by investigators according to International Classification of Diseases—9th revision—Clinical Modification (ICD-9-CM) criteria.16 Symptoms and complaints that could not be attributed to a specific diagnosis were placed under the ICD-9-CM category of Symptoms and Ill-Defined Conditions. Using a list derived from previous studies,1,2 patients were then asked whether they had used one or more of 16 CAM therapies or therapists for their principal medical condition during the past 12 months. Information was also collected on the level of satisfaction with these CAM therapies, level of satisfaction with care provided by their family physician for the problem, reasons for using a CAM therapy or therapist, and whether the family physician had been notified by the patient that he or she was using such alternatives. Patients’ level of satisfaction with conventional and CAM treatments was rated on a scale from 1 (not at all satisfied) to 10 (completely satisfied). Reasons for using a CAM therapy were derived from a list compiled by Lazar and O’Connor.17
Univariate statistics (percentages and means) were used to describe the characteristics of CAM use. Bivariate analyses (chi-square tests for categorical variables and paired-sample t tests and analysis of variance for continuous measures) were used to determine whether there were any significant differences between patients reporting use of any form of CAM therapy in the past year and those reporting no use of such therapy with respect to the following predictors: (1) social and demographic characteristics; (2) functional status and quality of wellbeing; (3) dissatisfaction with conventional treatments; and (4) ICD-9-CM diagnostic category of chief health complaint. Similar analyses were performed by 3 classes of therapy: (1) practitioner-based therapies (acupuncture, biofeedback, chiropractic, homeopathy, massage therapy, naturopathy); (2) self-care based therapies (energy healing, meditation and prayer, dietary interventions, herbal remedies, multivitamin supplements); and (3) traditional folk remedies. When appropriate (ie, based on the number of users), analyses were also conducted for individual types of therapy (chiropractic, acupuncture, herbal remedies, dietary interventions, massage therapy). Logistic regression models with stepwise entry of all potential independent variables were used to assess the odds of using a CAM therapy associated with each patient characteristic.
Characteristics of CAM Users
Of the 541 adults participating in our study, 116 (21%) reported using 1 or more forms of CAM therapy or therapists within the past year for the primary health problem contributing to the present clinic visit. A visit to a chiropractor was the most frequent form of alternative therapy, followed by the use of herbal remedies or supplements, and message therapy Figure 1.
Approximately 60% of these patients had informed their physicians of the use of these CAM therapies. Of those who had not done so, 60% had indicated that there had been no previous opportunity to inform their physicians, since this had been the first visit for the health problem in question. When examined by class of CAM usage, approximately two thirds of those using practitioner-based and self-care– based therapies reported use to their physician, compared with 40% of those using traditional folk remedies.
The timing of initial use of CAM therapies in treating the current health problem is shown in Figure 2. In general, one third of all users of CAM therapies initiated treatment with one or more therapies before their initial visit to a primary care physician for the same clinical problem. Thirty-seven percent initiated use of CAM concurrent with (ie, within 2 weeks) of their initial visit to a primary care provider, and 1 in 5 (19%) initiated use of a CAM therapy after their initial primary care visit. One third (36%) of those using practitioner-based and self-care–based therapies and 46.2% of those using traditional folk remedies reported initiating therapy before a visit with a primary care provider. One third (36%) of the users of self-care–based therapies, 43% of users of practitioner-based therapies, and none of the users of traditional folk remedies reported using such a therapy concurrent with their initial clinic visit. One in 4 of the practitioner-based therapies (24.6%) and traditional folk remedies (23.1%) and 14% of users of self-care–based therapies reported initiating use after their initial visit to a primary care provider.
Approximately 1 in 4 patients reported using CAM to avoid side effects of regular treatment because a friend or coworker had recommended the treatment or because conventional treatment had failed to cure the problem Table 1. Between 10% and 15% of the patients reported using these therapies for philosophical reasons, because they preferred to deal with the problem by themselves, or because older family members had used these treatments for the same problem. Only 7 patients reported using therapies because they were unhappy with the attitude of family physicians. When examined by class of therapy, approximately 1 in 3 users of practitioner-based therapies reported using them to avoid the side effects of regular treatment, failure of regular treatment to cure their problem, and a recommendation from a friend or coworker. In addition to a preference for dealing with the problem by themselves, these 3 reasons (side effects, failure of regular treatment, and a recommendation from a friend) were also the primary reasons for use of self-care– based therapies. In contrast, use by parents and relatives for the same problem represented the primary reason for traditional folk remedies, accounting for slightly less than one third (30.8%) of the patients using them.
Predictors of CAM Use
A comparison of the social and demographic characteristics of users and nonusers of CAM is provided in Table 2. Use of CAM therapies was positively associated with level of education but inversely associated with level of acculturation. When examined by specific categories of CAM, women were significantly more likely than men to use herbal remedies (P <.05; data not shown) and other self-care– based forms of alternative medicine and traditional folk medicines. Level of education was positively associated with self-care–based forms of CAM in general and use of herbal (P <.001; data not shown) and dietary (P <.05; data not shown) remedies in particular. However, education was inversely associated with use of traditional folk remedies. Self-care-based therapies in general and herbal remedies in particular (P <.05; data not shown) were significantly associated with the level of household income. Use of traditional folk remedies was significantly associated with Hispanic ethnicity, place of birth, and low acculturation. Dietary remedies were positively associated with level of acculturation (P <.05; data not shown). Patients belonging to an health maintenance organization or possessing other forms of non-government-sponsored insurance were significantly more likely to use massage therapy (P <.05; data not shown) or herbal remedies (P <.05; data not shown).
The health status and quality of well-being of users and nonusers of CAM therapies and therapists is provided in Table 3. Users of CAM therapies reported significantly lower emotional role functioning and perceived general health compared with nonusers of the same age. Users of practitioner-based therapies reported significantly lower social functioning, physical and emotional role functioning, mental health, and perceived general health, and more pain than nonusers. Users of self-care–based therapies and traditional folk remedies reported significantly lower levels of general health than a year ago. Users of acupuncture (P=.03; data not shown) and chiropractors (P=.001; data not shown) reported significantly lower levels of general perceived health than nonusers (data not shown). Users of chiropractors also reported significantly higher levels of pain (P=.015; data not shown) than nonusers.
Musculoskeletal problems, usually back pain, were cited as the most common health problem associated with CAM use, followed by endocrine and metabolic diseases (primarily diabetes or obesity), diseases of the respiratory system (primarily asthma), and diseases of the genitourinary system Table 4. CAM users were approximately twice as likely as nonusers to have a musculoskeletal system disorder and 2.5 times as likely to have a genitourinary system disorder. Users of practitioner-based therapies were 2.7 times as likely to have a musculoskeletal system disorder as nonusers. Users of chiropractors were 3.7 times (P <.001; data not shown) and users of massage therapy were 2.2 times (P <.05; data not shown) as likely to have a musculoskeletal disorder as nonusers.
Users of CAM therapies in general (P <.01) and practitioner-based therapies (P <.01) and chiropractors (P <.001; data not shown) in particular reported significantly less satisfaction than nonusers with the conventional treatment they received from their family physician Figure 3. However, CAM users also reported no significant difference in the level of satisfaction with these therapies and the level of satisfaction with the care received from their family physician. Users of folk remedies reported significantly higher levels of satisfaction with conventional treatment than nonusers (P <.05), and higher levels of satisfaction with their CAM therapy than other CAM users (P <.05).
We examined the independent association between each of the sociodemographic and health status characteristics of patients and CAM use with a series of logistic regression models. Age, sex, marital status, place of birth, education, household income, method of payment, level of acculturation, satisfaction with primary care received, SF-36 measures of functional status, and presence or absence of a musculoskeletal disorder were entered into the model in a stepwise fashion. The best fitting models are presented in Table 5. Physical role functioning was the only significant independent predictor of use of one or more CAM therapies. The model correctly classified 70% of the patients. Musculoskeletal disorders, emotional functioning, and perceived general health were significant independent predictors of use of a practitioner-based therapy. The model correctly classified 86.4% of the patients. Patients with musculoskeletal disorders were 7.37 times (95% confidence interval [CI], 2.37-23.51) as likely to use some form of practitioner-based therapy (usually a chiropractor or massage therapist) as patients with other physical conditions. Level of education and general perceived health compared with a year ago were significant independent predictors of use of self-care–based therapies. The model correctly classified 86.4% of the patients. College graduates were 1.44 times (95% CI, 1.04-2.01) as likely to use some form of self-care–based therapy as patients with 12 or fewer years of education. Hispanic ethnicity was the only significant independent predictor of use of traditional folk remedies. The model correctly classified 97.8% of the patients. Hispanics were 10.27 times (95% CI, 3.10-33.95) as likely to use traditional folk remedies as members of other ethnic groups.
Logistic regression analyses predicting use of specific CAM therapies revealed that general perceived health was a significant independent predictor of use of acupuncture (b=-0.0665; standard error [SE]=0.0253; P=.0086) and chiropractors (b=-0.0314; SE=0.0139; P=.0243). A musculoskeletal disorder was a significant independent predictor of use of chiropractors (b=2.0123; SE=0.6720; P=.0005) and massage therapists (b=1.8467; SE=0.7792; P=.0178). Patients with musculoskeletal disorders were 10.23 times (95% CI, 2.00-27.92) as likely to use a chiropractor and 6.34 times (95% CI, 1.38-29.19) as likely to use a massage therapist as patients with some other clinical condition. Emotional functioning was also a significant independent predictor of use of massage therapy (b=-0.0902; SE=0.0347; P=.0094), and household income was a significant independent predictor of use of acupuncture (b=2.5045; SE=1.2428; P=.0439).
In our study approximately 1 in 5 patients reported having used some form of complementary or alternative therapy or therapist in the past year in conjunction with a current health problem. This percentage is smaller than the 42% reported by Eisenberg and colleagues.2 However, that study was a population-based survey and was not tied to use of primary care services. Although previous studies of primary care patients have reported higher percentages of patients using CAM therapies, differences in methods preclude a comparison with those percentages. Drivdahl and Miser,9 for example, reported that 28% of 177 family practice patients in a military clinic had ever used some form of alternative medicine. Elder and colleagues10 reported that 50% of 113 family practice clinic patients had used some form of CAM, but this includes use for reasons other than those precipitating the visit to the physician. To our knowledge this is the largest study conducted of a broad spectrum of family practice patients, focusing on use related to a specific health problem that precipitated a visit to a family physician.
Consistent with the findings of previous studies,1,2,9 use of CAM therapies in general and self-care–based therapies in particular by this group of primary care patients, was significantly associated with a high level of education. This may be attributed to the fact that better educated patients tend to be more informed or at least more likely to be exposed to information about the benefits of CAM.17,18 Consistent with previous research,1,2,17,18 use of self-care–based therapies was also associated with high household income in our study. Many of these therapies are not always covered by health insurance plans, which means they require cash payments that those with higher incomes are more likely to be able to afford.
In our study use of traditional folk remedies was inversely associated with levels of education and acculturation and positively associated with Hispanic ethnicity and being foreign-born. Low-acculturated, predominately Hispanic immigrants are more likely to be uninsured or underinsured,19 not able to afford cannot afford conventional treatment,20 and be more familiar with the efficacy of those traditional folk remedies.21
We also found that users of CAM therapies generally perceive their health to be worse compared with others their age and with their health a year ago than nonusers. Emotional functioning was also a significant independent predictor of use of practitioner-based therapies. Given the cross-sectional nature of the study design, it is difficult to determine whether health status is a cause or consequence of CAM use. However, a further examination of the experience of these patients with conventional treatment and their specific clinical condition provides some insight into this relationship.
Failure of regular treatment to cure the problem and a desire to avoid side effects were each cited by 1 in 4 users of CAM therapies in our study. Users were also significantly less satisfied than nonusers with the care they had received from their primary care provider. They were significantly more likely to report visiting a primary care provider for a musculoskeletal or genitourinary disorder than nonusers. Both of these disorders are noteworthy for the limited treatment effectiveness or inconsistency in treatment approach of conventional therapies.22,23 Taken together, these observations suggest that many users of CAM do so because they are dissatisfied with the care received from their primary care provider.
However, complementary and alternative medicine users were found to be no more satisfied with these alternatives than with the care received from their family physician. Furthermore, unhappiness with the attitude of their family physician and failure to correctly diagnose the problem was cited by a relatively small number of patients as a reason for using CAM therapies. Only 20% of users reported doing so after seeing a physician; the others did so either before or concurrent with a visit. This suggests that experience with the family physician played a relatively minor role in the decision of most patients to use CAM therapies.
The results of our study can be used to acquaint family physicians with the characteristics of users of complementary and alternative therapies and therapists in conjunction with specific health problems. Such information may have implications for diagnosis and treatment regimens, especially if contraindications to certain forms of treatment arise as a result of potential adverse reactions when used in combination with specific forms of CAM (eg, lead poisoning resulting from the use of certain traditional Mexican remedies used as laxatives24). In contrast to the results of previous studies,25 relatively few patients were reluctant to notify their primary care provider of their use of CAM therapies. However, patients were more likely to share this information if the physician made an effort to ask. An understanding of the characteristics associated with CAM use should enable the physician to obtain this information.
The results of our study suggest that patterns and predictors of CAM use by primary care patients vary with the type of therapy used. It is important to realize that all CAM therapies are not alike. Self-care–based therapies are more likely to be used by patients who are well educated, while traditional folk remedies are more likely to be used by Hispanic immigrants with low levels of education. Practitioner-based therapies are more likely to be used by patients with musculoskeletal disorders. Family physicians should keep these distinctions in mind when evaluating the likelihood of CAM use by a particular patient and potential implications for primary care delivery.
Our study was funded by a grant from the California Academy of Family Physicians.
National Center for Complementary and Alternative Medicine
A branch of the National Institutes of Health that conducts and supports basic and applied research and training and disseminates information on complementary and alternative medicine to physicians and the public. www.nccam.nih.gov
Whole Health MD
Information on combining alternative medicine, supplements, vitamins, herbs, and nutrition with conventional medicine. www.wholehealth.com
Resources for books, reports, and practitioner searches serving various categories in alternative medicine therapies. www.alternativedr.com
Alternative and Complementary Medicine Center-provides in-depth information about a range of therapies, as well as discussion forums, conference listings, and other resources. www.healthy.net/clinic/therapy/altmedcolumn
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