ALTERNATIVE MEDICINE
• DR. LLOYD OPPEL
ALTERNATIVE MEDICINE
•WHAT IS IT? •WHO USES IT? •DOES IT WORK?
WHAT IS IT? • DEFINITIONS • HISTORY
DEFINITIONS
• UNPROVEN • GENERALLY UNAVAILABLE IN HOSPITALS • NOT USUALLY TAUGHT IN MEDICAL SCHOOLS
DEFINITIONS
WHY IS IT „ALTERNATIVE‟?
REASONS RANGE FROM….
• NO RIGOROUS PROOF, BUT NOT PREPOSTEROUS (e.g. some herbal remedies)….
TO...
• COMPLETELY UNSUPPORTABLE (e.g. homeopathy)
History
• PRE 1900: CAVEAT EMPTOR
• FLEXNER REPORT • MEDICINE SHOULD BE SCIENCEBASED
• GROWTH OF MODERN MEDICINE
HISTORY
SCIENCE +MEDICINE=?
• USE NEW DISCOVERIES TO IMPROVE TREATMENTS (openminded) • COOPERATION WITH SCIENCEBASED PROFESSIONS:
– PHARMACISTS – NURSES – PUBLIC HEALTH INITIATIVES
HISTORY
WHERE HAS THIS GOTTEN US??
• IMPROVED LIFE EXPECTANCY:
– LOWER INFANT MORTALITY – IMPROVED CARE OF DISEASES OF MIDDLE AGE – VACCINES
• BETTER TREATMENTS FOR (AS YET) INCURABLE DISEASES
HISTORY
“NEW AGE” =RECYCLED OLD AGE
• • • • • Spiritual Healing Herbal Medicine Magnets Chiropractic Religious and Cultural Beliefs (TCM, auverdic medicine)
HISTORY
• Mackay: Popular Delusions and the Madness of Crowds • Mesmer: “Don‟t listen to reason” • Ben Franklin did a critical appraisal
HISTORY
WHY THE RESURGENCE?
• • • • FEAR OF TECHNOLOGY MISTRUST OF ESTABLISHMENT NEED FOR HOPE DESIRE FOR COMFORTING PHILOSOPHY
HISTORY
NEW VARIATIONS
• GROWTH OF „JUNK SCIENCE‟ • PROMOTION IN POPULAR PRESS AND INTERNET • COLLEGE „COURSES‟ • RELAXED REGULATIONS
REGULATION
• Variable across states and provinces
• Validity is not a criterion for regulation
POLITICAL HOT POTATO
• PUBLIC PRESSURE
• GOVERNMENT WANTS TO CONTROL HEALTH COSTS
EFFORTS TO RATIONALIZE HEALTH SPENDING
• B.C. PHARMACARE BUDGET • PRACTICE GUIDELINES • THERAPEUTICS INITIATIVE
Summary
• Alternative Medicine is without a scientific basis. • Many elements are identical to old movements. • Regulation is not = effectiveness • Comes at the same time as funding pressures mount on health care.
WHO USES IT?
WHO USES IT?
• 73% DURING LIFETIME • 50% IN THE LAST YEAR
FRASER INSTITUTE, 1999
WHAT‟S BEING USED?
• • • • • CHIROPRACTIC - 36% RELAXATION 23% MASSAGE 23% PRAYER 21% HERBAL 17%
(WITHIN THE LAST YEAR)
FRASER INSTITUTE, 1999
USER PROFILE?
• • • • CHRONICALLY ILL WOMEN MORE THAN MEN ?PSYCHOLOGICAL DISTRESS? SOME POST SECONDARY EDUCATION
WHERE DO ILL PEOPLE GO?
6% 14% 35% NEITHER DOCTOR ONLY DOCTOR PLUS ALT. MED 45% ALT. MED. ONLY
FR ASER INSTI TUTE, 1 99 9
HOW MANY VISITS ARE THERE?
EISENBERG 1998
WHO SEES THE MOST PATIENTS?
OF ALL VISITS TO ALTERNATIVE PRACTITIONERS….
HALF
WERE FOR
CHIROPRACTIC OR MASSAGE
WHAT‟S GROWING THE FASTEST?
• • • • • • • HERBAL (380%) MASSAGE SELF-HELP VITAMINS FOLK REMEDIES ENERGY HEALING HOMEOPATHY
EISENBERG, 1998
WHAT DOES IT CO$T?
• CANADA: $1.8 PROVIDERS • CANADA: $2.0
BILLION -
BILLION - REMEDIES
USA:$27 BILLION
EQUALS OUT-OF-POCKET
EXPENSES FOR ALL
DOCTORS IN THE USA
INTERNATIONAL EXPENSE?
• AUSTRALIA1992/3
$621 million (AU) for remedies. $309 million for providers Compare with $360 million for patient drug contributions
MacLennan A, 1996
TO WHAT EXTENT IS IT COVERED BY PRIVATE CARRIERS?
• EISENBERG: MOST VISITS NOT COVERED • SAME AS IN 1990
WHAT MAKES AN INSURER COVER IT?
• Pelletier, 1997, AM J Health Promotion • Interviewed 18 insurers offering CAM • Surveyed seven hospitals offering 3 or more CAM programs • Wanted to know what the criteria were for inclusion
Factors Influencing Coverage
• MARKET DEMAND
Factors Influencing Whether to Increase Coverage
• Proven Effectiveness (#1)
• High Market Demand • Coverage Mandated by State Law • Potential Cost Savings
What was Being Covered?*
• Physical Therapy • Osteopathy
• Chiropractic
•Acupuncture
•Preventive Medicine
•Nutrition Counseling •Massage •Hypnotherapy
• Biofeedback • Psychotherapy
*To any extent under any policy by 9 or more of 18 insurers
Was CAM Coverage “Successful”?
“Although cost-benefit analyses are hotly debated
there are little empirical data brought to bear on whether CAM will indeed decrease costs, or whether coverage of CAM will be an added expense.”
Pelletier, 1997
SWISS EXPERIMENT
Sommer, 1999
• 7500 OF 677,000 SUBSCRIBERS WERE GIVEN FREE CAM COVERAGE • RESULT: NO EFFECT ON SUBJECTIVE STATE OF HEALTH
• NO DISCERNABLE EFFECT ON OVERALL SPENDING, BUT CAM USE WAS A POWERFUL PREDICTOR OF TRATMENT COSTS
“BECAUSE THE DEMAND FOR HEALTH CARE (AND PRESUMABLY ALTERNATIVE THERAPIES) IS SENSITIVE TO HOW MUCH PATIENTS MUST PAY OUT OF POCKET,
CURRENT USE IS LIKELY TO UNDERREPRESENT UTILIZATION PATTERNS IF INSURANCE COVERAGE FOR ALTERNATIVE THERAPIES INCREASES IN THE FUTURE.”
EISENBERG D, 1998
“However, until there is clear scientific proof of the efficacy of particular CAM therapies,
Each insurance company is left to decide for itself whether the effectiveness may exceed the costs of covering a particular therapy. Insurers want to know whether or not a particular therapy is cost effective.”
Pelletier, 1997
SUMMARY OF DEMOGRAPHICS
• Explosive growth in this decade • Use associated with chronic/incurable diseases and the “worried well” • More visits than to family doctors • Out of pocket costs top US $27 billion • Cost/benefit for insurers very
DOES IT WORK?
DOES IT WORK?
• CHALLENGES FOR HEALTH CARE MANAGERS
How to allocate resources to where they do the most good. Sort out reliable information.
WHO TO BELIEVE?
• PROPONENTS CITE PAPERS AS WELL AS TESTIMONIALS
• AN EXPERT IN ONE FIELD MAY KNOW LITTLE ABOUT ANOTHER • WHAT CONSTITUTES GOOD EVIDENCE?
THERE ARE SOME GROUND RULES
• STANDARD,WIDELY ACCEPTED PRINCIPLES OF EXPERIMENTAL DESIGN
• CRITERIA FOR RATING THE STRENGTH OF EVIDENCE
BORING
WHAT WE DO • BROAD-BASED COMMITTEE •BASIC SCIENTISTS •STATISTICIAN
•CLINICIANS
HOW WE DO IT
THE BROAD STROKES
1. CLIENT HAS A QUESTION
2. CLIENT FORWARDS INITIAL INFORMATION
3. PRELIMINARY REVIEW BY CHAIR 4. SEARCH OF SCIENTIFIC LITERATURE
HOW WE DO IT
THE BROAD STROKES
5. INPUT FROM PROPONENTS 6. SELECTION OF CLINICAL TRIALS (OR BEST EVIDENCE) 7. REVIEW BY ENTIRE COMMITTEE 8. MEETING 9. FINAL DOCUMENT TO CLIENT
SUMMARY
• ALTERNATIVE MEDICINE IS GENERALLY UNPROVEN • EXPLOSIVE GROWTH • MAY BE AN ADD-ON TO EXISTING HEALTH SYSTEM • OBJECTIVE EVALUATION IS URGENTLY NEEDED TO PLAN HEALTH SPENDING