Complementary/Alternative Medicine Use In Northeast Florida

Phyllis M. Tousey, RN, MSPH and Joseph A. DeNucci
Phyllis Tousey, RN is an Epidemiologist in the Organizational
Effectiveness Department at Baptist St. Vincent's.
Joseph DeNucci is the former director of Behavioral Services
Management Department for Baptist St. Vincent's.

Introduction

In 1990 and 1997, Eisenberg et al, at the Center for Alternative Medicine Research and Education, Beth Israel Deaconess Medical Center, and the Department of Health Care Policy, Harvard Medical School, conducted national surveys of "trends in alternative medicine use in the United States." These data, regarding annual spending, disclosure to physicians, application to medical conditions, and sociodemographic characteristics of users, have served as the catalyst of much discussion over the last several years, and the prevalence rates serve as the national standard for comparison.^1,2

Eisenberg established two ways of asking about prevalence of use of alternative medicine: 1) using at least one alternative therapy during the previous year, and 2) visiting an alternative medicine practitioner during the prior twelve months. Prevalence of using complementary/ alternative medicine (CAM ) increased from 34% in 1990 to 42% in 1997 in the U.S. Similarly, in 1997, 46% of the U.S. population had visited a CAM practitioner compared to 36% in 1990.²

As a result of the reported increase in prevalence of use nationwide, a decision was made at Baptist St Vincent's (BSV), a Jacksonville based health system, to initiate a strategic review of CAM, also called integrative medicine, and its implications for local health care. To illuminate the patterns and prevalence of CAM use within the community, and to determine the knowledge, beliefs and attitudes of the physicians relative to CAM, surveys of the community and the BSVHS physicians were conducted in 1998. This report contains the result of those surveys, and compares the local results with published national surveys.

Physician Survey — Methodology

The physician survey of 99 questions was mailed to all 1,129 credentialed active and provisional BSVHS 1998 medical staff. Responses were received from 334 MDs/DOs, for a response rate of 30%. Of the responding physicians, 50.9% were primary care, 46.4% specialists, and 3.6% psychiatrists. Applicability of the results may be somewhat limited to primary care physicians, since the distribution of the total medical staff is: 36.4% primary care, 60.0% medical and surgical specialists, and 3.6% psychiatrists.³ On the other hand, the conservative attitude demonstrated by the physician's prevalence of use rate helps to assure that the physician sample is not biased in their participation in the survey. The survey was conducted by the Behavioral Services Management and Corporate Communications departments of Baptist St Vincent's Health System between July 17, and August 7, 1998.

Physician Survey — Results

The 1998 local surveys documented that 45% of North Florida residents had seen a CAM professional, and 27% of BSVHS physicians had personal health experience with a CAM therapist. One can conclude that the sample of North Florida residents utilize CAM therapists at a rate similar to national averages [P<.84], and that as a subgroup of the population, local physicians demonstrate a lower than average personal use rate [P<.00].

In order to assess knowledge of CAM, a question was posed as to whether or not the respondent was "familiar" with a list of CAM therapies. An average of nearly one-half (48%) of the physicians indicated that they were "familiar" or "very familiar" (combined) with a range of CAM therapies, which included representatives from each of the six broad fields defined by the NIH Center for Complementary and Alternative Medicine Research.⁴ The 17 therapies and the (combined) "% familiar" statistic are displayed in Table 1, compared with the corresponding data from the community survey. Physicians in North Florida are most frequently familiar with: support groups (81%), biofeedback (79%), chiropractic (76%), and massage (74%).

While most physicians (62-81%) do not ask their patients if they self administer CAM or use a CAM provider, 82% acknowledge that their patients have mentioned to them using or considering CAM. Area physicians currently refer patients to CAM providers at a rate of 42%; 89% would refer for behavior-related chronic conditions; and 78% would refer hospitalized patients if the area had a "research based" CAM program. In fact, 86% want CAM care overseen or provided by medical doctors, and 82% believe that an "integrated clinic" would be a valuable option for patients. " If BSVHS brought in a highly qualified medical doctor well trained in CAM therapies," 76% of responding physicians would support granting this doctor medical staff privileges.

Community Survey — Methodology

The community survey was conducted as a random digit-dialed telephone survey of 703 households in the 4-county area comprised of Duval, St. Johns, Nassau, and Clay. The 130 question interview was administered to the person responsible for making the most healthcare decisions in the household. There were 3 call-backs before other numbers were substituted, and 85% of households contacted agreed to participate. The survey was administered by nationally recognized Professional Research Consultants, Inc. (PRC), and is certified by them to be representative of the population of 1,081,331 persons over age 21 with telephones, at a 95% level of confidence, with a 3.7% margin of error. The high education level (67.7% above high school) of the sample would somewhat limit its applicability to that segment of the area population with similar characteristics (Duval County has a 31.1% above high school education rate).⁵ The interviews were conducted between July 28 and August 5, 1998.

Community Survey — Results

As reported above, 45% of North Florida residents have visited a CAM therapist. As seen in Table 1, which lists 17 CAM therapies and compares knowledge of CAM methods between community members and physicians, community members are most frequently "familiar" with: chiropractic (63%), massage (47%), and botanical/herbal medicine (46%). As seen in Table 2, the CAM therapies which local residents use most frequently are chiropractic (22%), dietary/nutrition/vitamin (17.1/8.4/15.8%), and herbal (16.5%). Stating prevalence in other terms, 30.9% have visited a chiropractor, 16.4% have visited a massage therapist, 13.3% have visited a nutritionist/dietician, 6.5% have visited an acupuncturist, and 2.3% have visited a relaxation therapist (all other rates are less than 1%).

Of those who have used some form of CAM therapy, 43% have disclosed this to their physician or traditional health care provider . Area residents indicate that 83% would be likely to use CAM therapies if offered by a medical doctor, and 79% would use CAM therapies if they were offered under supervision of a traditional physician; 65% would use such therapies if offered by a licensed and certified alternative provider.

Regarding payment for CAM services, 36.5% reported that the alternative therapies or providers they have chosen are covered under their medical insurance. Additionally, 72% indicate that they would be more likely to choose an insurance policy if it covered alternative medicine, assuming all other things were equal including price, and paying an additional but reasonable premium (mean of $30.12) would be acceptable to 41%.

Comparison Of North Florida Surveys To National Surveys

In addition to the Eisenberg studies mentioned earlier, several other nationally recognized surveys which are available in the peer-reviewed internationally indexed literature have been compared to the North Florida surveys.

Comparing the local physician's responses to Kaiser (California) and Medalia Healthcare (Washington) physicians indicate a general trend toward lower rates of referral or recommendation to CAM providers locally. Lower rates of personal use and professional training are demonstrated locally. On the other hand, local physicians demonstated higher belief in the effectiveness of CAM services and the potential effectiveness from appropriate CAM integration.^6,7

Comparing the local community to the Kaiser regional HMO members indicated similar overall and therapy-specific use rates.⁶ National prevalence rates published by Eisenberg match those of North Florida residents.² The typical local CAM consumer is similar to the national data demographically in all but one aspect. Both are predominantly middle-aged (North Florida data: 16.9% age 21-34; 22.1% age 35-44; 24.4% age 45-54; 19.0% age 55-64; 17.6% age 65 & over). Both are predominantly female (68% female; 32% male). Both are predominantly well-educated (69% above high school education; 24% high school; 7% below high school).² North Florida consumers do not fit the national pattern of earning predominantly above $50,000 annually (56.0% under $50,000; 36.2% $50,000 or above; 7.6% missing data).² A nationally representative survey by Astin at Stanford University confirmed that higher educational attainment was predictive of CAM use, but age, race, gender and income were not.⁸

Conclusions And Recommendations

With such high interest in CAM demonstrated nationally and documented locally, it can be concluded that local health professionals will be taking an increasingly active role in the integration of CAM into health care. Baptist St Vincents Health System, with the inclination toward holistic health natural to a faith-based institution, has taken a leadership role in conducting the surveys reported here, and in sharing the results with area health professionals. What actions will be initiated in response to consumer interest are being strategically defined. One proposal focuses on the identification of a core network of quality CAM providers, including physicians already incorporating CAM into their practice. Another proposal begins with the establishment of formal (or adoption of existing) credentialing processes for CAM practitioners. The most far-reaching proposal establishes an integrated clinic.

All interested parties can agree on several points: increased communication between consumers and their physicians regarding the use of CAM is needed; increased physician familiarity and formal education in CAM is warranted; and increased viability and attention to CAM will produce much-needed research data indicating which CAM approaches are most appropriate with specific populations.

REFERENCES

1. Eisenberg DM, Kessler RC, Foster c, et al. Unconventional Medicine in the United States. N Engl J Med. 1993; 328:246-252.
2. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Von Rompay M, Kessaler RC. Trends in Alternative Medicine Use in the United States 1990-1997. JAMA. 1998; 280:1569-1575.
3. Personal communication: St. Vincent's Medical Center Medical Staff Office. September 13, 1999.
4. National Institutes of Health, National Center for Complementary and Alternative Medicine (1999). What is CAM? Classification of Alternative Medicine Practices. <<http://nccam.nih.gov/what-is-cam>>
5. U.S. Dept. Of Commerce, Economics and Statistics Administration, Bureau of the Census. 1990 Census of Population and Housing - Jacksonville, FL MSA. 1990 CPH-3-184, issued April 1993.
6. Gordon NP, Sobel DS, Tarazona EZ. Use of and Interest in Alternative Therapies Among Adult Primary Care Physicians and Adult Members in a Large Health Maintenance Organization. West J Med. 1998; 169:153-161.
7. Weeks J, Layton R. "Integration as Community Organizing: Toward a Model for Optimizing Relationships Between Networks of Conventional and Alternative Providers". Integrative Med. 1998; 1(1): 15-25.
8. Astin JA. "Why Patients Use Alternative Medicine - Results of a National Study". JAMA. 1998; 279 (19):1548-1553.

Jacksonville Medicine / January 2000