Integrative Medicine Use Up, but Outcomes Still Uncertain

Daniel M. Keller, PhD

February 15, 2012

February 15, 2012 — In a survey of US medical centers using integrative medicine, 75% reported success using integrative practices to treat chronic pain, with more than half reporting positive results in the areas of gastrointestinal conditions, depression, anxiety, cancer, and chronic stress, according to a report released today by the Bravewell Collaborative.

The Bravewell Collaborative "support[s] the advancement of integrative medicine by creating and translating emerging knowledge into broad practice," according to its Web site. In the report, the collaborative defines integrative medicine as "an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person's health."

The survey, Integrative Medicine in America: How Integrative Medicine Is Being Practiced in Clinical Centers Across the United States, involved 29 integrative medicine centers (9 of them in the Bravewell Clinical Network) at many leading medical institutions, including the Cleveland Clinic in Ohio; Duke University in Durham, North Carolina; the Mayo Clinic in Rochester, Minnesota; Stanford University in California; and the M.D. Anderson Cancer Center in Houston, Texas. These institutions provided a range of services including adult, geriatric, adolescent, obstetric-gynecologic, pediatric, and end-of-life care. The most frequently prescribed interventions, often in combination, were food and nutrition, supplements, yoga, meditation, traditional Chinese medicine (TCM) and acupuncture, massage, and pharmaceuticals.

Report coauthor Constance Pechura, PhD, senior advisor at the Bravewell Collaborative, said, during a telephone briefing on the release of the report that 29 centers were chosen from about 60 candidate integrative medicine centers (about 50 of them in an integrative medicine academic consortium). Coauthor Donald Abrams, MD, professor of clinical medicine and a consultant at the Osher Center for Integrative Medicine at the University of California, San Francisco, said the 29 centers were chosen based on their leadership, having been in operation for more than 3 years, having a significant patient volume, and having "contributed to the field." He told Medscape Medical News during the telephone briefing that, "[i]n fact, we were looking at some of the best centers, but I do think it's probably generalizable to certainly other centers in the academic consortium."

Conditions Treated With Best Success

During the briefing, Dr. Abrams said, "We were not measuring outcomes. We were asking the center directors and the clinical directors to give us their impressions of where they were having success."

The survey results were not necessarily objective measurements and did not compare institutions practicing integrative medicine with those that took a more conventional approach to providing care. Some of the reported measurements were mainly physician observation notes, patient comments and satisfaction surveys, assessment forms, biomarkers, and electronic medical record captures.

Furthermore, the measures of success were not uniform across the institutions surveyed. The report notes that patient satisfaction was "measured in a variety of ways, the most common being surveys created by the centers themselves," and that "with the exception of data derived from clinical trials, most of the centers stated that, although they do capture patient outcomes data, they did not have the staff and financial resources to collect and analyze it." The report suggests that analysis of these data should be a priority for future funding and could provide valuable information on treatment efficacy. It also says that future research at integrative medicine centers should focus on measures of cost and cost-effectiveness of treatments for specific conditions.

Dr. Abrams noted that most of the data came from surveys sent to directors of the 29 centers, asking about conditions treated. The respondents were asked to rate the 5 conditions out of 20 listed for which they were having the most clinical success. He said the determination of clinical success was left up to each center. More than half the institutional respondents listed the same 5 conditions: chronic pain (75%), gastrointestinal disorders (59%), depression and anxiety (55%), cancer (52%), and stress (52%).

Dr. Abrams, an oncologist, noted that techniques such as mind–body interventions, nutritional support, acupuncture, exercise, and massage therapies helped patients with cancer cope with the disease, manage their survivorship, and often helped relieve treatment-related adverse effects.

All of these same interventions, plus nutritional supplements, botanicals, and meditation, were often used in some combination for many of the conditions treated. "There's a lot of similarity as to what each center uses as far as integrative interventions for each condition," he said.

Models of Care

Report coauthor Sheldon Lewis said during the briefing that the survey looked at 3 models of how integrative care is being delivered," and we found that these are not mutually exclusive." The most common model is consultative care, in which care is delivered in consultation with a patient's primary care or specialist provider; this method is used by 90% of the surveyed centers. The second model is comprehensive care (62%) for a specific condition, in which the integrative practitioner is the point person who coordinates the care for that condition. The third model is primary care (45%), which is the overall care of a person's health by a physician or nurse practitioner.

Cardiologist Mimi Guarneri, MD, from the Scripps Center for Integrative Medicine in San Diego, California, discussed a model of comprehensive cardiovascular care, describing her evolution from being an interventional cardiologist to taking an approach addressing "all the underlying issues for cardiovascular disease" to prevent it in the first place. She told Medscape Medical News that "none of this was taught to me in medical school. Things like nutrition...the role of depression and stress, physical activity, and so on are key to cardiovascular health, to brain health, to cancer prevention, and so on."

Taken as a whole, the report delineates how some major medical centers are practicing integrative medicine now, but it is short on solid measures of patient outcomes or cost-effectiveness. In this regard, Benjamin Kligler, MD, vice chair of the Department of Integrative Medicine at Beth Israel Medical Center, associate professor of Family and Social Medicine at Albert Einstein College of Medicine, and research director of the Continuum Center for Health and Healing, all in New York City, reiterated the goals of the survey, saying it was not an effectiveness outcomes study.

"This study was much more in the vein of health services information or utilization information than it is in effectiveness," he said to Medscape Medical News. However, he pointed out that Bravewell is also sponsoring a project called BraveNet, a practice-based research network that is carrying out effectiveness studies based on comparative effectiveness, and not randomized clinical trials.

Is Integrative Medicine "Little More Than Quackery?"

Steven L. Salzberg, PhD, professor of medicine and biostatistics in the McKusick-Nathans Institute of Genetic Medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland, commented to Medscape Medical News about the survey and report. "It looks like a report that is simply trying to boost integrative medicine, which the Bravewell Collaborative funds a lot of integrative medicine programs, so they're basically boosting the things that they fund...something they call integrative medicine," he said. "But that is really a marketing term, and I would emphasize that strongly. That is a cover for a number of practices that are highly questionable and have no science to back them up — that don't actually help patients."

He continued, "It's little more than quackery, a lot of it. They are one of the leading groups doing it, and have money to back them up. There's lots of integrative medicine being practiced; therefore, the implication, which is the false part, is that therefore it must be good, must be valuable, must be giving people some benefit. But, of course, they're funding it, so it's spreading because there's money coming from groups like theirs that gets people to set up integrative medicine centers, and then they go around and say, 'Oh, look, there's more integrative medicine centers now than there used to be, so there must be something to it.' It's a completely circular argument."

Dr. Salzberg also objects to integrative medicine touting itself as "personalized" to the individual patient's situation, with the implication that traditional practices are not. "Any good physician looks at the whole patient...that's what good medical care is all about." He also cites treatments based on the relatively new field of genomic analysis as very personalized, "but we're doing it scientifically."

He calls integrative "just a buzz word" that includes some practices that are legitimate, but also some he says are not. "By putting them all under the same umbrella...they're [supposedly] all legitimate. But that isn't true. It's a logical fallacy, but it's an argumentative strategy that they use here, and that's used many times," Dr. Salzberg said.

He faulted the report for not saying "a single thing about the effectiveness of the treatments. All that really matters: Is the treatment they're giving effective or not?" He also objected to the authors' considering all the interventions in aggregate. In his opinion, some treatments are valid, such as food/nutrition, yoga, meditation, and massage. However, "there's a lot of data, especially recent data, showing that almost all supplements are ineffective unless you have a deficiency," he said.

By grouping 34 different interventions together in the survey, he said, one cannot tell which ones are effective.

Pharmaceuticals are "just conventional medicine," he said. "And then they throw in something which is just complete quackery in the middle," referring to TCM and acupuncture. He noted that all recent studies of acupuncture showed it is no better than placebo, and that the positive studies have been too small or poorly designed, in his opinion.

In conventional medicine, practices that are proven not to work are discarded. "The difference with pseudoscience is that they ignore the evidence, and they continue to practice and make excuses for why the studies didn't come out the way they wanted to come out," he explained. "The well-done studies are uniformly negative when they look at most of these modalities."

He said that in his view as a scientist, "if you're going to go do a survey about any medical practice, you want to see whether it's effective. That should be the first question, not how many people are using it, but how many people are getting benefit." A lot of the growth in the practice of integrative medicine "is driven by the fact that if you make money available," medical centers will pick up on it, Dr. Salzberg said, and furthermore, "these centers themselves do a lot of marketing, and people respond to marketing."

In a self-selected population such as patients going to integrative medicine practitioners, patients probably respond to the time and attention they receive, and so report high levels of satisfaction. Also, many conditions wax and wane, and patients often seek care when symptoms are at their worst, such as chronic pain. They may attribute relief of symptoms to the intervention, when in fact, symptoms may often subside on their own, Dr. Salzberg said.

Elaborate Placebo?

David Gorski, MD, PhD, associate professor of surgery at Wayne State University School of Medicine and the Breast Multidisciplinary Team Leader at the Karmanos Cancer Institute in Detroit, Michigan, told Medscape Medical News that the Bravewell report is "very credulous" and "totally buys into what we like to call the bait-and-switch of [complementary and alternative medicine], which is where they rebrand various things that should be science-based medicine as being somehow alternative."

He said that "there is nothing alternative" about food and nutrition; that yoga is exercise, so it is a lifestyle intervention; that meditation is relaxation; and that massage feels good — none of which he objects to — but he agrees with Dr. Salzberg that modalities such as TCM and acupuncture get "mixed in there."

Dr. Gorski referred to a lot of complementary and alternative medicine as "elaborate placebo, and we all know that placebo effects are strengthened when there is belief and trust in the practitioner, and that's certainly what a lot of this seems to boil down to.... They don't have good health outcome measures...I noticed that a lot of what they tracked as outcomes was patient satisfaction."

He said integrative medicine should be held to the same standards, using the same methods, as conventional medicine. Asked whether there should be a formal discipline of integrative medicine, he responded emphatically, "Absolutely not. It's a false dichotomy.... We already should be integrating things that are shown to be effective in clinical trials without having to have a special category for it."

Dr. Salzberg has disclosed no relevant financial relationships. Dr. Gorski is the managing editor of the Science-Based Medicine blog. Dr. Guarneri is a lecturer for GlaxoSmithKline and Abbott. The organizer of the briefing call, GYMR public relations firm, said the report authors had no relationships with supplement companies or relation to the centers, although Dr. Abrams is a member of the Osher Center.

Integrative Medicine in America: How Integrative Medicine Is Being Practiced in Clinical Centers Across the United States. Published online February 15, 2012. Full text

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