Do Clinicians Base CAM Recommendations to Patients on Evidence of Efficacy?

Désirée A. Lie, MD, MSEd

Disclosures

February 28, 2014

Do Healthcare Professionals Use CAM?

Since the 1990s, national survey data in the United States have reported a prevalence of CAM use that has risen from 1 in 3 patients to nearly one half of all patients.[1,2,3,4] A recent review of the 2007 National Health Interview Survey examined self-reported CAM use by healthcare workers (categorized as providers, such as physicians and nurses; technicians, such as sonographers and laboratory technicians; and support workers, such as nursing aides) using the National Center for Complementary and Alternative Medicine taxonomy (alternative medical systems, biologically based therapies, manipulative body therapies, mind/body therapies, and energy-healing therapies).[5]

The authors found a higher prevalence of use in the past year among all healthcare workers compared with the general population (41% vs 30%). As well, 76% of all healthcare workers reported using at least 1 modality in the prior year. Those working in the ambulatory setting were more likely than hospital workers to use CAM. Healthcare providers (such as physicians, nurses, and pharmacists) had a 2.2 times increased odds of seeking practitioner-based CAM modalities (such as acupuncture and manipulation) and 2.7 times increased odds of self-treated CAM modalities (such as botanicals or supplements) compared with support workers.

The most common reason given for CAM use by healthcare workers was "general wellness," and the most commonly treated condition was anxiety in this study. There was also a significant increase since 2002 in use of the following modalities by healthcare workers: acupuncture, deep breathing exercise, massage therapy, meditation, naturopathy, and yoga.

A previous literature review examined studies on CAM use by physicians, nurses, public health professionals, pharmacists, faculty, dietitians, and social workers.[6] On the basis of 21 published studies (4 conducted in Canada and 17 in the United States) examining different health professionals' attitudes toward CAM, the authors reported lower CAM use among physicians compared with the other healthcare professionals. Among physicians only, younger, less experienced, and female physicians were more likely to both report self-use and to recommend CAM to their patients.

An analysis of data from the Nurses' Health Study and Health Professionals Follow-Up Study collected between 1986 and 2006[7] found large increases in the use of many supplements among health professionals, particularly in women taking vitamin D (2.2% to 32.2%) and folic acid (0.8% to 10.7%). Use of fish oil increased significantly for both sexes (1.6% to 18.1% for women and 3.3% to 22.2% for men). On the other hand, use of the antioxidants vitamin A, beta-carotene, vitamin C, and vitamin E declined steadily.

Use of CAM by Nurses

A high prevalence of CAM use by healthcare professionals has been well documented specifically among nurses. For example, 63% of nurse practitioners in Connecticut reported personal use of CAM,[8] and 96% of critical care nurses reported CAM use in national surveys.[9,10] Among British nurses, 81% reported CAM use in one study.[11] In a survey of registered nurses in Hong Kong, 80% reported personal CAM use, with 41% reporting recommending some form of CAM to their patients.[12] These studies point to a high rate of self-reported use of CAM among all nurses and subspecialty nurses.

Among the modalities reported, mind/body interventions (such as massage, relaxation, meditation, and yoga) and supplements (such as cod liver oil and cranberry juice) were most likely to be used and to be recommended to patients. Nurses were likely in these cross-sectional surveys to believe that CAM was effective, but over 60% of respondents reported little or limited knowledge about the efficacy of modalities they practiced or used.[13]

Use of CAM by Pharmacists

A high prevalence of CAM use has also been reported among pharmacists. A survey conducted in Minnesota found that 53% of pharmacists used dietary supplements, herbals, or natural products, and one half reported recommending them to a family member or patient.[14] However, in this study, only 19% of pharmacists surveyed believed that the products they used were effective.

In another study conducted at an international congress, over 80% of pharmacists surveyed reported self-use of CAM but also reported that they had inadequate knowledge to recommend CAM to patients.[15] Similarly, a systematic review of US and Canadian pharmacists' recommendation of dietary supplements concluded that many pharmacists recommend dietary supplements yet felt unprepared to appraise evidence about their efficacy.[16]

Thus among pharmacists, the literature suggests a high rate of self-reported use of CAM, accompanied by low confidence in knowledge about the efficacy of the products used.

Use of CAM by Physicians

The reported rates of CAM use among physicians is lower than among nurses or pharmacists, but wide geographic variation in the United States has been observed. For example, 24% of physicians surveyed in Denver, Colorado,[17] reported personal CAM use, whereas 49% of physicians in Kentucky[18] and 83% of primary care physician faculty at a medical school[19] reported ever using a CAM modality.

A systematic review of CAM use among UK physicians reported the average prevalence of CAM use across all studies to be around 20.6%,[20] with acupuncture, homeopathy, and relaxation therapy reported most frequently. This review also concluded that CAM was recommended to patients by 46% of the physicians studied; only 10.3% reported receiving training in CAM.

Internationally, a high rate of use of CAM was reported among hospital physicians in Vietnam.[21] In a survey of Russian physicians practicing at 3 hospitals, 99% of respondents reported self-use of CAM, and all referred their patients for CAM therapies.[22] Among 300 general practitioners in New Zealand, 20% offered acupuncture or other CAM modalities as part of their practice.[22] So, physician CAM use appears to also vary widely by international geography.

Medscape's Physician Lifestyle Report 2014 found a higher rate of CAM use among female physicians (48% vs 30% among male physicians). The most common indications for CAM use were back and neck pain and arthritis, with the most common modalities being acupuncture, massage, and osteopathic or chiropractic manipulation.

This same survey asked specific questions about supplement use (Figure). About one third of male physicians and 37% of female physicians who responded take a multivitamin, which is similar to rates among the general US population.[23] About one fifth of all physicians reported taking omega-3 fatty acids. Despite a lack of evidence supporting the value of antioxidant supplements, 19% of male and 17% of female physicians who responded use them. A smaller number (11% of men and 8% of women) take coenzyme Q10, mostly to prevent statin-related myalgia, according to verbal responses to the question on specific CAM therapies used.

Figure. Reported supplement use by physicians in the Medscape Physician Lifestyle Report 2014.

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