http://www.floppybunny.org/robin/web/virtualclassroom/chap16/s1/articles/pragmatic%20trials_macpherson%202004.pdf

Pragmatic clinical trials

Objective To determine the effects of a policy of “use acupuncture” on headache, health status, days off sick, and use of resources in patients with chronic headache compared with a policy of “avoid acupuncture.”

Design Randomised, controlled trial.

Setting General practices in England and Wales.

Participants 401 patients with chronic headache, predominantly migraine.

Interventions Patients were randomly allocated to receive up to 12 acupuncture treatments over three months or to a control intervention offering usual care.

Main outcome measures Headache score, SF-36 health status, and use of medication were assessed at baseline, three, and 12 months. Use of resources was assessed every three months.

Results Headache score at 12 months, the primary end point, was lower in the acupuncture group (16.2, SD 13.7, n = 161, 34% reduction from baseline) than in controls (22.3, SD 17.0, n = 140, 16% reduction from baseline). The adjusted difference between means is 4.6 (95% confidence interval 2.2 to 7.0; P = 0.0002). This result is robust to sensitivity analysis incorporating imputation for missing data. Patients in the acupuncture group experienced the equivalent of 22 fewer days of headache per year (8 to 38). SF-36 data favoured acupuncture, although differences reached significance only for physical role functioning, energy, and change in health. Compared with controls, patients randomised to acupuncture used 15% less medication (P = 0.02), made 25% fewer visits to general practitioners (P = 0.10), and took 15% fewer days off sick (P = 0.2).

Conclusions Acupuncture leads to persisting, clinically relevant benefits for primary care patients with chronic headache, particularly migraine. Expansion of NHS acupuncture services should be considered.

https://www.bmj.com/content/bmj/328/7442/744.full.pdf

Acupuncture for chronic headache in primary care: large, pragmatic, randomised trial

Out-of-pocket expenditures of over $34 billion per year in the US are an apparent testament to a widely held belief that complementary and alternative medicine (CAM) therapies have benefits that outweigh their costs. However, regardless of public opinion, there is often little more than anecdotal evidence on the health and economic implications of CAM therapies. The objectives of this study are to present an overview of economic evaluation and to expand upon a previous review to examine the current scope and quality of CAM economic evaluations. The data sources used were Medline, AMED, Alt-HealthWatch, and the Complementary and Alternative Medicine Citation Index; January 1999 to October 2004. Papers that reported original data on specific CAM therapies from any form of standard economic analysis were included. Full economic evaluations were subjected to two types of quality review. The first was a 35-item checklist for reporting quality, and the second was a set of four criteria for study quality (randomization, prospective collection of economic data, comparison to usual care, and no blinding). A total of 56 economic evaluations (39 full evaluations) of CAM were found covering a range of therapies applied to a variety of conditions. The reporting quality of the full evaluations was poor for certain items, but was comparable to the quality found by systematic reviews of economic evaluations in conventional medicine. Regarding study quality, 14 (36%) studies were found to meet all four criteria. These exemplary studies indicate CAM therapies that may be considered cost-effective compared to usual care for various conditions: acupuncture for migraine, manual therapy for neck pain, spa therapy for Parkinson's, self-administered stress management for cancer patients undergoing chemotherapy, pre- and post-operative oral nutritional supplementation for lower gastrointestinal tract surgery, biofeedback for patients with "functional" disorders (eg, irritable bowel syndrome), and guided imagery, relaxation therapy, and potassium-rich diet for cardiac patients. Whereas the number and quality of economic evaluations of CAM have increased in recent years and more CAM therapies have been shown to be of good value, the majority of CAM therapies still remain to be evaluated.

/pdf/is-complementary-and-alternative-medicine-cam-cost-effective-3ybwc9wrb5.pdf

Is complementary and alternative medicine (CAM) cost-effective? a systematic review

Objectives: Although complementary and alternative medicine (CAM) use is becoming increasingly prevalent in the United States, knowledge regarding complementary and alternative therapy use in older adults is limited. The purposes of this study were to (1) assess the prevalence and patterns of CAM use in a probability-based sample of older adults; (2) describe the characteristics of older CAM users; and (3) identify factors associated with complementary and alternative medicine use/nonuse. Methods: A cross-sectional survey design was used. An age-stratified sample of community-dwelling adults ages ≥65 (N = 1200) was randomly selected from the Minnesota Driver's License/Identification Tape using names from the Twin Cities seven-county metropolitan area. The mailed questionnaire included items on demographics, health status, health care utilization, CAM modality use, reasons for use, costs, and complementary and alternative therapy use satisfaction. Descriptive statistics, chi-square tests, and regr...

Use of complementary and alternative therapies in community-dwelling older adults.

This systematic review aimed to estimate the prevalence of use of complementary and alternative medicine (CAM) in the UK. Five databases were searched for English language, peer-reviewed surveys published between 1 January 2000 and 7 October 2011. In addition, relevant book chapters and files from our own departmental records were searched by hand. Eighty-nine surveys were included, with a total of 97,222 participants. Most studies were of poor methodological quality. Across surveys on CAM in general, the average one-year prevalence of use of CAM was 41.1% and the average lifetime prevalence was 51.8%. In methodologically sound surveys, the equivalent rates were 26.3% and 44%, respectively. In surveys with response rates >70%, average one-year prevalence was nearly threefold lower than in surveys with response rates between 21% and 50%. Herbal medicine was the most popular CAM, followed by homeopathy, aromatherapy, massage and reflexology. Many patients and consumers in the UK use CAM; healthcare professionals should therefore responsibly advise their patients about the use of CAM.

/pdf/prevalence-of-use-of-complementary-and-alternative-medicine-18c5xxu6ou.pdf

Prevalence of use of complementary and alternative medicine (CAM) by patients/consumers in the UK: systematic review of surveys

Providing Complementary and Alternative Medicine in primary care: the primary care workers’ perspective

NHS patients’ perspective on complementary medicine: a survey

Homeopathic clinical case reports: Development of a supplement (HOM-CASE) to the CARE clinical case reporting guideline

BACKGROUND
A study was undertaken to investigate the preferences of patients with asthma for attributes or characteristics associated with treatment for their asthma and to investigate the extent to which such preferences may differ between patient subgroups.


METHODS
The economic technique of conjoint analysis (CA) was used to investigate patients' strength of preference for several key attributes associated with services for the treatment of asthma. A CA questionnaire was administered to two groups of asthma outpatients aged 18 years or older, 150 receiving conventional treatment at Whipps Cross Hospital (WC) and 150 receiving homeopathic treatment at the Royal London Homoeopathic Hospital (RL).


RESULTS
An overall response rate of 47% (n=142) was achieved. Statistically significant attributes in influencing preferences for both the WC and RL respondents were (1) the extent to which the doctor gave sufficient time to listen to what the patient has to say, (2) the extent to which the treatment seemed to relieve symptoms, and (3) the travel costs of attending for an asthma consultation. The extent to which the doctor treated the patient as a whole person was also a statistically significant attribute for the RL respondents.


CONCLUSIONS
This study has shown that aspects associated with the process of delivery of asthma services are important to patients in addition to treatment outcomes. The homeopathic respondents expressed stronger preferences for the doctor to treat them as a whole person than the patients receiving conventional treatment. Overall, the preferences for the attributes included in the study were similar for both groups.

R van Haselen

Papers

Providing Complementary and Alternative Medicine in primary care: the primary care workers’ perspective

NHS patients’ perspective on complementary medicine: a survey

Homeopathic clinical case reports: Development of a supplement (HOM-CASE) to the CARE clinical case reporting guideline

Assessing patients’ preferences for characteristics associated with homoeopathic and conventional treatment of asthma: a conjoint analysis study

Accruing large numbers of patients in primary care trials by retrospective recruitment methods.