Jennifer Hunter

Appealing to Altruism is Not Enough: Motivators for Participating in Health Services Research

This pilot study sought to identify motivators and barriers to participating in a longitudinal survey; we interviewed patients and practitioners at a multidisciplinary primary care clinic where the proposed project would be based. While altruism motivates participation in medical research, we found that for many potential participants, the opportunity to benefit directly was the primary, and sometimes the only motive to participate or encourage participation in the research project. Patients often wanted direct feedback from their individual results, and they expected to provide consent before the results were forwarded to other parties such as their practitioners. Similarly, some practitioners were more likely to support the project if participation benefited patients directly. Other factors were also identified that influenced the acceptability and perceived risks and benefits of participating. More work is needed to understand these motivators and how patients might benefit directly from participating in health services research, especially when direct medical benefit is not possible.

Is it time to abandon paper? The use of emails and the Internet for health services research – a cost‐effectiveness and qualitative study

RATIONALE A multidisciplinary primary care clinic in Sydney, Australia, was planning to use electronic questionnaires to measure patient-reported outcomes. METHODS Semi-structured interviews with 20 patients were undertaken to explore, among other things, practical issues regarding different questionnaire formats. The response rates and costs of email versus postal invitations were also evaluated. RESULTS Compared with postal invitations, email invitations offered a cost-effective and practical alternative, with a greater proportion of patients volunteering for an interview. Assuming the interface is well-designed and user-friendly, many patients were happy to use the Internet to answer questionnaires. Most patients thought alternate formats should also be offered. Patients discussed advantages and disadvantages of the Internet format. Although more younger patients and females had given the clinic an email address; both sexes, and young and old patients, expressed strong preferences for either wanting or not wanting to use the Internet. CONCLUSION Researchers should consider using email invitations as a cost-effective first-line strategy to recruit patients to participate in health services research. Internet questionnaires are potentially cheaper than paper questionnaires, and the format is acceptable to many patients. However, for the time being, concurrent alternate formats need to be offered to ensure wider acceptability and to maximize response rates.

Integrative medicine outcomes: What should we measure?

The outcomes of Integrative medicine (IM) that combine biomedicine with traditional, complementary and alternative medicine (TCAM) are broad, reflecting the integration. IM is concerned with acute and chronic diseases, holistic approaches, and health promotion and wellness. Before commencing a research program in a primary care IM clinic, stakeholders were interviewed about IM outcomes. Everyone thought Physical Health and Mental Health were important. Those with a more holistic view of health thought a broader range of topics should be measured. Less important topics were lifestyle; health-related aspects of life satisfaction and quality of life; and healthcare evaluation. However, no one thought these should be excluded. Spirituality was the most contentious. Some commended its inclusion. For others, once religiousness and God were removed, the remaining elements should be relocated to the domains of mental health and life satisfaction. The results highlight the importance of consulting stakeholders before measuring outcomes.

The Challenges of Establishing an Integrative Medicine Primary Care Clinic in Sydney, Australia

BACKGROUND In May 2006, a multidisciplinary community-based integrative medicine (IM) clinic was established in Sydney, Australia. It was designed to offer a wide range of IM services, for primary care and to serve as a referral center. OBJECTIVE The aim of this study was to determine which factors were successful and which ones posed challenges for establishing this kind of clinic. METHOD A study of the first 4 years of this primary care integrative medicine clinic was undertaken, using mixed methods--both qualitative and quantitative. RESULTS Consistent with success factors identified in the literature, the clinic had an open-minded culture, credible supporters, suitable facilities, and clinically competent practitioners. Throughout the 4 years of its existence, the clinic strove to create an economically sustainable environment and to develop the service. As time progressed, it became evident that at least half of the practitioners needed to be biomedical doctors for the practice to remain viable. The challenges encountered were creating an economically sustainable clinic, managing high staff and practitioner turnover, finding the right balance between practitioners and services offered, developing an integrative medicine team, and building research capacity to evaluate the clinic and patient outcomes. CONCLUSIONS Although many integrative medicine clinics fail to survive the first few years, after 4 years, this multidisciplinary primary care clinic had succeeded in establishing a viable health care service offering both integrative medicine and conventional, traditional, complementary, and alternative medicine. Finding the right mix of staff members and following up with evaluations to track progress are important.

The Integrative Medicine Team—Is Biomedical Dominance Inevitable?

INTRODUCTION As traditional, complementary, and alternative medicines (TCAM) continue to find their way into mainstream medical practice, questions arise about the future of integrative medicine (IM). Concern has been voiced that the biomedical profession will dominate IM and many of the core principles and philosophies governing the practice of TCAM will be lost. METHODS Using mixed methods, an IM primary care clinic in Sydney, Australia, was compared to the IM models discussed in the literature. RESULTS Commercial concerns greatly influenced the teams development and the services provided by the practice under study. Questions arose as to whether the clinic was simply incorporating TCAM or truly integrating it. Further analysis of the data revealed evidence of biomedical dominance. CONCLUSIONS Given the current health care system in Australia, it seems likely that the biomedical doctor will continue to occupy a central logistical and leadership role in this clinics IM team.

Guidance for establishing an integrative oncology service in the Australian healthcare setting : a discussion paper

There is an obvious mismatch between the high reported rates of use of traditional and complementary medicines (T&CM) by Australian cancer patients and cancer survivors and the low numbers of Australian cancer services integrating T&CM. An estimated 65% of Australian cancer patients use at least one form of T&CM. Over half use T&CM in conjunction with conventional cancer therapy. Yet, less than 20% of Australian hospital cancer care facilities provide access to T&CM. This compares to around 70% of UK cancer care facilities offering at least one T&CM therapy. Barriers to developing integrative oncology services include determining an appropriate service model and revenue structure; concerns with ethical and legal issues such as regulations and credentialing; and inadequate high-quality scientific evidence demonstrating safety and effectiveness, including concerns about the possibility of adversely affecting chemotherapy or radiotherapy treatment. This paper aims to provide general guidance and practical strategies for those seeking to develop integrative oncology services in Australian cancer care facilities.

Complementary medicine products: interpreting the evidence base

Many patients use complementary medicine (CM) products, such as vitamins, minerals and herbs as part of self‐care without professional advice or disclosure to their doctors. While use of CM products is gaining awareness by the medical community and there is mounting evidence for their safety, efficacy and cost‐effectiveness, there is also the potential for adverse events from inappropriate use and/or withdrawal, as well as interactions with other medicines. Due to the unique and complex properties of many CM products, research evidence is specific to individual preparations and this can lead to confusion when assessing label claims and interpreting the results of clinical trials and systematic reviews. While the Australian regulatory environment for CM products is the same as for prescription medicines and is based on risk, there is a great need for consumers and clinicians to have access to easily understood, evidence‐based information to facilitate informed decision‐making.

An interpretive review of consensus statements on clinical guideline development and their application in the field of traditional and complementary medicine

BackgroundDespite ongoing consumer demand and an emerging scientific evidence-base for traditional and complementary medicine (T&CM), there remains a paucity of reliable information in standard clinical guidelines about their use. Often T&CM interventions are not mentioned, or the recommendations arising from these guidelines are unhelpful to end-users (i.e. patients, practitioners and policy makers). Insufficient evidence of efficacy may be a contributing factor; however, often informative recommendations could still be made by drawing on relevant information from other avenues. In light of this, the aim of this research was to review national and internationally endorsed consensus statements for clinical guideline developers, and to interpret how to apply these methods when making recommendations regarding the use of T&CM.MethodThe critical interpretive review method was used to identify and appraise relevant consensus statements published between 1995 and 2015. The statements were identified using a purposive sampling technique until data saturation was reached. The most recent edition of a statement was included in the analysis. The content, scope and themes of the statements were compared and interpreted within the context of the T&CM setting; including history, regulation, use, emerging scientific evidence-base and existing guidelines.ResultsEight consensus statements were included in the interpretive review. Searching stopped at this stage as no new major themes were identified. The five themes relevant to the challenges of developing T&CM guidelines were: (1) framing the question; (2) the limitations of using an evidence hierarchy; (3) strategies for dealing with insufficient, high quality evidence; (4) the importance of qualifying a recommendation; and (5) the need for structured consensus development.ConclusionEvidence regarding safety, efficacy and cost effectiveness are not the only information required to make recommendations for clinical guidelines. Modifying factors such as burden of disease, magnitude of effect, current use, demand, equity and ease of integration should also be considered. Uptake of the recommendations arising from this review are expected to result in the development of higher quality clinical guidelines that offer greater assistance to those seeking answers about the appropriate use of T&CM.

Evidence based practice in traditional & complementary medicine: An agenda for policy, practice, education and research

OBJECTIVE To develop a policy, practice, education and research agenda for evidence-based practice (EBP) in traditional and complementary medicine (T&CM). METHODS The study was a secondary analysis of qualitative data, using the method of roundtable discussion. The sample comprised seventeen experts in EBP and T&CM. The discussion was audio-recorded, and the transcript analysed using thematic analysis. RESULTS Four central themes emerged from the data; understanding evidence and EBP, drivers of change, interpersonal interaction, and moving forward. Captured within these themes were fifteen sub-themes. These themes/sub-themes translated into three broad calls to action: (1) defining terminology, (2) defining the EBP approach, and (3) fostering social movement. These calls to action formed the framework of the agenda. CONCLUSIONS This analysis presents a potential framework for an agenda to improve EBP implementation in T&CM. The fundamental elements of this action plan seek clarification, leadership and unification on the issue of EBP in T&CM.

Evaluating integrative medicine acute stroke inpatient care in South Korea

High demand for traditional Korean medicine led to a policy change in 2010 allowing hospitals to provide Integrative medicine care that combines Western medicine and Korean medicine. This study evaluated the effects of Integrative medicine compared to Western medicine-only for managing acute stroke in South Korean hospitals. A retrospective matched case-control observational study was conducted for acute stroke patients admitted nationwide in 2012 and 2013. Propensity score matching was used to adjust for the likelihood of selecting Integrative medicine. Hierarchical generalized linear models were used to control for patient characteristics at the episode of care (level 1) and cluster effects from the hospitals (level 2). A total of 1182 patients and 65 hospitals were matched and analyzed. Receiving Integrative medicine significantly increased the average length of stay (OR 1.27; 95% CI 1.13-1.42), total cost of inpatient care (OR 1.93; 95% CI 1.62-2.31), and per-day cost (OR 1.34; 95% CI 1.21-1.47). Receiving Integrative medicine did not affect all-cause 3-month emergency readmissions (OR 1.36; 95% CI 0.92-2.02). However, Integrative medicine was associated with a reduced risk of all-cause mortality at 3 months (OR 0.36; 90% CI 0.13-0.99) and 12 months (OR 0.34; 95% CI 0.15-0.75) after admission. Receiving Integrative medicine was associated with improved 3-month and 12-month survival, greater healthcare utilization and higher costs. Further economic evaluations are needed to guide policy for efficient integration of Korean medicine and Western medicine.