Patricia M. Herman

Hospital Admissions for Acute Myocardial Infarction, Angina, Stroke, and Asthma After Implementation of Arizona's Comprehensive Statewide Smoking Ban

OBJECTIVES We examined the impact of Arizonas May 2007 comprehensive statewide smoking ban on hospital admissions for diagnoses for which there is evidence of a causal relationship with secondhand smoke (SHS) exposure (acute myocardial infarction [AMI], angina, stroke, and asthma). METHODS We compared monthly hospital admissions from January 2004 through May 2008 for these primary diagnoses and 4 diagnoses not associated with SHS (appendicitis, kidney stones, acute cholecystitis, and ulcers) for Arizona counties with preexisting county or municipal smoking bans and counties with no previous bans. We attributed reductions in admissions to the statewide ban if they occurred only in diagnoses associated with SHS and if they were larger in counties with no previous bans. We analyzed the data with Poisson regressions, controlling for seasonality and admissions trends. We also estimated cost savings. RESULTS Statistically significant reductions in hospital admissions were seen for AMI, angina, stroke, and asthma in counties with no previous bans over what was seen in counties with previous bans. No ban variable coefficients were statistically significant for diagnoses not associated with SHS. CONCLUSIONS Arizonas statewide smoking ban decreased hospital admissions for AMI, stroke, asthma, and angina.

Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations

Objective A comprehensive systematic review of economic evaluations of complementary and integrative medicine (CIM) to establish the value of these therapies to health reform efforts. Data sources PubMed, CINAHL, AMED, PsychInfo, Web of Science and EMBASE were searched from inception through 2010. In addition, bibliographies of found articles and reviews were searched, and key researchers were contacted. Eligibility criteria for selecting studies Studies of CIM were identified using criteria based on those of the Cochrane complementary and alternative medicine group. All studies of CIM reporting economic outcomes were included. Study appraisal methods All recent (and likely most cost-relevant) full economic evaluations published 2001–2010 were subjected to several measures of quality. Detailed results of higher-quality studies are reported. Results A total of 338 economic evaluations of CIM were identified, of which 204, covering a wide variety of CIM for different populations, were published 2001–2010. A total of 114 of these were full economic evaluations. And 90% of these articles covered studies of single CIM therapies and only one compared usual care to usual care plus access to multiple licensed CIM practitioners. Of the recent full evaluations, 31 (27%) met five study-quality criteria, and 22 of these also met the minimum criterion for study transferability (‘generalisability’). Of the 56 comparisons made in the higher-quality studies, 16 (29%) show a health improvement with cost savings for the CIM therapy versus usual care. Study quality of the cost-utility analyses (CUAs) of CIM was generally comparable to that seen in CUAs across all medicine according to several measures, and the quality of the cost-saving studies was slightly, but not significantly, lower than those showing cost increases (85% vs 88%, p=0.460). Conclusions This comprehensive review identified many CIM economic evaluations missed by previous reviews and emerging evidence of cost-effectiveness and possible cost savings in at least a few clinical populations. Recommendations are made for future studies.

A Cancer Screening Intervention for Underserved Latina Women by Lay Educators

OBJECTIVES Inadequate screening adherence for breast, cervical, and colorectal cancer among Latinas places them at greater risk for poor survival rates, once diagnosed. The purpose of this study was to examine two delivery methods of lay health educators (promotoras de salud) to increase screening behavior and evaluate costs. METHODS This community-based group randomized trial assigned Latinas due for breast, cervical, or colorectal cancer screening (n=1006) to promotora-taught cancer screening/prevention classes delivered individually (IND) or in social support groups (SSG) over 8 weeks. Screening behaviors were assessed immediately after and 3 and 15 months after intervention. Intervention costs per study arm were compared. RESULTS Screening and maintenance behaviors were not significantly different between SSG and IND for any one type of cancer screening, but with a study entry requirement that participants were either never screened or due for screening, postintervention screening rates (that is, completing a screening that was due) were notable (39.4% and 45.5%, respectively). The cost of achieving any one screening was much higher for IND participants. CONCLUSIONS SSG vs. IND delivery did not significantly affect cancer screening behaviors, but both interventions produced robust achievement of screenings for previously nonadherent participants. Group-based promotora-led interventions supporting social involvement are recommended as a more cost-effective approach to achieving cancer screening among Latina women.

Health Insurance Status, Medical Debt, and Their Impact on Access to Care in Arizona

OBJECTIVES We examined the impact of health insurance status on medical debt among Arizona residents and the impact of both of these factors on access to care. METHODS We estimated logistic regression models for medical debt (problems paying and currently paying medical bills) and access to care (medical care and medications delayed or missed because of cost or lack of insurance). RESULTS Insured status did not predict medical debt after control for health status, income, age, and household characteristics. Insured status (adjusted odds ratio [AOR] = 0.32), problems paying medical bills (AOR = 4.96), and currently paying off medical bills (AOR = 3.04) were all independent predictors of delayed medical care, but only problems paying (AOR = 6.16) and currently paying (AOR = 3.68) medical bills predicted delayed medications. Inconsistent coverage, however, was a strong predictor of problems paying bills, and both of these factors led to delays in medical care and medications. CONCLUSIONS At least in Arizona, health insurance does not protect individuals from medical debt, and medical debt and lack of insurance coverage both predict reduced access to care. These results may represent a troubling message for US health care in general.

Naturopathic medicine for the prevention of cardiovascular disease: a randomized clinical trial

Background: Although cardiovascular disease may be partially preventable through dietary and lifestyle-based interventions, few individuals at risk receive intensive dietary and lifestyle counselling. We performed a randomized controlled trial to evaluate the effectiveness of naturopathic care in reducing the risk of cardiovascular disease. Methods: We performed a multisite randomized controlled trial of enhanced usual care (usual care plus biometric measurement; control) compared with enhanced usual care plus naturopathic care (hereafter called naturopathic care). Postal workers aged 25–65 years in Toronto, Vancouver and Edmonton, Canada, with an increased risk of cardiovascular disease were invited to participate. Participants in both groups received care by their family physicians. Those in the naturopathic group also received individualized care (health promotion counselling, nutritional medicine or dietary supplementation) at 7 preset times in work-site clinics by licensed naturopathic doctors. The body weight, waist circumference, lipid profile, fasting glucose levels and blood pressure of participants in both groups were measured 3 times during a 1-year period. Our primary outcomes were the 10-year risk of having a cardiovascular event (based on the Framingham risk algorithm) and the prevalence of metabolic syndrome (based on the Adult Treatment Panel III diagnostic criteria). Results: Of 246 participants randomly assigned to a study group, 207 completed the study. The characteristics of participants in both groups were similar at baseline. Compared with participants in the control group, at 52 weeks those in the naturopathic group had a reduced adjusted 10-year cardiovascular risk (control: 10.81%; naturopathic group: 7.74%; risk reduction −3.07% [95% confidence interval (CI) −4.35% to −1.78%], p < 0.001) and a lower adjusted frequency of metabolic syndrome (control group: 48.48%; naturopathic care: 31.58%; risk reduction −16.90% [95% CI −29.55% to −4.25%], p = 0.002). Interpretation: Our findings support the hypothesis that the addition of naturopathic care to enhanced usual care may reduce the risk of cardiovascular disease among those at high risk. Trial registration: ClinicalTrials.gov, no. NCT0071879.

IMPACT - Integrative Medicine PrimAry Care Trial: protocol for a comparative effectiveness study of the clinical and cost outcomes of an integrative primary care clinic model

BackgroundIntegrative medicine (IM) is a patient-centered, healing-oriented clinical paradigm that explicitly includes all appropriate therapeutic approaches whether they originate in conventional or complementary medicine (CM). While there is some evidence for the clinical and cost-effectiveness of IM practice models, the existing evidence base for IM depends largely on studies of individual CM therapies. This may in part be due to the methodological challenges inherent in evaluating a complex intervention (i.e., many interacting components applied flexibly and with tailoring) such as IM.Methods/DesignThis study will use a combination of observational quantitative and qualitative methods to rigorously measure the health and healthcare utilization outcomes of the University of Arizona Integrative Health Center (UAIHC), an IM adult primary care clinic in Phoenix, Arizona. There are four groups of study participants. The primary group consists of clinic patients for whom clinical and cost outcomes will be tracked indicating the impact of the UAIHC clinic (n = 500). In addition to comparing outcomes pre/post clinic enrollment, where possible, these outcomes will be compared to those of two matched control groups, and for some self-report measures, to regional and national data. The second and third study groups consist of clinic patients (n = 180) and clinic personnel (n = 15-20) from whom fidelity data (i.e., data indicating the extent to which the IM practice model was implemented as planned) will be collected. These data will be analyzed to determine the exact nature of the intervention as implemented and to provide covariates to the outcomes analyses as the clinic evolves. The fourth group is made up of patients (n = 8) whose path through the clinic will be studied in detail using qualitative (periodic semi-structured interviews) methods. These data will be used to develop hypotheses regarding how the clinic works.DiscussionThe US health care system needs new models of care that are more patient-centered and empower patients to make positive lifestyle changes. These models have the potential to reduce the burden of chronic disease, lower the cost of healthcare, and offer a sustainable financial paradigm for our nation. This protocol has been designed to test whether the UAIHC can achieve this potential.Trial registrationClinical Trials.gov NCT01785485.

Yoga, Physical Therapy, or Education for Chronic Low Back Pain: A Randomized Noninferiority Trial

Background Yoga is effective for mild to moderate chronic low back pain (cLBP), but its comparative effectiveness with physical therapy (PT) is unknown. Moreover, little is known about yogas effectiveness in underserved patients with more severe functional disability and pain. Objective To determine whether yoga is noninferior to PT for cLBP. Design 12-week, single-blind, 3-group randomized noninferiority trial and subsequent 40-week maintenance phase. (ClinicalTrials.gov: NCT01343927). Setting Academic safety-net hospital and 7 affiliated community health centers. Participants 320 predominantly low-income, racially diverse adults with nonspecific cLBP. Intervention Participants received 12 weekly yoga classes, 15 PT visits, or an educational book and newsletters. The maintenance phase compared yoga drop-in classes versus home practice and PT booster sessions versus home practice. Measurements Primary outcomes were back-related function, measured by the Roland Morris Disability Questionnaire (RMDQ), and pain, measured by an 11-point scale, at 12 weeks. Prespecified noninferiority margins were 1.5 (RMDQ) and 1.0 (pain). Secondary outcomes included pain medication use, global improvement, satisfaction with intervention, and health-related quality of life. Results One-sided 95% lower confidence limits were 0.83 (RMDQ) and 0.97 (pain), demonstrating noninferiority of yoga to PT. However, yoga was not superior to education for either outcome. Yoga and PT were similar for most secondary outcomes. Yoga and PT participants were 21 and 22 percentage points less likely, respectively, than education participants to use pain medication at 12 weeks. Improvements in yoga and PT groups were maintained at 1 year with no differences between maintenance strategies. Frequency of adverse events, mostly mild self-limited joint and back pain, did not differ between the yoga and PT groups. Limitations Participants were not blinded to treatment assignment. The PT group had disproportionate loss to follow-up. Conclusion A manualized yoga program for nonspecific cLBP was noninferior to PT for function and pain. Primary Funding Source National Center for Complementary and Integrative Health of the National Institutes of Health.

Economic analysis of complementary, alternative, and integrative medicine: considerations raised by an expert panel

BackgroundAn international panel of experts was convened to examine the challenges faced in conducting economic analyses of Complementary, Alternative and Integrative Medicine (CAIM).MethodsA one and a half-day panel of experts was convened in early 2011 to discuss what was needed to bring about robust economic analysis of CAIM. The goals of the expert panel were to review the current state of the science of economic evaluations in health, and to discuss the issues involved in applying these methods to CAIM, recognizing its unique characteristics. The panel proceedings were audiotaped and a thematic analysis was conducted independently by two researchers. The results were then discussed and differences resolved. This manuscript summarizes the discussions held by the panel members on each theme.ResultsThe panel identified seven major themes regarding economic evaluation that are particularly salient to determining the economics of CAIM: standardization (in order to compare CAIM with conventional therapies, the same basic economic evaluation methods and framework must be used); identifying the question being asked, the audience targeted for the results and whose perspective is being used (e.g., the patient perspective is especially relevant to CAIM because of the high level of self-referral and out-of-pocket payment); the analytic methods to be used (e.g., the importance of treatment description and fidelity); the outcomes to be measured (e.g., it is important to consider a broad range of outcomes, particularly for CAIM therapies, which often treat the whole person rather than a specific symptom or disease); costs (e.g., again because of treating the whole person, the impact of CAIM on overall healthcare costs, rather than only disease-specific costs, should be measured); implementation (e.g., highlighting studies where CAIM allows cost savings may help offset its image as an “add on” cost); and generalizability (e.g., proper reporting can enable study results to be useful beyond the study sample).ConclusionsThe business case for CAIM depends on economic analysis and standard methods for conducting such economic evaluations exist. The challenge for CAIM lies in appropriately applying these methods. The deliberations of this panel provide a list of factors to be considered in meeting that challenge.

Out-Of-Pocket Expenditures on Complementary Health Approaches Associated With Painful Health Conditions in a Nationally Representative Adult Sample.

UNLABELLED National surveys suggest that millions of adults in the United States use complementary health approaches such as acupuncture, chiropractic manipulation, and herbal medicines to manage painful conditions such as arthritis, back pain, and fibromyalgia. Yet, national and per person out-of-pocket (OOP) costs attributable to this condition-specific use are unknown. In the 2007 National Health Interview Survey, the use of complementary health approaches, the reasons for this use, and the associated OOP costs were captured in a nationally representative sample of 5,467 adults. Ordinary least square regression models that controlled for comorbid conditions were used to estimate aggregate and per person OOP costs associated with 14 painful health conditions. Individuals using complementary approaches spent a total of

Using participatory methods to enhance patient-centred mental health care in a federally qualified community health center serving a Mexican American farmworker community.

14.9 billion (standard error [SE] =