Informed Consent in Complementary and Alternative Medicine

The objective of this study was to examine complementary and alternative medicine (CAM) practitioners' (i) attitudes toward informed consent and (ii) to assess whether standards of practice exist with respect to informed consent, and what these standards look like. The design and setting of the study constituted face-to-face qualitative interviews with 28 non-MD, community-based providers representing 11 different CAM therapeutic modalities. It was found that there is great deal of variability with respect to the informed consent process in CAM across providers and modalities. No unique profession-based patterns were identified. The content analysis yielded five major categories related to (i) general attitude towards the informed consent process, (ii) type and amount of information exchange during that process, (iii) disclosure of risks, (iv) discussions of alternatives, and (v) potential benefits. There is a widespread lack of standards with respect to the practice of informed consent across a broad range of CAM modalities. Addressing this problem requires concerted and systematic educational, ethical and judicial remedial actions. Informed consent, which is often viewed as a pervasive obligation is medicine, must be reshaped to have therapeutic value. Acknowledging current conceptions and misconception surrounding the practice of informed consent may help to bring about this change. More translational research is needed to guide this process

Potential Synergism between Hypnosis and Acupuncture—Is the Whole More Than the Sum of Its Parts?

Both hypnosis and acupuncture have gained credibility over the years in their effectiveness for treating various health conditions. Currently, each of these treatments is administered in distinct settings and separate times. That is, even if patients receive both treatments as part of a multidimensional therapeutic program, they would typically receive them separately rather than simultaneously at the same session. This separation however might be undesirable since, at least theoretically, hypnosis and acupuncture could potentially augment each other if administered concomitantly. In this article we outline the rationale for this hypothesis and discuss the potential ramifications of its implementation

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

BACKGROUND: 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. METHODS: 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). RESULTS: 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. CONCLUSION: 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

How good are we? A meta-analytic study of effect sizes in medicine

Background. Although Cohen's convention regarding small (∼0.2), medium (∼0.5), and large (∼0.8) effect sizes (ES) that originated in the socio-behavioral sciences approximately 40 years ago has been used heuristically in medicine as well, the extent to which it characterizes the range of ES for various medical therapies remains unknown. Objectives. (1) To calibrate the robustness of current interventions in medicine using different ES indices as the underlying metric, and (2) to examine whether the efficacy of therapeutic interventions in medicine have changed over the years. Methods. Three complementary studies have been conducted. Study I, which provides an indication of the range of ES in medicine currently, is a meta-meta analysis that summarizes 91 different meta-analyses of various treatments, from medicine to surgery to psychology. Study II used a pool of 250 different ES computed from 52 original clinical trials published over the last 25 years to examine time trends associated with ES. Study III used traditional and cumulative meta-analyses of 76 trials representing 30 different treatments for sepsis. Number-needed-to-treat (NNT) was calculated and adjusted for different control death rates to assess systematically objectives (1) and (2). Results. Study I: The mean ES for continuous variables was d 0.50 (SD 0.35, 95%CI 0.32-0.69) and for dichotomous variables odds ratio 1.51 (SD 1.39, 95%CI 0.9-2.13; p > 0.05). Study II: A parsimonious theory-specified model accounted for 93.2% of the variance associated with ES estimates over the years. ES was statistically significant correlated with many design features but not with year of publication. Study III: Neither traditional meta-analysis nor cumulative meta-analysis found most treatment categories for sepsis to be effective. Whereas the pooled relative risk estimate for the entire cohort of almost 22,000 patients was statistically significant with very narrow confidence interval (RR 0.92; 95%CI 0.88-0.96; p = 0.00028), the NNT adjusted analysis had a wide range, including the potential for harm. Conclusion. Cohen's convention applies well to medicine. Most therapeutic interventions in this study had a small to moderate ES, indicating they have not changed dramatically over the years. These findings suggest that the ever-increasing biomedical knowledge does not result in ever-improving therapeutic efficacy

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

Abstract Background 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. Methods 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). Results 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. Conclusion 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.</p