integration of unconventional treatments in health services · exploring integrative medicine for...
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Associate Professor Torkel FalkenbergLeader – R esearch Unit for Studies of Integrative Health Care,
Department of Neurobiology, Care Sciences and Societ y, Divisionof Nursing, Karolinska Institutet
Head of Research – The Vidar Institute Foundation
Integration of unconventionaltreatments in Health Services
MEDICINA INTEGRATA per la qualità di vita delle donne
”Our research aim is to contribute to integrativehealth care development based on a broadand multidisciplinary 'evidence house' whereresearch methods are triangulated to generateresults relevant for health sector reform andbest practice development…”
TM/CAM is widely and increasinglyused in all regions of the world
Populations usingtraditional medicinefor primary healthcare
Ethiopia
Benin
India
Rwanda
Tanzania
Uganda
Populations indev eloped countrieswho hav e usedcomplementary andalternative medicineat least once
Canada
Australia
France
USA
Belgium
Sources:Eisenberg DM etal.1998;Fisher P&Ward A, 1994;Health Canada,2001;World Health Organization,1998;and government reports submitted to WHO.
The herbal medicines market
0
1 000
2 000
3 000
4 000
5 000
6 000
1990 1991 1994 1996 1997 1998 1999 2000 2002
2 400
1 000
JapanJapan
92 184UK
5 400
860
USAUSA
Million USD
WHO, 2002
POST-MODERN MEDICINEsocial concerns and trends
for many patients, the process of care is as importantas the outcome;
the process of care can influence the outcomes ofcare, not only with respect to patient satisfaction butalso in terms of the patient’s state of health andeffectiveness of treatment;
modern medicine and complementary medicine canbe used together in what has been called’’integrative medicineintegrative medicine’;
that patients are more concerned about the risks ofmodern medicine than the medical establishmentwhich, until now, has emphasized the benefits.
JA Muir Gray. Evidence-based Healthcare. How to make health policy and management
decisions. Churchil l Liv ingstone. 2001.
Integrative Medicine (IM)
• An evidence-based approach integrating conventionalcare with complementary therapies
• Reinforces patient-provider partnership in health• Focuses on health and healing as well as disease and
symptomatic treatment
Trends:
- IM in conventional care settings and county councils- IM in medical education and university hospitals- IM in health care organisations and insurance plans
NCCAM/NIH 2010; Carlsson & Falkenberg 2007; Vohra et al 2005; Sipkoff 2005; Eisenberg et al2002; Wolsko et al 2002; Rees & Weil 2001; Landstingsförbundet 2001
United States> 400 programs for integrative medicine
Memorial Sloan-Kettering Cancer Center(Total Employees 7,953)
The Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center was established in 1999 tocomplement mainstream medical care and addressthe emotional, social, and spiritual needs of patientsand families
Research perspective
20 years ago: no academic infrastructure & scarce funding
Today: NCCAM >100 million USD/year
EU funded project: “CAMbrella”
6 professor CAM chairs in Germany
Osher Center Europe Karolinska Institutet
Raising campaign against CAM
Exploring Integrative Medicinefor Back and Neck Pain
On the integration of manual and complementarytherapies in Swedish primary care
Tobias SundbergPT, DO, MMedSc
Feb 12, 2010
Torkel FalkenbergAssociate professorMain supervisor
Per WändellAssociate professorSupervisor
Health Technology Assessment &Evidence Based Decision Making
Rawlins M. The Harveian oration of 2008. London: Royal College of Physicians
“Hierarchies of evidence should bereplaced by accepting - indeedembracing - a diversity of approaches.”
Sir Henry Rawlins, president NICE, UK
Sundberg et al 2007-2010
Health ServicesResearch
RandomisedClinical Trial
Focus GroupDiscussions
Cost-UtilityAnalysis
Triangulation of researchmethods
Towards a model for integrativemedicine in Swedish primary care
Sundberg et al 2007
Sundberg T, Halpin J, Warenmark A, Falkenberg TBMC Health Services Research 2007, 7:107
“Developing the IM model – what is an appropriateIM model for Swedish primary care?”
Study 1
Exploring Integrative Medicine forBack and Neck Pain – a pragmatic
randomised clinial pilot trial
Sundberg et al 2009
Sundberg T, Petzold M, Wandell P, Rydén A, Falkenberg TBMC Complementary and Alternative Medicine 2009, 9:33
“Implementing and testing the model.”
Study 2
Patients’ experiences and perceptionsof integrative medicine for
back and neck painAndersson S, Sundberg T, Johansson E, Falkenberg TSubmitted
“Patients’ perspectives – generating hypothesisof integrative care characteristics.”
Study 3
Andersson & Sundberg et al 2010
Integrative medicine for back and neck pain– exploring cost-effectiveness alongside a
randomised clinical pilot trial
Sundberg et al 2010
Sundberg T, Hagberg L, Wandell P, Falkenberg TSubmitted
Study 4
“Health economic evaluation.”
Sundberg et al 2007
Qualitative group basedaction research
Immersion/crystallization& research group consensus
Meeting notes, ongoingworking documents
Group reflection, refinementof strategi es and actions
Further data collection
Research group meetings,FGDs, seminars (CC, CT, RES)
- Processes- Structures- Outcomes
- Facilitators- Barriers- Strategies
Sundberg et al 2007
SFunding
IMproviders
IM clinicat PC unit
IM clinicdecentralized
Clin
ical
meeting
s
Ethical
clea
rance
Patient
group
Diagn
oses
Educatio
nal
semin
ars
Snowbal
lingfor
provid
ers
Logisti cs
Docu
men
tatio
n
Refer
rals
CTs
Referralnetwork
P
Results:Processes (P) and Structures (S)
Conventionalcare
MassageManip ther
ShiatsuAcupQigong
CTintegration(≤12 wks)
Plan
PrimaryCare Unit
?
Results:IM Model Outcome
Sundberg et al 2007
AdviceAnalgesics
Sick-leavePhysio
From To Percentunits
Percentunits
Integrative care
diff P, OR(95% CI)
Outcome From To
Conventionalcare
Sundberg et al 2009
Comparative effectiveness after 4 months:Change in use of analgesics and health care
Theme Integrative care combines valuable conv entional medicaldiagnosis with empowering self -help strategies
Categories Managementcharacteristics
Carestrenghts
Careweaknesses
Sub-categories
Specialist andreductionist
management(Conventi onal)
Health insuranceparadox
(Conventi onal)
Whole-personmanagement
(Complementary)
Valuable diagnosticsupport (Conventional)
Increased treatmentresponse and reduced
need f or analgesics(Complementary)
Indiv idual support,empowerment andself -help strategies
(Complementary)
Lack ofaccessibility time
and guidance(Conventi onal)
Financial andcollaborativ echallenges
(Complementary)
Andersson & Sundberg et al 2010
Sundberg et al 2010
Costs, gained QALYs, cost/QALY and likelihood of cost-effectiveness (%) for the IM model vs conventional care
Summary of results
Sundberg et al 2010
The IM model
The clinicalpilot trial
Patients’perspectives
Cost-effectiveness
Implications for research
Sundberg et al 2010
Challenges
Care vs Cure
If it works? (pRCT) vs How it works? (RCT)
Models of integration – assimilation or true
integration?
Evidence Based Medicine (EBM) definition
Breaking of the dominance of the pharmacological
model
Health Services Research
Multiple avenues to evidence
Reduce sick-leave?
Reduce drug utilisation?
Increase care giver andpatient satisfaction?
Increase patient safety?
Re
se
arc
hq
ues
tio
ns
Opportunities
Thank you for theattention!