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A comparison of the effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care
Complementary Therapies in Medicine (2011) 19, 264—275
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/ctim
A comparison of the effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care Wendy Wong a,∗, L.K. Cindy Lam a, Rita Li b, Sze Hon Ho b, Leung Kwok Fai c, Zhao Li d a
Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong Tung Wah Group of Hospitals, Hong Kong c Department of Occupational Therapy, Queen Elizabeth Hospital, Hong Kong d School of Chinese Medicine, The Chinese University of Hong Kong, Hong Kong Available online 9 August 2011 b
KEYWORDS Chinese medicine; Western medicine; Primary care; Health-related quality of life
∗
Summary Background: Traditional Chinese medicine (TCM) plays an important role in the primary care system in many places, but research evidence on its effectiveness is largely lacking. The aim of the present study was to compare the effectiveness between TCM and Western medicine (WM) consultations in primary care. Objectives: To evaluate whether medical consultations could improve the quality of life and health condition of patients in primary care and to find out whether there was any difference in the effectiveness bewteen TCM and WM. Design, setting and subjects: This was a prospective, longitudinal study on 290 patients of one TCM public and 841 patients of two WM general outpatient clinics (GOPC) in Hong Kong when they consulted for an episodic illness. Methods: All patients attending a TCM GOPC in TWH, and the two WM GOPC (TWH and ALC), who fullfilled the inclusion criteria were invited to participate. Each patient answered a structured questionnaire on the presenting complaint, socio-demography, chronic morbidity and service utilization, the Chinese Quality of Life instrument (ChQOL) and the SF-36V2 Health Survey immediately before and two weeks after the doctor consultation. The Global Rating on change Scale (GRS) was also administered in the week 2 assessment. Outcome measures: The primary outcomes were changes in the ChQOL and SF-36V2 HRQOL scores. Secondary outcomes included the GRS score. The significance of the change within individual were tested by paired t-tests. The differences in change in scores between WM and TCM were tested by independent sample-t-tests or chi-square, as appropriate. Multivariate regresions were used to determine the independent effect of type of medicine on the change in HRQOL scores.
Corresponding author. Tel.: +852 25185656; fax: +852 28147475. E-mail address: [email protected] (W. Wong).
0965-2299/$ — see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctim.2011.07.001
Effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care
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Results: Mean ChQOL and SF-36V2 scores of subjects improved significantly two weeks after TCM or WM consultations in all domains except for the Physical form domain of ChQOL. The greatest improvements were found in the SF-36V2 physical-health related domains. 78% TCM clinics and 71% of subjects WM clinics reported an improvement in GRS. The proportion of subjects who had improvement in HRQOL scores were lower among subjects consulting the WM clinic (72.3%) than those consulting TCM clinics (100%) but the difference was not significant after correction for baseline scores. Conclusions: Both TCM and WM consultations were associated with significant improvement in HRQOL in over 90% of patients. There was no singificant difference between the effectiveness of TCM and WM consultations. The results support the role of TCM as an alternative primary care service in Hong Kong. © 2011 Elsevier Ltd. All rights reserved.
Introduction
Methods
Primary health care serves every person and manages over 90% of the illnesses.1 The effectiveness of primary care has profound impact on the health of the population as well as the demand on expensive secondary care. Although Western medicine (WM) is the most commonly used form primary care in Hong Kong, 50—60% of people also consult Traditional Chinese medicine (TCM).2,3 In fact, the two types of medicine are often used sequentially or concurrently in our current health care system.4 There is a constant debate on whether WM or TCM is more effective, but few if any, data on their absolute or relative effectiveness is available.5 To evaluate the effectiveness of a health service, an appropriate outcome measure is needed.6 Health-related quality of life (HRQOL) is probably the most suitable outcome measure for primary care services where most of the health problems are functional rather than pathological.7,8 The special advantage of generic HRQOL is that it can be applied across different types of patients, illnesses and medical services. TCM claims that improving quality of life is its main treatment objective but there is very little research evidence available. The SF-36 Health Survey and Chinese Quality of Life Instrument (ChQOL) have been shown to be valid, responsive and sensitive in local patients in primary care and the latter is specifically designed to measure the effectiveness of TCM.9—12 This study aimed to evaluate the effectiveness of TCM consultations in improving the HRQOL of patients in primary care and compared it with WM primary care consultations. To the best of our knowledge, this is the first study to evaluate the effectiveness of primary care service in general with a common outcome measure. The results could inform the public, health care providers and policy makers about the benefit of each medical service.13
Study design, setting and subjects
Objectives (1) To investigate whether WM consultations provided by a public primary care clinic could improve HRQOL and global health conditions. (2) To compare the effectiveness of WM and TCM consultations in improving HRQOL and health condition. (3) To investigate factors including socio-demographics, comorbidities, use of other services that may affect the effectiveness of WM consultations in primary care.
Prospective studies were carried out in one TCM primary care clinic and two WM public general outpatient clinics (GOPC) in Hong Kong. The TCM primary care clinic was the Chinese medicine general outpatient clinic of the TWH (TWH TCM) that provided free internal medicine and bone-setting services. The WM GOPC in Tung Wah Hospital (TWH) and Ap Lei Chau (ALC) clinic were used as comparison groups for the TCM clinic. The TWH GOPC served as the natural comparison for the TCM clinic in the same hospital. The ALC GOPC is an academic family practice that was used as a benchmark for the WM consultations. Since most illnesses managed in primary care are not severe, a relatively small effect size (0.3—0.5) change was expected. An effect size change of 0.3—0.5 has been found to correspond to a minimally clinically important difference in HRQOL measured by several instruments.14—16 Our local study also found a similar effect size change in SF-36 scores after treatment of the elderly with psychological problems.17 400 subjects were recruited from each clinic to account for 30% drop outs. Patients were recruited from the TCM clinic from November, 2005 to June, 2006, and two WM clinics from June to December, 2007. The months covered both summer and winter and were similar for both types of clinics. All patients aged >18 consulting these clinics for the first time or a new episode of illness were invited to participate. We included only subjects presenting with acute episodic illnesses because they are the most common reasons for consultations in primary care, and the outcomes could be measured after a relatively short period. 535 new patients attending the TWH TCM clinic were approached, 43 were not eligible, and 85 refused to participate. 407 patients from TWH TCM clinics completed the baseline assessment and 290 of whom completed the follow-up assessment (Fig. 1). 7052 patients were identified from two WM GOPCs (ALC and TWH). 5320 patients were excluded because (1) consulting for chronic illnesses (n = 2926); (2) unable to communicate in Chinese (n = 426), (3) too ill or cognitively impaired to complete the interview (n = 1330) or (4) age < 18 (n = 638). 1062 patients completed the baseline assessment and 841 of whom completed the follow-up assessment. Fig. 2 summarizes the patient recruitment and completion rates in
266
W. Wong et al.
535 new patients were identified (Internal Medicine n =214; Bone Setting n =321)
492 eligible
85 Refused to participate 39 Unwilling to commit the time 24 lacked in interest in the study 22 did not give any reason
290 completed follow up assessment
43 not eligible
407 agreed to participate in the study (Response rate = 407/492 = 82.72%)
82 refused to be followed up
35 could not be contacted
Overall follow up rate = 290/407 x 100 = 71.25% Legend TWH TCM clinic: Tung Wah Hospital Traditional Chinese Medicine General Outpatient clinic that provided free internal medicine and bone-setting services Figure 1 Recruitment and follow-up of patients in TWH TCM clinics. TWH TCM clinic: Tung Wah Hospital Traditional Chinese Medicine General Outpatient clinic that provided free internal medicine and bone-setting services.
WMGOPC and TCM which ranged from 58 to 83% and 71 to 79%, respectively. There were significant differences in the characteristics between subjects of the TWH TCM clinic and TWH WM GOPC, suggesting that TCM and WM serve different patient populations even if they are in the same hospital and district. There were also some differences between patients consulting the ALC and TWH GOPCs, which reflect differences in the general populations of the two districts (Table 1). Multivariate logistic regressions showed that being female, in non-professional occupations, and higher income were predictors of WM clinic use (Table 2).
the subject’s responses to the HRQOL measures. All subjects were followed up either by face to face or telephone interviews 2 weeks after the initial consultation. The follow up interval was set at 2 weeks base on the clinical experience that response to treatment is expected to occur within this period for most episodic illnesses. We allowed follow up by either means in order to achieve as high a follow up rate as possible and our previous study has shown that there was no significant difference in the results of SF-36 scores between face to face and telephone administration by a trained interviewer.18 The same questionnaire was administered with the addition of a Global Rating on Change scale (GRS).
Data collection Data analysis Written informed consent was obtained from all patients and they completed an interview before their Western or Chinese medicine consultations for the presenting complaint, socio-demography, morbidity, health service utilization, ChQOL (HK version) and the Chinese (Hong Kong) SF-36 Health Survey Version 2. After the consultation, the WM doctor/CMP completed an evaluation form on the severity of the subject’s illness on a 5-point Likert scale [(1) very mild to (5) extremely severe]. Subjects and interviewers were blinded to the WM doctor/Chinese Medicine Practitioners’ (CMP) assessment and the WM doctor/CMP was blinded to
Primary outcomes were the changes in ChQOL (HK version) and the Chinese (HK) SF-36 scores from baseline to 2 weeks after the WM/TCM consultations. Secondary outcomes were the GRS scores. The presenting complaints were classified by the International Classification of Primary Care-2 (ICPC2).19 The ChQOL (HK version), the SF-36V2 and GRS scores were analyzed by descriptive statistics and the changes after consultation were tested by paired-t-tests. The changes in ChQOL (HK version) and SF-36V2 scores and the GRS scores after WM or TCM consultations were compared, and were
Effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care
267
7052 patients were identified (ALC n = 2539; TWH n = 4513) 1732 eligible (ALC n = 891; TWH n = 841)
670 refused to participate 301 unwilling to commit the time 194 said they were too ill 114 lacked interest in the study 61 did not give any reason
841 completed follow up assessment (ALC n = 441; TWH n = 400)
5320 not eligible (ALC n = 1648; TWH n = 3672)
1062 agreed to participate in the study (ALC n = 524; TWH n = 538) (Response rate: ALC = 524/891=58.8% TWH = 538/841=64%)
103 refused follow up
118 could not be contacted
Overall follow up rate = 841/1062 x 100 = 79.2% Legend ALC: Ap Lei Chau general outpatient clinic; TWH: Tung Wah Hospital western medicine general outpatient clinic Figure 2 Recruitment and follow-up of subjects of Western medicine clinics. ALC: Ap Lei Chau general outpatient clinic; TWH: Tung Wah Hospital Western medicine general outpatient clinic.
Results
respiratory symptoms/complaints (coded R in ICPC-2) and only 101 (9.5%) presented with musculo-skeletal symptoms/complaints (coded L in ICPC-2). A similar distribution was found in ALC and TWH WMGOPC. While majority of patients (52.9%) consulted TCM clinics for musculo-skeletal problems (coded L in ICPC-2) and only 7.9% presented with respiratory symptoms/complaints (coded R in ICPC-2). The top 10 complaints made up 64% of all presenting problems in the TCM clinic while they made up under 50% of all presenting problems in the WMGOPCs.
Presenting problems and health services utilization of subjects
Baseline health related quality of life
The morbidity pattern found in WMGOPC clinics (Table 3) was quite different from that found in TCM clinics where 278 (26.2%) of the WMGOPC’s subjects presented with
The baseline SF-36V2 and ChQOL (HK version) scores and the doctor’s severity rating of the illness of the subjects are shown in Table 4. The HK general population SF-36V2 norms
tested by independent sample t-tests as appropriate. Multivariable linear regressions of the change in ChQOL (HK version), SF-36V2-HK or GRS scores on WM or TCM consultations were carried out, controlling for socio-demographic, severity of illness, chronic morbidity and other service utilization variables. Statistical significance was set at p < 0.05 and SPSS version 16.0 was used.
268 Table 1
W. Wong et al. Socio-demographic characteristic of study subjects at enrolment.
n Age mean (s.d.) Range Gender (%) Male Female Education level (%) Nil Primary Secondary (including matriculation) Tertiary I don’t know Martial status (%) Married living with spouse Widow/widower Single Separate or divorced Occupation (%) Professional Associate professional Skilled worker Semi-skilled worker Unskilled worker Housewife Full-time student Others I don’t know Income range (%)HK$60,000 Refuse to answer
TCM (TWH) 407
WM (overall) 1062
WM (ALC) 524
WM (TWH) 538
Census (2005) 5659570
56.07 (14.23)*,†,‡ 18—87
49.26 (15.94)*,‡ 18—95
46.73 (13.74) 18—87
51.73 (17.48)† 18—95
44.74 (16.2)* 18—85
32.4*,†,‡ 67.6
40.7*,‡ 59.3
41.8 58.2
39.6† 60.4
47.4* 52.6
12.3*,†,‡ 29.5 47.2 10.6 0.5
5.8*,‡ 21.5 55.4 17.3 0
5.2 22.1 55.7 17 0
6.5† 20.8 55 17.7 0
8.4* 20.5 54.6 16.4 0
75.9*,†,‡ 10.1 10.1 3.9
66.3*,‡ 5.4 24.1 4.2
70.4§ 3.2 21.2 5.2
62.3†, § 7.4 27 3.4
59.4* 2.7 31.9 2.7
4.9†,‡ 4.2 16.7 11.1 13.5 46.9 1.7 0.5 0.5
2.7†,‡ 11.4 29.8 23.9 13.4 14.2 3.9 0.4 0.3
3.1§ 11.3 30.2 17 12.8 19.9 4.6 0.6 0.6
2.4†, § 11.5 29.4 30.7 13.9 8.7 3.2 0.2 0
N.A. N.A. N.A. N.A. N.A. N.A. N.A. N.A. N.A.
19.9*,†,‡ 17.9 17.9 10.6 5.2 0.7 27.8
17.5*,‡ 15.5 21.5 19.2 20.3 3.9 2.2
10.5§ 14.9 20.5 20.7 26.1 5 2.3
24.2†, § 16 22.5 17.8 14.7 2.8 2
12.3* 37.7 26.2 12.9 8.2 2.6 0
Note: N.A. — no available information for comparison. * Significant difference between patients from WM (overall) or TCM (TWH) groups and HK general population by independent sample t-test or chi-square tests (*p < 0.05). † Significant difference between patients from TCM (TWH) and WM (TWH) groups by independent sample t-test or chi-square test († p < 0.05). ‡ Significant difference between TCM (TWH) and WM (overall) groups by independent sample t-test of chi-square tests (‡ p < 0.05). § Significant difference between WM (ALC) and WM (TWH) groups by independent sample t-test or chi-square tests (§ p < 0.05).
are shown for comparison. The WM (ALC) GOPC subjects had lower SF-36V2 RP, BP, SF, RE and PCS scores but higher ChQOL Vitality and Spirit scores than WM (TWH) subjects. The SF36V2 scores of TCM clinic subjects were generally lower than the HK population norm except for the MH and MCS scores. These differences showed that different clinic populations had very different baseline health status, which must be controlled for in the evaluation of the effectiveness of the service. Comparing to WMGOPC patients from the same hospital (TWH), TCM subjects generally had lower HRQOL scores except for SF-36V2 MH and MCS and ChQOL Vitality and Spirit scores than subjects from the WM (TWH) GOPC. There were
also significant differences in the HRQOL scores between patients from the two different WMGOPCs.
Changes in health related quality of life after consultations The SF-36V2 and ChQOL scores at 2 weeks after the WM or TCM consultations are compared in Table 4. All SF-36V2 domain scores also improved significantly after the WM consultations with PF, GH, VT and SF reaching or exceeding the general population norm. All SF-36V2 domain scores except MCS were improved significantly after the TCM consultations
Effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care Table 2
269
Predictors of user with WM Vs. TCM clinics. Adjusted odds ratio
Gender Female Age Education level Nil Primary Secondary (including matriculation) Tertiary Martial status Married living with spouse Widow/widower Single Separated or divorced Occupation Professional* Associate professional Skilled worker Semi-skilled worker Unskilled worker Housewife Full-time student Others Income rangeHK$ 60,000
95% C.I. Lower
Upper
1.67* 0.98
1.14 0.97
2.45 1.00
1 1.18 1.09 0.88
N.A. 0.68 0.62 0.42
N.A. 2.04 1.91 1.86
1 1.13 1.15 0.91
N.A. 0.62 0.66 0.43
N.A. 2.05 2.00 1.90
1 8.41* 5.67* 10.87* 5.61* 1.04 6.54* 2.44
N.A. 3.37 2.59 4.65 2.36 0.45 1.80 0.37
N.A. 20.97 12.41 25.42 13.34 2.40 23.75 15.95
1 0.77 1.09 1.50 3.60* 6.21*
N.A. 0.49 0.69 0.88 1.88 1.66
N.A. 1.22 1.74 2.55 6.87 23.30
Notes: The odds ratio represents the ratio of likelihood of being subject of WM clinics to likelihood of subjects of TCM clinic by logistic regression mode. Odd ratio: >1: more likely user of WM clinic and <1 more likely user of TCM Variables that had a significant effect in the final model are shown. * Significant difference within groups by logistic regression model (*p < 0.05).
Table 3
Top ten presenting complaints by TCM and WM clinics.
TCM (TWH) (n = 407) *
Knee symptom/complaint ( L15) Low back symptom/complaint (L03) Cough (R05) Shoulder symptom/complaint (L08) Ankle symptom/complaint (L16) Joint symptom/complaint (L20) Foot/toe symptom/complaint (L17) Leg/thigh symptom/complaint (L14) Wrist symptom/complaint (L11) Hand/finger symptom/complaint (L12) Headache (N01) Others Total
%
WMGOPC (n = 1062)
%
9.8 9.6 7.9 5.7 5.2 5.2 4.9 4.4 4.2 3.9 3.2 36 100
Cough (R05) Sneezing/nasal congestion (R07) Throat symptom/complaint (R21) Hand/finger symptom/complaint (L12) Leg/thigh symptom/complaint (L14) Headache (N01) Abdominal pain/cramps general (D01) Vertigo/dizziness (N17) Dermatitis/atopic eczema (S87) Lump/swelling localized (S04) Lump/swelling localized (S04) Others Total
13.1 7.4 5.7 4.0 3.5 3.2 3.1 3.0 2.4 2.1 2.1 50.5 100
Notes: TCM clinic: Tung Wah Hospital Traditional Chinese Medicine Clinic. WMGOPC: Ap Lei Chau and Tung Wah General Outpatient Clinics. * ICPC-2 = International Classification of Primary Care.19
270
Table 4
Baseline and 2-weeks after of SF-36V2, ChQOL scores of subjects in the TCM and WM clinics.
n SF-36 (HK mean, SD) PF (91.8, 12.9) RP (82.4,31.0) BP (84.0, 31.0) GH (56.0, 20.2) VT (60.3, 18.7) SF (91.2, 16.5) RE (71.7, 38.4) MH (72.8, 16.6) PCS (50, 10) MCS (50, 10) ChQOL Physical Vitality and Spirit Emotion Overall Severity of illness (%) Extremely mild/mild Moderate Severe/extremely severe
TCM (TWH) baseline
TCM (TWH) after 2 wk
WM (Overall) after 2 wk 841
WM (ALC) baseline
WM (ALC) after 2 wk
WM (TWH) baseline
WM (TWH) after 2 wk
290
WM (Overall) baseline 1062
407
524
442
538
399
71.3(24.0)*,† 45.0(43.0)*,† 49.2(33.8)*,† 52.1(27.7) 59.2(23.6) 84.5(23.5)* 71.1(42.7)* 75.3(21.8) 33.2(15.1)*,† 56.2(12.8)*,†
78.1(21.5) 62.6(41.8) 69.5(29.6) 57.0(26.7) 66.3(21.6) 89.8 (20.0) 79.1(38.3) 81.0(18.9) 39.9(13.6) 57.7(10.7)a
87.7 (15.9)† 64.4(39.3)† 63.9(28.7)† 53.6(21.5) 61.2(20.7) 85.7(23.3) 73.6(39.1) 74.2(18.6) 43.2(10.8)† 52.2(10.9)†
90.3(15.7) 78.0(36.3) 79.3(26.9) 60.6(23.8) 68.6(19.2) 91.2(19.3) 82.7(34.6) 78.0(17.5) 47.8(10.6) 54.5(9.5)
87.8 (15.5) 58.9(40.6)‡ 61.1(29.1)‡ 54.5(21.8) 61.6(20.6) 81.5(25.4)‡ 70.6(40.3)‡ 74.8(19.9) 42.3(11.2)‡ 51.7(11.6)
91.7(13.0) 76.7(37.3) 77.4(27.6) 62.2(23.8) 69.5(20.2) 90.0(20.7) 81.2(35.8) 78.7(18.4) 48.0(10.3) 54.3(10.4)
87.7 (16.3)* 69.8(37.3)*,‡ 66.7(28.1)*,‡ 52.7(21.1) 60.9(20.9) 89.8(20.2)*,‡ 76.5(37.8)*,‡ 73.7(17.4) 43.9(10.4)*,‡ 52.7(10.2)*
88.8(18.2) 79.5(35.1) 81.4(25.9) 58.9(23.7) 67.6(17.9) 92.5(17.6) 84.4(33.1) 77.2(16.4) 47.5(10.9) 54.7(8.4)
63.9(15.6)*,† 67.9(18.9)* 76.7(17.9) 69.5(14.6)†
64.1(12.7) 74.2(17.9) 83.5(15.9) 73.9(13.1)
68.2(13.5)† 67.8(15.2) 77.8(15.2) 71.3(12.2)†
65.8(10.3) 74.8(16.5) 83.2(13.8) 74.6(11.3)
68.0(14.2) 70.4(15.5)‡ 77.3(15.9) 71.9(13.1)
66.1(10.4) 77.8(16.1) 82.9(14.2) 75.6(11.7)
68.5(12.8)* 65.3(14.5)*,‡ 78.4(14.6) 70.8(11.2)
65.4(10.1) 71.5(16.3) 83.5(13.3) 73.5(10.9)
32.7* 61.3 6
68.9 25.6 5.5
81.0‡ 17.9 1
59.3*,‡ 31.2 9.5
Notes: PF = physical functioning; RP = role limitation due to physical problems; BP = bodily pain; GH = general health; VT = vitality; SF = social functioning; RE = role limitation due to emotional problems; MH = mental health; PCS = physical component score; MCS = mental component score; NA: no information available. * Significant difference between the TCM (TWH) and WM (TWH) groups by independent sample t-test (*p < 0.05); † Significant difference between TCM (TWH) and WM (overall) groups by independent sample t-test († p < 0.05); ‡ Significant difference between the WM (ALC) and WM (TWH) groups by independent sample t-test (‡ p < 0.05). The changes from baseline in all Sf-36 and ChQOL scores were significant by paired-t-tests in all groups, except for the MCS score of the TCM (TWH) group (a).
W. Wong et al.
Effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care Table 5
271
Mean changes (effect sizes) of HRQOL scores two weeks after TCM and WM consultations.
n Mean change (effect size) SF-36 PF RP BP GH VT SF RE MH PCS MCS ChQOL Physical Vitality and Spirit Emotion Overall
TCM (TWH) 290
WM (overall) 841
WM (ALC) 442
WM (TWH) 399
7.91 17.76 21.18 5.89 6.60 5.47 7.82 4.66 7.48 0.87
(0.33)*,† (0.41) (0.63)*,† (0.21) (0.28) (0.23) (0.18) (0.21) (0.49)*,† (0.07)*,†
2.96 14.65 16.14 7.68 7.62 6.17 10.79 3.67 5.02 2.35
(0.19)† (0.37) (0.56)† (0.36) (0.37) (0.27) (0.28) (0.20) (0.46)† (0.22)†
3.86 17.18 16.44 7.54 8.05 8.03 10.61 4.07 5.55 2.50
(0.25) (0.42) (0.57) (0.35) (0.39) (0.32)‡ (0.26) (0.20) (0.50) (0.22)
1.98 11.87 15.82 7.85 7.14 4.13 11.00 3.22 4.43 2.20
(0.12)* (0.32) (0.56)* (0.37) (0.34) (0.20)‡ (0.29) (0.19) (0.42)* (0.22)*
−0.02 6.86 6.13 4.32
(0.00)*,† (0.36) (0.34) (0.30)
−2.05 7.21 5.97 3.76
(−0.15)† (0.47) (0.39) (0.31)
−1.48 7.71 5.96 4.16
(−0.10) (0.50) (0.38) (0.32)
−2.67 6.65 5.97 3.32
(−0.21)* (0.46) (0.41) (0.30)
N.A.: no information available. * Significant difference between the TCM (TWH) and WM (TWH) groups by independent sample t-test (*p < 0.05). † Significant difference between TCM (TWH) and WM (overall) groups by independent sample t-test († p < 0.05). ‡ Significant difference between the WM (ALC) and WM (TWH) groups by independent sample t-test (‡ p < 0.05).
with RE, GH, VT and MH reaching or exceeding their general population norm. The PF, RP, BP and PCS at two weeks after the TCM consultation were still much lower than the general population norm, although they had significantly improved. Table 5 summarizes the mean and effect size changes in the HRQOL scores at two weeks after WM or TCM consultations. The scores all significantly improved except for the physical form domain of the ChQOL in which a deterioration of −2.05 and −0.02 points was found in the WMGOPCs and TCM clinic, respectively. The greatest improvement was found in the SF-36V2 BP and PCS scores and ChQOL Vitality and Spirit domain scores with effect sizes ranging from 0.41 to 0.63 for both WMGOPCs and TCM patients. Subjects from the WMGOPC (n = 399) and TCM clinic (n = 290) of TWH had similar improvements in most HRQOL scores, except TCM was associated with greater effect sizes in the SF-36 PF (effect size 0.33 vs 0.12), BP (effect size 0.63 vs 0.56) and PCS (effect size 0.49 vs 0.42) scores, but the reverse was found with the SF-36V2 MCS score (effect size 0.22 Vs. 0.07). There was not much difference in the HRQOL score changes between the two WM GOPCs (ALC vs. TWH). Linear regression analysis found that specific clinic had an effect only on the ChQOL Vitality and Spirit score but not on any others after adjustment of confounding variables (Table 6). TCM (TWH) or WM (ALC) clinics were associated with more improvement than the WM (TWH) clinic. Baseline HRQOL score was found to be the strongest determinant of the changes in all HRQOL scores with more improvement found in patients with lower baseline scores. The use of other practitioner service before the index consultation had an effect on the SF-36V2 PCS score in that patients who had prior TCM consultations improved more than those who had not consulted any others, but those who had consulted both WM and TCM improved less. Age and gender had weak
but significant effects on the physical HRQOL (SF-36V2 PCS and ChQOL physical form and overall) scores. There was an inverse relationship between age and the improvements in the scores. Male patients had significantly more improvement than females. Other variables were entered into the model but did not have any significant effect (the use of medication or visiting other practitioner after the index consultation, co-existing chronic diseases; severity of the presenting illness, the number of consultations in the last month; patients’ usual initial illness action; marital status; social class; household income and education level.
Global rating on change in condition after consultation Table 7 shows the results of the patients’ global rating on change in condition scale (GRS) score. 78% and 71% of subjects perceived that their condition had become better after the WM or TCM consultations, respectively. Very few subjects reported worsening of their conditions. The proportion of patients from TCM clinic reporting a global improvement in their conditions was slightly higher than that found in the WM clinics, but the difference was not statistically significant. There was also no significant difference in the outcomes between WM (ALC) and WM (TWH) GOPCs. There were only weak correlations between the change in HRQOL (SF-36V2 and ChQOL) scores and subjects’ GRS scores (Spearman correlations 0.10—0.21). The proportion of subjects who had improvement in HRQOL scores were lower among subjects consulting the WM clinic (72.3%) than those consulting TCM clinics (100%) but the difference was not significant after correction for baseline scores.
*
†
a
Data are presented as un-standardized coefficients by multivariable linear regression, controlling for baseline scores, socio-demographics, and use of other service. This category was set as the indicator variable. Significant difference by general linear model (*p < 0.05). Significant difference when comparing with the indicator († p < 0.05).
Discussions
b
0.37 (−1.72, 2.45) −0.93 (−2.61, 0.76) 0 3.59 (0.89, 6.30)*,† 3.66 (1.46, 5.85)† 0 0.94 (−0.79, 2.68) 0.11 (−1.29, 1.51) 0 −0.56 (−2.29, 1.16) 1.02 (−0.58, 2.61) 0.49 (−0.85, 1.84) 0.01 (−1.27, 1.28) 0 0 Clinic TCM (TWH) WM (ALC) b WM (TWH)
Emotion Vitality and Spirit Physical PCS
MCS
Domains of ChQOL SF-36
B (95% C.I.) a
Adjusted effects of clinics on changes in HRQOL scores after consultations. Table 6
1.53 (−0.19, 3.25) 0.89 (−0.51, 2.29) 0
W. Wong et al.
Overall health
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The study showed that HRQOL of patients improved significantly after TCM or WM consultation with effect sizes greater than the minimally important difference of 0.3 SD in most domains.14—16 The results of the patient’s global rating on change in health condition (GRS) score further confirmed the effectiveness of TCM primary care consultations. General linear regression analysis did not find any difference in HRQOL changes between TCM and WM after adjustment for confounding variables. As expected, patients presenting to primary care had lower scores in almost all HRQOL domains than the general population because they were ill. TCM clinic patients had lower baseline SF-36V2 PF, RP, BP and PCS scores than those in the WM GOPC because the former had acute musculo-skeletal problems that were associated with more pain/limitations in physical/role functioning. The SF-36V2 MCS score of the subjects was higher than the general population mean. This could be explained by the older age of the study subjects (55.65 vs. 44.74) since mental HRQOL increases with age.20 To the best of our knowledge, this was the first study to compare the effectiveness of WM or TCM consultations using the same outcome measure. The results are probably generalizable to public primary care since the characteristics of the study sample were typical of those of the patients using public primary care services in Hong Kong, with a higher proportion of females and elderly.9,21 We used two different HRQOL measures based on the HRQOL concepts in the Chinese and Western cultures, respectively, to improve the sensitivity and responsiveness in detecting effectiveness, and to cross-validate the results. We have demonstrated that the SF-36V2 Health Survey as a generic HRQOL was responsive to not only Western but also Chinese Medicine treatment effects, and vice versa for the ChQOL. The scores of the physical-health related quality of life domains (SF36V2 PCS, RP, BP and PF) improved more significantly than mental-health related domains (SF-36V2 MCS, VT, RE and MH) because most patients consulted for physical illnesses. The differential increase in the HRQOL scores suggested that the changes were not random measurement variations or systematic regression to the mean (RTM) but indication of real changes. The Chinese culture specific ChQOL showed a difference between the effects of the clinics but the SF-36V2 Health Survey did not, suggesting that it might be more sensitive and responsive in patients of the relevant culture. Less improvement in ChQOL Vitality and Spirit and emotion scores were found in the TWH WM GOPC than the other clinics not related to the type of medicine. Michlig et al.’s study also did not find any significant difference in change in SF-36V2 PCS and MCS scores between patients consulting TCM certified physicians and conventional primary care physicians, although there was more satisfaction in the former than latter.22 The ideal methodology to determine the effectiveness of an intervention is a randomized placebo controlled trial but this is probably not ethical or feasible in the evaluation of primary care consultations. The second best possible method is a case control study with matching of patients
Effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care Table 7
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Global ratings on change in condition two weeks after consultation.
n Global rating on change Got better No change Got worse
TCM (TWH) 290 77.5% 21.5% 1%
WM (Overall) 841 70.6% 26.0% 3.4%
but this requires a very large sample because of the wide spectrum of problems presenting to primary care. Our study sampled subjects from WM and TCM clinics from the same hospital with the intent to reduce confounding effects of geographic and socio-economic factors, and to use subjects from an academic family medicine teaching clinic (ALC) as a benchmark of the standard of care of WM GOPC. However, significant differences in patients characteristics and presenting problems between TCM and WM clinics were found, which could have biased the perceived outcomes of consultations. We tried to adjust for the effect of illness severity, judged by WM doctor TCM practitioner, in the comparison of the effectiveness of the consultations between TCM and WM but no effect was found. The results should be interpreted with caution because the reliability of the illness severity rating could be limited by the lack of standardization of the assessment criteria of illness severity among different doctors and practitioners in the study. Musculo-skeletal problems were the most common reason for TCM consultations (26.2%), reflecting the popularity of bone-setting in our Chinese community. A Swiss study by Michlig et al. also found diseases of the musculoskeletal system and connective tissue were the most common reasons for consulting TCM certified physicians in the primary care.22 The top 10 conditions in this study made up 64% of all presenting problems in TCM, while the top 10 conditions made up <50% of all presenting problems in WM clinics, suggesting people consulting TCM for more selected types of illnesses. It was surprising to find the Physical form score of the ChQOL deteriorated after TCM consultations although it was not statistically significant and a same trend was found in WM patients. Further studies have to be carried out to investigate whether this was related to the natural history of illness, an adverse effect from the consultation or a psychometric deficiency of the ChQOL. Although SF-36V2 PCS and ChQOL-physical form scores are called ‘physical’, a moderate correlation between them, gave different results as they measure different HRQOL concepts. The SF-36V2 PCS is mainly determined by physical functioning, bodily pain and role functioning23 while the ChQOL physical form correlates with complexion, sleep, stamina, appetite and digestion and adaptation to climate.10 These two domains reflected the different HRQOL concepts in Western and Chinese cultures. It was a bit surprising that TCM consultations were associated with less improvement in mental-health related QOL scores than WM consultations since the former is emphasizes holistic care. The HRQOL effect size changes after WM consultations were larger than those from TCM consultations in the SF-36V2 MCS domains but vice versa in other domains (SF-36V2 PF, RP and PCS), which suggest the two
WM (ALC) 442 68.3% 27.2% 4.5%
WM (TWH) 399 73.4% 24.6% 2%
types of medicine have different benefits and serve different health needs. Our study included only patients consulting for acute episodic illnesses and our follow-up period was only 2 weeks, which could capture the immediate medical treatment effect but could not assess the more long-term effect of TCM. A study on homeopathic treatment for migraine with a follow-up period of 2-years showed similar effect size change in the SF-36V2 PCS score (0.35—0.45) but a much larger effect in the SF-36V2 MCS (0.38—0.42).24 Further studies on the effect of WM and TCM consultations for patients with chronic diseases with longer follow up period should be done in Hong Kong to assess their effectiveness more fully. WM might be able to relieve patients’ mental stress from respiratory or digestive symptoms while TCM might be more effective in relieving the pain and disability from musculoskeletal problems. Western medicine and TCM should complement and supplement each other in a health care system where both are widely available, like the one in Hong Kong. However the two medical services operate almost exclusive of each other with no official referral system, which makes integration very difficult. A recent study by Chung et al. found that while many WM doctors had a positive attitude towards TCM with nearly 40% of them using herbal medicine themselves but referral to TCM was uncommon.25 They found WM doctors who had some formal education in TCM were associated with a higher likelihood of referral to TCM. The inclusion of TCM in the education and training of WM doctors and the establishment of some formal channels of mutual referral in Hong Kong would help to maximize the health benefit from both WM and TCM. Our study showed that doctor shopping especially the use of both CMP and WM doctors before the index consultation was associated with less improvement. This could be the result of selection of patients who had more resistant illnesses but it could also reflect the problem of lack of continuity of care. The use of other consultations or medications after the index consultation had no effect on the change in HRQOL at two weeks indicating the use of additional services may represent wastage of health care resources.
Limitations This study was conducted in only one TCM clinic in Hong Kong so the results may not be generalizable to other TCM primary care services especially those in the private sector. The follow-up period of 2 weeks might not be able to capture the full effect of treatments. Without a no-treatment control or placebo group it was uncertain that the change in HRQOL was truly the result of the TCM or WM consul-
274 tations, rather than a natural history of the illnesses. The subjects from the two medical services were not matched, which could have biased the results of comparison between the two types of medicine. Further research with a proper case control design and the inclusion of patients consulting different public and private TCM and WM primary care should be carried out to detect any difference in the effectiveness between TCM and WM for different patient or illness groups. Studies with a longer follow up period will also provide information on the long-term benefit of TCM especially for patients with chronic disease.
Conclusion This study has shown that WM and TCM consultations in primary care are equally effective in improving quality of life with over 95% of patients presenting with episodic illnesses reporting a benefit. There was no significant difference in the effectiveness between WM and TCM consultations although they might have some differential effects on different HRQOL domains. A direct comparison of the effectiveness between WM and TCM that have very different clinical indicators was shown to be feasible with the use of generic health-related quality of life measures. There were major differences in patient characteristics and morbidity patterns presenting to TCM and WM primary care clinics, which indicate the two types of medicine serve different populations and health needs. TCM is most commonly used for musculo-skeletal problems and WM was most commonly consulted for respiratory problems. Two types of medicine should complement each other in providing more choices of primary care. However, duplication and wastage of health care resources could be a problem because TCM seemed to be used mainly as a supplement rather than an alternative to WM. Further research with longer follow up period is needed to examine the long-term HRQOL outcomes of TCM, especially in the treatment of chronic conditions. More research is also needed to find out how doctor-shopping can be reduced among patients consulting TCM services.
Acknowledgements We would like to acknowledge the collaboration from the Tung Wah Group of Hospitals in this study. Special thanks to Mr. Ho Siu Wai, William, Ms. Choi Sze Yu, Mr. Ng Sze Tuen and Mr. Leung Kam Fong for their help in enabling us to recruit subjects from Tung Wah Group of Hospitals. Special thanks to all Chinese Medicine Practitioners, doctors and nurses of the Tung Wah Hospital and the Ap Lei Chau General outpatient clinic, for their help in the patient recruitment and follow up and to all patients who participated in this study.
References 1. Hutchison A, et al. In: Hutchison A, editor. Health outcomes for primary and out-patient care: an editorial overview. Amsterdam: Harwood Academic Publishers; 1996. p. 1—7.
W. Wong et al. 2. Lau JTF, Leung EMF, Tsui HY. Predicting traditional Chinese medicine’s use and the marginalization of medical care in Hong Kong. American Journal of Chinese Medicine 2001;29:547—58. 3. Lau JTF, Yu A. The choice between Chinese medicine and Western medicine practitioners by Hong Kong adolescents. American Journal of Chinese Medicine 2000;28:131—9. 4. WHO. WHO global atlas of traditional, complementary and alternative medicine. Kobe, Japan: WHO Centre for Health Development; 2005. 5. Busato A, et al. Health status and health care utilisation of patients in complementary and conventional primary care in Switzerland — an observational study. Family Practice 2006;23:116—24. 6. Critchley JAJH, et al. Alternative therapies and medical science: designing clinical trials of alternative/complementary medicines — is evidence-based traditional Chinese medicine attainable? Journal of Clinical Pharmacology 2000;40:462—7. 7. Tonelli MR, Callahan TC. Why alternative medicine cannot be evidence-based. Academic Medicine 2001;76:1213—20. 8.
1997;18:649—51. 9. Lam CLK, Lauder IJ. The impact of chronic diseases on the health-related quality of life (HRQOL) of Chinese patients in primary care. Family Practice 2000;17(2):159—66. 10. Leung KF, et al. Development and validation of the Chinese quality of life instrument. Health and quality of life Outcomes 2005:26. 11. Zhao L, Leung KF, Chan K. The Chinese Quality of Life instrument: reliability and validity of the Hong Kong Chinese version (ChQOL-HK). The Hong Kong Practitioner 2007;29: 220—32. 12. Wong W, et al. Is the content of the Chinese Quality of Life Instrument (ChQOL) really valid in the context of traditional Chinese Medicine in Hong Kong? Complementary Therapies in Medicine 2009;17(1):29—36. 13. Tang JL, Wong TW. The need to evaluate the clinical effectiveness of traditional Chinese medicine. HKMJ 1998;4: 208—10. 14. Kazis LE, Anderson JJ, Meenan RF. Effect sizes for interpreting changes in health status. Medical Care 1989;27(suppl 3):S178—89. 15. Wyrwich KW, et al. Estimating clinically significant differences in quality of life outcomes. Quality of Life Research 2005;14:285—95. 16. Cowling BJ. Errors, power & sample size. Department of Community Medicine, University of Hong Kong; 2005. 17. Lam CLK, et al. Brief problem-solving treatment in primary care (PST-PC) was not more effective than placebo for elderly patients screened — positive of psychological problems. International Journal of Geriatric Psychiatry 2009, doi:10.1002(2435). 18. Lam CLK. Reliablity and construct validity of the Chinese (Hong Kong) SF-36 for patients in primary care. Hong Kong Practitioner 2003;25(10):468—75. 19. WONCA Classification Committee of the World Organization of National Colleges, Academies, and Academic Associations of General Practitioners. ICPC-2: International classification of primary care. 1998. 20. Lam CLK, et al. Population based norming of the Chinese (HK) version of the SF-36 health survey. The Hong Kong Practitioner 1999;21:460—70. 21. HKSAR Census and Statistics Department. Thematic household survey report no. 30. 2007; p. 62—76. 22. Michlig M, Ausfeld-Hafter B, Busato A. Patient satisfaction with primary care: a comparison between conventional care
Effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care and traditional Chinese Medicine. Complementary Therapies in Medicine 2008;16:350—8. 23. Lam CLK, et al. The SF-36 summary scales were valid, reliable, and equivalent in a Chinese population. Journal of Clinical Epidemiology 2005;58:815—22. 24. Witt CM, Ludtke R, Willich SN. Homeopathic treatment of patients with Migraine: a prospective observational study with
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a 2-year follow-up period. The Journal of Alternative and Complementary Medicine 2010;16(4):347—55. 25. Chung VC, et al. Referral to and the attitude towards traditional Chinese medicine amongst western medical doctors in postcolonial Hong Kon. Social Science and Medicine 2011;72:247—55.
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/ctim
A comparison of the effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care Wendy Wong a,∗, L.K. Cindy Lam a, Rita Li b, Sze Hon Ho b, Leung Kwok Fai c, Zhao Li d a
Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong Tung Wah Group of Hospitals, Hong Kong c Department of Occupational Therapy, Queen Elizabeth Hospital, Hong Kong d School of Chinese Medicine, The Chinese University of Hong Kong, Hong Kong Available online 9 August 2011 b
KEYWORDS Chinese medicine; Western medicine; Primary care; Health-related quality of life
∗
Summary Background: Traditional Chinese medicine (TCM) plays an important role in the primary care system in many places, but research evidence on its effectiveness is largely lacking. The aim of the present study was to compare the effectiveness between TCM and Western medicine (WM) consultations in primary care. Objectives: To evaluate whether medical consultations could improve the quality of life and health condition of patients in primary care and to find out whether there was any difference in the effectiveness bewteen TCM and WM. Design, setting and subjects: This was a prospective, longitudinal study on 290 patients of one TCM public and 841 patients of two WM general outpatient clinics (GOPC) in Hong Kong when they consulted for an episodic illness. Methods: All patients attending a TCM GOPC in TWH, and the two WM GOPC (TWH and ALC), who fullfilled the inclusion criteria were invited to participate. Each patient answered a structured questionnaire on the presenting complaint, socio-demography, chronic morbidity and service utilization, the Chinese Quality of Life instrument (ChQOL) and the SF-36V2 Health Survey immediately before and two weeks after the doctor consultation. The Global Rating on change Scale (GRS) was also administered in the week 2 assessment. Outcome measures: The primary outcomes were changes in the ChQOL and SF-36V2 HRQOL scores. Secondary outcomes included the GRS score. The significance of the change within individual were tested by paired t-tests. The differences in change in scores between WM and TCM were tested by independent sample-t-tests or chi-square, as appropriate. Multivariate regresions were used to determine the independent effect of type of medicine on the change in HRQOL scores.
Corresponding author. Tel.: +852 25185656; fax: +852 28147475. E-mail address: [email protected] (W. Wong).
0965-2299/$ — see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctim.2011.07.001
Effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care
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Results: Mean ChQOL and SF-36V2 scores of subjects improved significantly two weeks after TCM or WM consultations in all domains except for the Physical form domain of ChQOL. The greatest improvements were found in the SF-36V2 physical-health related domains. 78% TCM clinics and 71% of subjects WM clinics reported an improvement in GRS. The proportion of subjects who had improvement in HRQOL scores were lower among subjects consulting the WM clinic (72.3%) than those consulting TCM clinics (100%) but the difference was not significant after correction for baseline scores. Conclusions: Both TCM and WM consultations were associated with significant improvement in HRQOL in over 90% of patients. There was no singificant difference between the effectiveness of TCM and WM consultations. The results support the role of TCM as an alternative primary care service in Hong Kong. © 2011 Elsevier Ltd. All rights reserved.
Introduction
Methods
Primary health care serves every person and manages over 90% of the illnesses.1 The effectiveness of primary care has profound impact on the health of the population as well as the demand on expensive secondary care. Although Western medicine (WM) is the most commonly used form primary care in Hong Kong, 50—60% of people also consult Traditional Chinese medicine (TCM).2,3 In fact, the two types of medicine are often used sequentially or concurrently in our current health care system.4 There is a constant debate on whether WM or TCM is more effective, but few if any, data on their absolute or relative effectiveness is available.5 To evaluate the effectiveness of a health service, an appropriate outcome measure is needed.6 Health-related quality of life (HRQOL) is probably the most suitable outcome measure for primary care services where most of the health problems are functional rather than pathological.7,8 The special advantage of generic HRQOL is that it can be applied across different types of patients, illnesses and medical services. TCM claims that improving quality of life is its main treatment objective but there is very little research evidence available. The SF-36 Health Survey and Chinese Quality of Life Instrument (ChQOL) have been shown to be valid, responsive and sensitive in local patients in primary care and the latter is specifically designed to measure the effectiveness of TCM.9—12 This study aimed to evaluate the effectiveness of TCM consultations in improving the HRQOL of patients in primary care and compared it with WM primary care consultations. To the best of our knowledge, this is the first study to evaluate the effectiveness of primary care service in general with a common outcome measure. The results could inform the public, health care providers and policy makers about the benefit of each medical service.13
Study design, setting and subjects
Objectives (1) To investigate whether WM consultations provided by a public primary care clinic could improve HRQOL and global health conditions. (2) To compare the effectiveness of WM and TCM consultations in improving HRQOL and health condition. (3) To investigate factors including socio-demographics, comorbidities, use of other services that may affect the effectiveness of WM consultations in primary care.
Prospective studies were carried out in one TCM primary care clinic and two WM public general outpatient clinics (GOPC) in Hong Kong. The TCM primary care clinic was the Chinese medicine general outpatient clinic of the TWH (TWH TCM) that provided free internal medicine and bone-setting services. The WM GOPC in Tung Wah Hospital (TWH) and Ap Lei Chau (ALC) clinic were used as comparison groups for the TCM clinic. The TWH GOPC served as the natural comparison for the TCM clinic in the same hospital. The ALC GOPC is an academic family practice that was used as a benchmark for the WM consultations. Since most illnesses managed in primary care are not severe, a relatively small effect size (0.3—0.5) change was expected. An effect size change of 0.3—0.5 has been found to correspond to a minimally clinically important difference in HRQOL measured by several instruments.14—16 Our local study also found a similar effect size change in SF-36 scores after treatment of the elderly with psychological problems.17 400 subjects were recruited from each clinic to account for 30% drop outs. Patients were recruited from the TCM clinic from November, 2005 to June, 2006, and two WM clinics from June to December, 2007. The months covered both summer and winter and were similar for both types of clinics. All patients aged >18 consulting these clinics for the first time or a new episode of illness were invited to participate. We included only subjects presenting with acute episodic illnesses because they are the most common reasons for consultations in primary care, and the outcomes could be measured after a relatively short period. 535 new patients attending the TWH TCM clinic were approached, 43 were not eligible, and 85 refused to participate. 407 patients from TWH TCM clinics completed the baseline assessment and 290 of whom completed the follow-up assessment (Fig. 1). 7052 patients were identified from two WM GOPCs (ALC and TWH). 5320 patients were excluded because (1) consulting for chronic illnesses (n = 2926); (2) unable to communicate in Chinese (n = 426), (3) too ill or cognitively impaired to complete the interview (n = 1330) or (4) age < 18 (n = 638). 1062 patients completed the baseline assessment and 841 of whom completed the follow-up assessment. Fig. 2 summarizes the patient recruitment and completion rates in
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W. Wong et al.
535 new patients were identified (Internal Medicine n =214; Bone Setting n =321)
492 eligible
85 Refused to participate 39 Unwilling to commit the time 24 lacked in interest in the study 22 did not give any reason
290 completed follow up assessment
43 not eligible
407 agreed to participate in the study (Response rate = 407/492 = 82.72%)
82 refused to be followed up
35 could not be contacted
Overall follow up rate = 290/407 x 100 = 71.25% Legend TWH TCM clinic: Tung Wah Hospital Traditional Chinese Medicine General Outpatient clinic that provided free internal medicine and bone-setting services Figure 1 Recruitment and follow-up of patients in TWH TCM clinics. TWH TCM clinic: Tung Wah Hospital Traditional Chinese Medicine General Outpatient clinic that provided free internal medicine and bone-setting services.
WMGOPC and TCM which ranged from 58 to 83% and 71 to 79%, respectively. There were significant differences in the characteristics between subjects of the TWH TCM clinic and TWH WM GOPC, suggesting that TCM and WM serve different patient populations even if they are in the same hospital and district. There were also some differences between patients consulting the ALC and TWH GOPCs, which reflect differences in the general populations of the two districts (Table 1). Multivariate logistic regressions showed that being female, in non-professional occupations, and higher income were predictors of WM clinic use (Table 2).
the subject’s responses to the HRQOL measures. All subjects were followed up either by face to face or telephone interviews 2 weeks after the initial consultation. The follow up interval was set at 2 weeks base on the clinical experience that response to treatment is expected to occur within this period for most episodic illnesses. We allowed follow up by either means in order to achieve as high a follow up rate as possible and our previous study has shown that there was no significant difference in the results of SF-36 scores between face to face and telephone administration by a trained interviewer.18 The same questionnaire was administered with the addition of a Global Rating on Change scale (GRS).
Data collection Data analysis Written informed consent was obtained from all patients and they completed an interview before their Western or Chinese medicine consultations for the presenting complaint, socio-demography, morbidity, health service utilization, ChQOL (HK version) and the Chinese (Hong Kong) SF-36 Health Survey Version 2. After the consultation, the WM doctor/CMP completed an evaluation form on the severity of the subject’s illness on a 5-point Likert scale [(1) very mild to (5) extremely severe]. Subjects and interviewers were blinded to the WM doctor/Chinese Medicine Practitioners’ (CMP) assessment and the WM doctor/CMP was blinded to
Primary outcomes were the changes in ChQOL (HK version) and the Chinese (HK) SF-36 scores from baseline to 2 weeks after the WM/TCM consultations. Secondary outcomes were the GRS scores. The presenting complaints were classified by the International Classification of Primary Care-2 (ICPC2).19 The ChQOL (HK version), the SF-36V2 and GRS scores were analyzed by descriptive statistics and the changes after consultation were tested by paired-t-tests. The changes in ChQOL (HK version) and SF-36V2 scores and the GRS scores after WM or TCM consultations were compared, and were
Effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care
267
7052 patients were identified (ALC n = 2539; TWH n = 4513) 1732 eligible (ALC n = 891; TWH n = 841)
670 refused to participate 301 unwilling to commit the time 194 said they were too ill 114 lacked interest in the study 61 did not give any reason
841 completed follow up assessment (ALC n = 441; TWH n = 400)
5320 not eligible (ALC n = 1648; TWH n = 3672)
1062 agreed to participate in the study (ALC n = 524; TWH n = 538) (Response rate: ALC = 524/891=58.8% TWH = 538/841=64%)
103 refused follow up
118 could not be contacted
Overall follow up rate = 841/1062 x 100 = 79.2% Legend ALC: Ap Lei Chau general outpatient clinic; TWH: Tung Wah Hospital western medicine general outpatient clinic Figure 2 Recruitment and follow-up of subjects of Western medicine clinics. ALC: Ap Lei Chau general outpatient clinic; TWH: Tung Wah Hospital Western medicine general outpatient clinic.
Results
respiratory symptoms/complaints (coded R in ICPC-2) and only 101 (9.5%) presented with musculo-skeletal symptoms/complaints (coded L in ICPC-2). A similar distribution was found in ALC and TWH WMGOPC. While majority of patients (52.9%) consulted TCM clinics for musculo-skeletal problems (coded L in ICPC-2) and only 7.9% presented with respiratory symptoms/complaints (coded R in ICPC-2). The top 10 complaints made up 64% of all presenting problems in the TCM clinic while they made up under 50% of all presenting problems in the WMGOPCs.
Presenting problems and health services utilization of subjects
Baseline health related quality of life
The morbidity pattern found in WMGOPC clinics (Table 3) was quite different from that found in TCM clinics where 278 (26.2%) of the WMGOPC’s subjects presented with
The baseline SF-36V2 and ChQOL (HK version) scores and the doctor’s severity rating of the illness of the subjects are shown in Table 4. The HK general population SF-36V2 norms
tested by independent sample t-tests as appropriate. Multivariable linear regressions of the change in ChQOL (HK version), SF-36V2-HK or GRS scores on WM or TCM consultations were carried out, controlling for socio-demographic, severity of illness, chronic morbidity and other service utilization variables. Statistical significance was set at p < 0.05 and SPSS version 16.0 was used.
268 Table 1
W. Wong et al. Socio-demographic characteristic of study subjects at enrolment.
n Age mean (s.d.) Range Gender (%) Male Female Education level (%) Nil Primary Secondary (including matriculation) Tertiary I don’t know Martial status (%) Married living with spouse Widow/widower Single Separate or divorced Occupation (%) Professional Associate professional Skilled worker Semi-skilled worker Unskilled worker Housewife Full-time student Others I don’t know Income range (%)
TCM (TWH) 407
WM (overall) 1062
WM (ALC) 524
WM (TWH) 538
Census (2005) 5659570
56.07 (14.23)*,†,‡ 18—87
49.26 (15.94)*,‡ 18—95
46.73 (13.74) 18—87
51.73 (17.48)† 18—95
44.74 (16.2)* 18—85
32.4*,†,‡ 67.6
40.7*,‡ 59.3
41.8 58.2
39.6† 60.4
47.4* 52.6
12.3*,†,‡ 29.5 47.2 10.6 0.5
5.8*,‡ 21.5 55.4 17.3 0
5.2 22.1 55.7 17 0
6.5† 20.8 55 17.7 0
8.4* 20.5 54.6 16.4 0
75.9*,†,‡ 10.1 10.1 3.9
66.3*,‡ 5.4 24.1 4.2
70.4§ 3.2 21.2 5.2
62.3†, § 7.4 27 3.4
59.4* 2.7 31.9 2.7
4.9†,‡ 4.2 16.7 11.1 13.5 46.9 1.7 0.5 0.5
2.7†,‡ 11.4 29.8 23.9 13.4 14.2 3.9 0.4 0.3
3.1§ 11.3 30.2 17 12.8 19.9 4.6 0.6 0.6
2.4†, § 11.5 29.4 30.7 13.9 8.7 3.2 0.2 0
N.A. N.A. N.A. N.A. N.A. N.A. N.A. N.A. N.A.
19.9*,†,‡ 17.9 17.9 10.6 5.2 0.7 27.8
17.5*,‡ 15.5 21.5 19.2 20.3 3.9 2.2
10.5§ 14.9 20.5 20.7 26.1 5 2.3
24.2†, § 16 22.5 17.8 14.7 2.8 2
12.3* 37.7 26.2 12.9 8.2 2.6 0
Note: N.A. — no available information for comparison. * Significant difference between patients from WM (overall) or TCM (TWH) groups and HK general population by independent sample t-test or chi-square tests (*p < 0.05). † Significant difference between patients from TCM (TWH) and WM (TWH) groups by independent sample t-test or chi-square test († p < 0.05). ‡ Significant difference between TCM (TWH) and WM (overall) groups by independent sample t-test of chi-square tests (‡ p < 0.05). § Significant difference between WM (ALC) and WM (TWH) groups by independent sample t-test or chi-square tests (§ p < 0.05).
are shown for comparison. The WM (ALC) GOPC subjects had lower SF-36V2 RP, BP, SF, RE and PCS scores but higher ChQOL Vitality and Spirit scores than WM (TWH) subjects. The SF36V2 scores of TCM clinic subjects were generally lower than the HK population norm except for the MH and MCS scores. These differences showed that different clinic populations had very different baseline health status, which must be controlled for in the evaluation of the effectiveness of the service. Comparing to WMGOPC patients from the same hospital (TWH), TCM subjects generally had lower HRQOL scores except for SF-36V2 MH and MCS and ChQOL Vitality and Spirit scores than subjects from the WM (TWH) GOPC. There were
also significant differences in the HRQOL scores between patients from the two different WMGOPCs.
Changes in health related quality of life after consultations The SF-36V2 and ChQOL scores at 2 weeks after the WM or TCM consultations are compared in Table 4. All SF-36V2 domain scores also improved significantly after the WM consultations with PF, GH, VT and SF reaching or exceeding the general population norm. All SF-36V2 domain scores except MCS were improved significantly after the TCM consultations
Effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care Table 2
269
Predictors of user with WM Vs. TCM clinics. Adjusted odds ratio
Gender Female Age Education level Nil Primary Secondary (including matriculation) Tertiary Martial status Married living with spouse Widow/widower Single Separated or divorced Occupation Professional* Associate professional Skilled worker Semi-skilled worker Unskilled worker Housewife Full-time student Others Income range
95% C.I. Lower
Upper
1.67* 0.98
1.14 0.97
2.45 1.00
1 1.18 1.09 0.88
N.A. 0.68 0.62 0.42
N.A. 2.04 1.91 1.86
1 1.13 1.15 0.91
N.A. 0.62 0.66 0.43
N.A. 2.05 2.00 1.90
1 8.41* 5.67* 10.87* 5.61* 1.04 6.54* 2.44
N.A. 3.37 2.59 4.65 2.36 0.45 1.80 0.37
N.A. 20.97 12.41 25.42 13.34 2.40 23.75 15.95
1 0.77 1.09 1.50 3.60* 6.21*
N.A. 0.49 0.69 0.88 1.88 1.66
N.A. 1.22 1.74 2.55 6.87 23.30
Notes: The odds ratio represents the ratio of likelihood of being subject of WM clinics to likelihood of subjects of TCM clinic by logistic regression mode. Odd ratio: >1: more likely user of WM clinic and <1 more likely user of TCM Variables that had a significant effect in the final model are shown. * Significant difference within groups by logistic regression model (*p < 0.05).
Table 3
Top ten presenting complaints by TCM and WM clinics.
TCM (TWH) (n = 407) *
Knee symptom/complaint ( L15) Low back symptom/complaint (L03) Cough (R05) Shoulder symptom/complaint (L08) Ankle symptom/complaint (L16) Joint symptom/complaint (L20) Foot/toe symptom/complaint (L17) Leg/thigh symptom/complaint (L14) Wrist symptom/complaint (L11) Hand/finger symptom/complaint (L12) Headache (N01) Others Total
%
WMGOPC (n = 1062)
%
9.8 9.6 7.9 5.7 5.2 5.2 4.9 4.4 4.2 3.9 3.2 36 100
Cough (R05) Sneezing/nasal congestion (R07) Throat symptom/complaint (R21) Hand/finger symptom/complaint (L12) Leg/thigh symptom/complaint (L14) Headache (N01) Abdominal pain/cramps general (D01) Vertigo/dizziness (N17) Dermatitis/atopic eczema (S87) Lump/swelling localized (S04) Lump/swelling localized (S04) Others Total
13.1 7.4 5.7 4.0 3.5 3.2 3.1 3.0 2.4 2.1 2.1 50.5 100
Notes: TCM clinic: Tung Wah Hospital Traditional Chinese Medicine Clinic. WMGOPC: Ap Lei Chau and Tung Wah General Outpatient Clinics. * ICPC-2 = International Classification of Primary Care.19
270
Table 4
Baseline and 2-weeks after of SF-36V2, ChQOL scores of subjects in the TCM and WM clinics.
n SF-36 (HK mean, SD) PF (91.8, 12.9) RP (82.4,31.0) BP (84.0, 31.0) GH (56.0, 20.2) VT (60.3, 18.7) SF (91.2, 16.5) RE (71.7, 38.4) MH (72.8, 16.6) PCS (50, 10) MCS (50, 10) ChQOL Physical Vitality and Spirit Emotion Overall Severity of illness (%) Extremely mild/mild Moderate Severe/extremely severe
TCM (TWH) baseline
TCM (TWH) after 2 wk
WM (Overall) after 2 wk 841
WM (ALC) baseline
WM (ALC) after 2 wk
WM (TWH) baseline
WM (TWH) after 2 wk
290
WM (Overall) baseline 1062
407
524
442
538
399
71.3(24.0)*,† 45.0(43.0)*,† 49.2(33.8)*,† 52.1(27.7) 59.2(23.6) 84.5(23.5)* 71.1(42.7)* 75.3(21.8) 33.2(15.1)*,† 56.2(12.8)*,†
78.1(21.5) 62.6(41.8) 69.5(29.6) 57.0(26.7) 66.3(21.6) 89.8 (20.0) 79.1(38.3) 81.0(18.9) 39.9(13.6) 57.7(10.7)a
87.7 (15.9)† 64.4(39.3)† 63.9(28.7)† 53.6(21.5) 61.2(20.7) 85.7(23.3) 73.6(39.1) 74.2(18.6) 43.2(10.8)† 52.2(10.9)†
90.3(15.7) 78.0(36.3) 79.3(26.9) 60.6(23.8) 68.6(19.2) 91.2(19.3) 82.7(34.6) 78.0(17.5) 47.8(10.6) 54.5(9.5)
87.8 (15.5) 58.9(40.6)‡ 61.1(29.1)‡ 54.5(21.8) 61.6(20.6) 81.5(25.4)‡ 70.6(40.3)‡ 74.8(19.9) 42.3(11.2)‡ 51.7(11.6)
91.7(13.0) 76.7(37.3) 77.4(27.6) 62.2(23.8) 69.5(20.2) 90.0(20.7) 81.2(35.8) 78.7(18.4) 48.0(10.3) 54.3(10.4)
87.7 (16.3)* 69.8(37.3)*,‡ 66.7(28.1)*,‡ 52.7(21.1) 60.9(20.9) 89.8(20.2)*,‡ 76.5(37.8)*,‡ 73.7(17.4) 43.9(10.4)*,‡ 52.7(10.2)*
88.8(18.2) 79.5(35.1) 81.4(25.9) 58.9(23.7) 67.6(17.9) 92.5(17.6) 84.4(33.1) 77.2(16.4) 47.5(10.9) 54.7(8.4)
63.9(15.6)*,† 67.9(18.9)* 76.7(17.9) 69.5(14.6)†
64.1(12.7) 74.2(17.9) 83.5(15.9) 73.9(13.1)
68.2(13.5)† 67.8(15.2) 77.8(15.2) 71.3(12.2)†
65.8(10.3) 74.8(16.5) 83.2(13.8) 74.6(11.3)
68.0(14.2) 70.4(15.5)‡ 77.3(15.9) 71.9(13.1)
66.1(10.4) 77.8(16.1) 82.9(14.2) 75.6(11.7)
68.5(12.8)* 65.3(14.5)*,‡ 78.4(14.6) 70.8(11.2)
65.4(10.1) 71.5(16.3) 83.5(13.3) 73.5(10.9)
32.7* 61.3 6
68.9 25.6 5.5
81.0‡ 17.9 1
59.3*,‡ 31.2 9.5
Notes: PF = physical functioning; RP = role limitation due to physical problems; BP = bodily pain; GH = general health; VT = vitality; SF = social functioning; RE = role limitation due to emotional problems; MH = mental health; PCS = physical component score; MCS = mental component score; NA: no information available. * Significant difference between the TCM (TWH) and WM (TWH) groups by independent sample t-test (*p < 0.05); † Significant difference between TCM (TWH) and WM (overall) groups by independent sample t-test († p < 0.05); ‡ Significant difference between the WM (ALC) and WM (TWH) groups by independent sample t-test (‡ p < 0.05). The changes from baseline in all Sf-36 and ChQOL scores were significant by paired-t-tests in all groups, except for the MCS score of the TCM (TWH) group (a).
W. Wong et al.
Effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care Table 5
271
Mean changes (effect sizes) of HRQOL scores two weeks after TCM and WM consultations.
n Mean change (effect size) SF-36 PF RP BP GH VT SF RE MH PCS MCS ChQOL Physical Vitality and Spirit Emotion Overall
TCM (TWH) 290
WM (overall) 841
WM (ALC) 442
WM (TWH) 399
7.91 17.76 21.18 5.89 6.60 5.47 7.82 4.66 7.48 0.87
(0.33)*,† (0.41) (0.63)*,† (0.21) (0.28) (0.23) (0.18) (0.21) (0.49)*,† (0.07)*,†
2.96 14.65 16.14 7.68 7.62 6.17 10.79 3.67 5.02 2.35
(0.19)† (0.37) (0.56)† (0.36) (0.37) (0.27) (0.28) (0.20) (0.46)† (0.22)†
3.86 17.18 16.44 7.54 8.05 8.03 10.61 4.07 5.55 2.50
(0.25) (0.42) (0.57) (0.35) (0.39) (0.32)‡ (0.26) (0.20) (0.50) (0.22)
1.98 11.87 15.82 7.85 7.14 4.13 11.00 3.22 4.43 2.20
(0.12)* (0.32) (0.56)* (0.37) (0.34) (0.20)‡ (0.29) (0.19) (0.42)* (0.22)*
−0.02 6.86 6.13 4.32
(0.00)*,† (0.36) (0.34) (0.30)
−2.05 7.21 5.97 3.76
(−0.15)† (0.47) (0.39) (0.31)
−1.48 7.71 5.96 4.16
(−0.10) (0.50) (0.38) (0.32)
−2.67 6.65 5.97 3.32
(−0.21)* (0.46) (0.41) (0.30)
N.A.: no information available. * Significant difference between the TCM (TWH) and WM (TWH) groups by independent sample t-test (*p < 0.05). † Significant difference between TCM (TWH) and WM (overall) groups by independent sample t-test († p < 0.05). ‡ Significant difference between the WM (ALC) and WM (TWH) groups by independent sample t-test (‡ p < 0.05).
with RE, GH, VT and MH reaching or exceeding their general population norm. The PF, RP, BP and PCS at two weeks after the TCM consultation were still much lower than the general population norm, although they had significantly improved. Table 5 summarizes the mean and effect size changes in the HRQOL scores at two weeks after WM or TCM consultations. The scores all significantly improved except for the physical form domain of the ChQOL in which a deterioration of −2.05 and −0.02 points was found in the WMGOPCs and TCM clinic, respectively. The greatest improvement was found in the SF-36V2 BP and PCS scores and ChQOL Vitality and Spirit domain scores with effect sizes ranging from 0.41 to 0.63 for both WMGOPCs and TCM patients. Subjects from the WMGOPC (n = 399) and TCM clinic (n = 290) of TWH had similar improvements in most HRQOL scores, except TCM was associated with greater effect sizes in the SF-36 PF (effect size 0.33 vs 0.12), BP (effect size 0.63 vs 0.56) and PCS (effect size 0.49 vs 0.42) scores, but the reverse was found with the SF-36V2 MCS score (effect size 0.22 Vs. 0.07). There was not much difference in the HRQOL score changes between the two WM GOPCs (ALC vs. TWH). Linear regression analysis found that specific clinic had an effect only on the ChQOL Vitality and Spirit score but not on any others after adjustment of confounding variables (Table 6). TCM (TWH) or WM (ALC) clinics were associated with more improvement than the WM (TWH) clinic. Baseline HRQOL score was found to be the strongest determinant of the changes in all HRQOL scores with more improvement found in patients with lower baseline scores. The use of other practitioner service before the index consultation had an effect on the SF-36V2 PCS score in that patients who had prior TCM consultations improved more than those who had not consulted any others, but those who had consulted both WM and TCM improved less. Age and gender had weak
but significant effects on the physical HRQOL (SF-36V2 PCS and ChQOL physical form and overall) scores. There was an inverse relationship between age and the improvements in the scores. Male patients had significantly more improvement than females. Other variables were entered into the model but did not have any significant effect (the use of medication or visiting other practitioner after the index consultation, co-existing chronic diseases; severity of the presenting illness, the number of consultations in the last month; patients’ usual initial illness action; marital status; social class; household income and education level.
Global rating on change in condition after consultation Table 7 shows the results of the patients’ global rating on change in condition scale (GRS) score. 78% and 71% of subjects perceived that their condition had become better after the WM or TCM consultations, respectively. Very few subjects reported worsening of their conditions. The proportion of patients from TCM clinic reporting a global improvement in their conditions was slightly higher than that found in the WM clinics, but the difference was not statistically significant. There was also no significant difference in the outcomes between WM (ALC) and WM (TWH) GOPCs. There were only weak correlations between the change in HRQOL (SF-36V2 and ChQOL) scores and subjects’ GRS scores (Spearman correlations 0.10—0.21). The proportion of subjects who had improvement in HRQOL scores were lower among subjects consulting the WM clinic (72.3%) than those consulting TCM clinics (100%) but the difference was not significant after correction for baseline scores.
*
†
a
Data are presented as un-standardized coefficients by multivariable linear regression, controlling for baseline scores, socio-demographics, and use of other service. This category was set as the indicator variable. Significant difference by general linear model (*p < 0.05). Significant difference when comparing with the indicator († p < 0.05).
Discussions
b
0.37 (−1.72, 2.45) −0.93 (−2.61, 0.76) 0 3.59 (0.89, 6.30)*,† 3.66 (1.46, 5.85)† 0 0.94 (−0.79, 2.68) 0.11 (−1.29, 1.51) 0 −0.56 (−2.29, 1.16) 1.02 (−0.58, 2.61) 0.49 (−0.85, 1.84) 0.01 (−1.27, 1.28) 0 0 Clinic TCM (TWH) WM (ALC) b WM (TWH)
Emotion Vitality and Spirit Physical PCS
MCS
Domains of ChQOL SF-36
B (95% C.I.) a
Adjusted effects of clinics on changes in HRQOL scores after consultations. Table 6
1.53 (−0.19, 3.25) 0.89 (−0.51, 2.29) 0
W. Wong et al.
Overall health
272
The study showed that HRQOL of patients improved significantly after TCM or WM consultation with effect sizes greater than the minimally important difference of 0.3 SD in most domains.14—16 The results of the patient’s global rating on change in health condition (GRS) score further confirmed the effectiveness of TCM primary care consultations. General linear regression analysis did not find any difference in HRQOL changes between TCM and WM after adjustment for confounding variables. As expected, patients presenting to primary care had lower scores in almost all HRQOL domains than the general population because they were ill. TCM clinic patients had lower baseline SF-36V2 PF, RP, BP and PCS scores than those in the WM GOPC because the former had acute musculo-skeletal problems that were associated with more pain/limitations in physical/role functioning. The SF-36V2 MCS score of the subjects was higher than the general population mean. This could be explained by the older age of the study subjects (55.65 vs. 44.74) since mental HRQOL increases with age.20 To the best of our knowledge, this was the first study to compare the effectiveness of WM or TCM consultations using the same outcome measure. The results are probably generalizable to public primary care since the characteristics of the study sample were typical of those of the patients using public primary care services in Hong Kong, with a higher proportion of females and elderly.9,21 We used two different HRQOL measures based on the HRQOL concepts in the Chinese and Western cultures, respectively, to improve the sensitivity and responsiveness in detecting effectiveness, and to cross-validate the results. We have demonstrated that the SF-36V2 Health Survey as a generic HRQOL was responsive to not only Western but also Chinese Medicine treatment effects, and vice versa for the ChQOL. The scores of the physical-health related quality of life domains (SF36V2 PCS, RP, BP and PF) improved more significantly than mental-health related domains (SF-36V2 MCS, VT, RE and MH) because most patients consulted for physical illnesses. The differential increase in the HRQOL scores suggested that the changes were not random measurement variations or systematic regression to the mean (RTM) but indication of real changes. The Chinese culture specific ChQOL showed a difference between the effects of the clinics but the SF-36V2 Health Survey did not, suggesting that it might be more sensitive and responsive in patients of the relevant culture. Less improvement in ChQOL Vitality and Spirit and emotion scores were found in the TWH WM GOPC than the other clinics not related to the type of medicine. Michlig et al.’s study also did not find any significant difference in change in SF-36V2 PCS and MCS scores between patients consulting TCM certified physicians and conventional primary care physicians, although there was more satisfaction in the former than latter.22 The ideal methodology to determine the effectiveness of an intervention is a randomized placebo controlled trial but this is probably not ethical or feasible in the evaluation of primary care consultations. The second best possible method is a case control study with matching of patients
Effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care Table 7
273
Global ratings on change in condition two weeks after consultation.
n Global rating on change Got better No change Got worse
TCM (TWH) 290 77.5% 21.5% 1%
WM (Overall) 841 70.6% 26.0% 3.4%
but this requires a very large sample because of the wide spectrum of problems presenting to primary care. Our study sampled subjects from WM and TCM clinics from the same hospital with the intent to reduce confounding effects of geographic and socio-economic factors, and to use subjects from an academic family medicine teaching clinic (ALC) as a benchmark of the standard of care of WM GOPC. However, significant differences in patients characteristics and presenting problems between TCM and WM clinics were found, which could have biased the perceived outcomes of consultations. We tried to adjust for the effect of illness severity, judged by WM doctor TCM practitioner, in the comparison of the effectiveness of the consultations between TCM and WM but no effect was found. The results should be interpreted with caution because the reliability of the illness severity rating could be limited by the lack of standardization of the assessment criteria of illness severity among different doctors and practitioners in the study. Musculo-skeletal problems were the most common reason for TCM consultations (26.2%), reflecting the popularity of bone-setting in our Chinese community. A Swiss study by Michlig et al. also found diseases of the musculoskeletal system and connective tissue were the most common reasons for consulting TCM certified physicians in the primary care.22 The top 10 conditions in this study made up 64% of all presenting problems in TCM, while the top 10 conditions made up <50% of all presenting problems in WM clinics, suggesting people consulting TCM for more selected types of illnesses. It was surprising to find the Physical form score of the ChQOL deteriorated after TCM consultations although it was not statistically significant and a same trend was found in WM patients. Further studies have to be carried out to investigate whether this was related to the natural history of illness, an adverse effect from the consultation or a psychometric deficiency of the ChQOL. Although SF-36V2 PCS and ChQOL-physical form scores are called ‘physical’, a moderate correlation between them, gave different results as they measure different HRQOL concepts. The SF-36V2 PCS is mainly determined by physical functioning, bodily pain and role functioning23 while the ChQOL physical form correlates with complexion, sleep, stamina, appetite and digestion and adaptation to climate.10 These two domains reflected the different HRQOL concepts in Western and Chinese cultures. It was a bit surprising that TCM consultations were associated with less improvement in mental-health related QOL scores than WM consultations since the former is emphasizes holistic care. The HRQOL effect size changes after WM consultations were larger than those from TCM consultations in the SF-36V2 MCS domains but vice versa in other domains (SF-36V2 PF, RP and PCS), which suggest the two
WM (ALC) 442 68.3% 27.2% 4.5%
WM (TWH) 399 73.4% 24.6% 2%
types of medicine have different benefits and serve different health needs. Our study included only patients consulting for acute episodic illnesses and our follow-up period was only 2 weeks, which could capture the immediate medical treatment effect but could not assess the more long-term effect of TCM. A study on homeopathic treatment for migraine with a follow-up period of 2-years showed similar effect size change in the SF-36V2 PCS score (0.35—0.45) but a much larger effect in the SF-36V2 MCS (0.38—0.42).24 Further studies on the effect of WM and TCM consultations for patients with chronic diseases with longer follow up period should be done in Hong Kong to assess their effectiveness more fully. WM might be able to relieve patients’ mental stress from respiratory or digestive symptoms while TCM might be more effective in relieving the pain and disability from musculoskeletal problems. Western medicine and TCM should complement and supplement each other in a health care system where both are widely available, like the one in Hong Kong. However the two medical services operate almost exclusive of each other with no official referral system, which makes integration very difficult. A recent study by Chung et al. found that while many WM doctors had a positive attitude towards TCM with nearly 40% of them using herbal medicine themselves but referral to TCM was uncommon.25 They found WM doctors who had some formal education in TCM were associated with a higher likelihood of referral to TCM. The inclusion of TCM in the education and training of WM doctors and the establishment of some formal channels of mutual referral in Hong Kong would help to maximize the health benefit from both WM and TCM. Our study showed that doctor shopping especially the use of both CMP and WM doctors before the index consultation was associated with less improvement. This could be the result of selection of patients who had more resistant illnesses but it could also reflect the problem of lack of continuity of care. The use of other consultations or medications after the index consultation had no effect on the change in HRQOL at two weeks indicating the use of additional services may represent wastage of health care resources.
Limitations This study was conducted in only one TCM clinic in Hong Kong so the results may not be generalizable to other TCM primary care services especially those in the private sector. The follow-up period of 2 weeks might not be able to capture the full effect of treatments. Without a no-treatment control or placebo group it was uncertain that the change in HRQOL was truly the result of the TCM or WM consul-
274 tations, rather than a natural history of the illnesses. The subjects from the two medical services were not matched, which could have biased the results of comparison between the two types of medicine. Further research with a proper case control design and the inclusion of patients consulting different public and private TCM and WM primary care should be carried out to detect any difference in the effectiveness between TCM and WM for different patient or illness groups. Studies with a longer follow up period will also provide information on the long-term benefit of TCM especially for patients with chronic disease.
Conclusion This study has shown that WM and TCM consultations in primary care are equally effective in improving quality of life with over 95% of patients presenting with episodic illnesses reporting a benefit. There was no significant difference in the effectiveness between WM and TCM consultations although they might have some differential effects on different HRQOL domains. A direct comparison of the effectiveness between WM and TCM that have very different clinical indicators was shown to be feasible with the use of generic health-related quality of life measures. There were major differences in patient characteristics and morbidity patterns presenting to TCM and WM primary care clinics, which indicate the two types of medicine serve different populations and health needs. TCM is most commonly used for musculo-skeletal problems and WM was most commonly consulted for respiratory problems. Two types of medicine should complement each other in providing more choices of primary care. However, duplication and wastage of health care resources could be a problem because TCM seemed to be used mainly as a supplement rather than an alternative to WM. Further research with longer follow up period is needed to examine the long-term HRQOL outcomes of TCM, especially in the treatment of chronic conditions. More research is also needed to find out how doctor-shopping can be reduced among patients consulting TCM services.
Acknowledgements We would like to acknowledge the collaboration from the Tung Wah Group of Hospitals in this study. Special thanks to Mr. Ho Siu Wai, William, Ms. Choi Sze Yu, Mr. Ng Sze Tuen and Mr. Leung Kam Fong for their help in enabling us to recruit subjects from Tung Wah Group of Hospitals. Special thanks to all Chinese Medicine Practitioners, doctors and nurses of the Tung Wah Hospital and the Ap Lei Chau General outpatient clinic, for their help in the patient recruitment and follow up and to all patients who participated in this study.
References 1. Hutchison A, et al. In: Hutchison A, editor. Health outcomes for primary and out-patient care: an editorial overview. Amsterdam: Harwood Academic Publishers; 1996. p. 1—7.
W. Wong et al. 2. Lau JTF, Leung EMF, Tsui HY. Predicting traditional Chinese medicine’s use and the marginalization of medical care in Hong Kong. American Journal of Chinese Medicine 2001;29:547—58. 3. Lau JTF, Yu A. The choice between Chinese medicine and Western medicine practitioners by Hong Kong adolescents. American Journal of Chinese Medicine 2000;28:131—9. 4. WHO. WHO global atlas of traditional, complementary and alternative medicine. Kobe, Japan: WHO Centre for Health Development; 2005. 5. Busato A, et al. Health status and health care utilisation of patients in complementary and conventional primary care in Switzerland — an observational study. Family Practice 2006;23:116—24. 6. Critchley JAJH, et al. Alternative therapies and medical science: designing clinical trials of alternative/complementary medicines — is evidence-based traditional Chinese medicine attainable? Journal of Clinical Pharmacology 2000;40:462—7. 7. Tonelli MR, Callahan TC. Why alternative medicine cannot be evidence-based. Academic Medicine 2001;76:1213—20. 8.
1997;18:649—51. 9. Lam CLK, Lauder IJ. The impact of chronic diseases on the health-related quality of life (HRQOL) of Chinese patients in primary care. Family Practice 2000;17(2):159—66. 10. Leung KF, et al. Development and validation of the Chinese quality of life instrument. Health and quality of life Outcomes 2005:26. 11. Zhao L, Leung KF, Chan K. The Chinese Quality of Life instrument: reliability and validity of the Hong Kong Chinese version (ChQOL-HK). The Hong Kong Practitioner 2007;29: 220—32. 12. Wong W, et al. Is the content of the Chinese Quality of Life Instrument (ChQOL) really valid in the context of traditional Chinese Medicine in Hong Kong? Complementary Therapies in Medicine 2009;17(1):29—36. 13. Tang JL, Wong TW. The need to evaluate the clinical effectiveness of traditional Chinese medicine. HKMJ 1998;4: 208—10. 14. Kazis LE, Anderson JJ, Meenan RF. Effect sizes for interpreting changes in health status. Medical Care 1989;27(suppl 3):S178—89. 15. Wyrwich KW, et al. Estimating clinically significant differences in quality of life outcomes. Quality of Life Research 2005;14:285—95. 16. Cowling BJ. Errors, power & sample size. Department of Community Medicine, University of Hong Kong; 2005. 17. Lam CLK, et al. Brief problem-solving treatment in primary care (PST-PC) was not more effective than placebo for elderly patients screened — positive of psychological problems. International Journal of Geriatric Psychiatry 2009, doi:10.1002(2435). 18. Lam CLK. Reliablity and construct validity of the Chinese (Hong Kong) SF-36 for patients in primary care. Hong Kong Practitioner 2003;25(10):468—75. 19. WONCA Classification Committee of the World Organization of National Colleges, Academies, and Academic Associations of General Practitioners. ICPC-2: International classification of primary care. 1998. 20. Lam CLK, et al. Population based norming of the Chinese (HK) version of the SF-36 health survey. The Hong Kong Practitioner 1999;21:460—70. 21. HKSAR Census and Statistics Department. Thematic household survey report no. 30. 2007; p. 62—76. 22. Michlig M, Ausfeld-Hafter B, Busato A. Patient satisfaction with primary care: a comparison between conventional care
Effectiveness between Western medicine and Chinese medicine outpatient consultations in primary care and traditional Chinese Medicine. Complementary Therapies in Medicine 2008;16:350—8. 23. Lam CLK, et al. The SF-36 summary scales were valid, reliable, and equivalent in a Chinese population. Journal of Clinical Epidemiology 2005;58:815—22. 24. Witt CM, Ludtke R, Willich SN. Homeopathic treatment of patients with Migraine: a prospective observational study with
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a 2-year follow-up period. The Journal of Alternative and Complementary Medicine 2010;16(4):347—55. 25. Chung VC, et al. Referral to and the attitude towards traditional Chinese medicine amongst western medical doctors in postcolonial Hong Kon. Social Science and Medicine 2011;72:247—55.