- Email: [email protected]
Complementary and alternative medicine (CAM) use patterns and disclosure to physicians in acute coronary syndromes patients
Complementary Therapies in Medicine (2005) 13, 34—40
Complementary and alternative medicine (CAM) use patterns and disclosure to physicians in acute coronary syndromes patients Debra Barraco a, Gretchen Valencia a, Arthur L. Riba a, Suneetha Nareddy b, Cathy B.S.N. Draus a, Steven M. Schwartz c,∗ a
Cardiology Education and Research, USA Medical Education, Internal Medicine, USA c Research Office, Suite 126, Oakwood Healthcare System, 18101 Oakwood Blvd., Dearborn, MI 48123-2500, USA b
KEYWORDS Acute coronary syndromes; CAM use; Communications with physicians
Summary This study assessed the frequency and types of CAM therapies used by patients hospitalized with acute coronary syndromes for general health purposes and cardiac reasons. We profiled CAM users including gender differences and degree of disclosure with treating physicians’. Data collection occurred via semi-structured interview and included demographics, past medical history, CAM use, physician visits, and patient—physician communications. Eight hundred and forty-six patients were screened for eligibility with 223 patients meeting eligibility criteria and completing data collection. Sixty-three percent of this sample used at least one CAM therapy for general health purposes in the year prior to the index hospitalization. Only 11.7% of patients reported using CAM for cardiac specific reasons. Women were more likely to use CAM relative to men and also tended to use a greater number of CAM therapies. More than one third (35.9%) of the patients that used CAM therapies did not inform their physician. Only a small fraction of CAM use was specific to cardiovascular health. These data suggest that a significant portion of patients do not report CAM use to their physicians and physicians seldom ask. © 2005 Elsevier Ltd. All rights reserved.
Introduction There continues to be growing interest in the use of complementary and alternative medicine (CAM)
* Corresponding author. Tel.: +1 313 436 2783; fax: +1 313 593 5931. E-mail address: [email protected] (S.M. Schwartz).
therapies for a wide array of common health concerns. A number of studies (e.g.1—6 ) have documented a significant and increasing trend towards CAM use in the U.S. adult population. For example, Kessler et al. (2001) found that nearly 68% of respondents to their telephone survey had used at least one CAM therapy in their lifetime. Further, there has been a concomitant increase in healthcare expenditures for CAM therapies with out of
0965-2299/$ — see front matter © 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctim.2005.02.003
Complementary and alternative medicine use patterns and disclosure in ACS patients pocket expenditures estimated at approximately 27 million dollars for 1997.3,5 Despite the popularity of CAM among the general public, mainstream medicine has been slow to embrace many of its concepts and techniques. The credibility of CAM relative to mainstream Western medicine has been hampered by several factors. First, there is a vast and heterogeneous array of practices being lumped under the rubric of CAM. These practices can range widely from various forms of ‘‘folk medicine’’ to sophisticated computerized biofeedback systems. Second, some of these practices have supporting data and show promise as viable treatment options (both as primary and adjuvant therapies), while others may show little or no promise and may even be harmful under certain clinical circumstances. In support of CAM therapies, there is growing support for the role of various forms of relaxation training and biofeedback in clinical practice to control anxiety, pain and other manifestations of sympathetic drive like hypertension (e.g.7—10 ). In other circumstances CAM use may interfere or complicate care (e.g.11—13 ). Because of (or perhaps in spite of) these factors, there has been increased attention to CAM efficacy, prompting the National Institutes of Health to establish the National Center for complementary and alternative medicine in 1998 in an attempt to bring greater methodological rigor and financial resources to CAM research endeavors. The use of CAM therapies has important implications for Western Medicine. First, it has been argued that one aspect of the rise in CAM popularity is dissatisfaction with certain aspects of Western Medicine.14—19 Astin20 examined why patients use CAM therapies and found that among other things, respondents felt a distrust of conventional practices, greater congruence of CAM with their personal values, and greater control over health matters when using CAM. A second, more clinical implication is that treating physicians may not be informed of their patient’s use of CAM (e.g.21 ) and/or may underestimate the use of CAM in their patient population.22 Because there is a perception that many CAM therapies are more natural, less invasive, and safer than conventional medical treatments, many patients may feel it is not necessary to discuss these practices with their doctor and many doctors may not inquire. Others may feel that their physician may have a ‘‘closed’’ attitude towards such practices and wish to avoid that interaction. Because the use of some CAM therapies may complicate or compromise more traditional treatments it is important to identify barriers to open discussion of CAM use with treating physicians.
35
Until very recently there had been a paucity of data concerning the use of CAM therapies in patients with established cardiovascular disease (CVD). One of the most often cited study by Eisenberg2 only queried respondents about hypertension. Importantly, there is reason to believe that particular CAM therapies, such as relaxation training, mindfulness or other forms of stress management might provide important therapeutic benefit (e.g.9,23,24 ). Several outcomes studies have now been published lending initial support for certain CAM therapies in cardiovascular disease (e.g.8,25—29 ) and Kreitzer and Snyder30 have recently provided models for integration of CAM into more traditional cardiovascular care. Given these trends and the emerging data on CAM use for CVD, the following study was undertaken to develop a benchmark profile for CAM use in patients presenting with acute coronary syndromes (ACS). The primary purpose of the study was to take a cross-sectional ‘‘snap-shot’’ of the frequency and types of CAM therapies used by ACS patients for both general health purposes and heart disease specifically. Secondarily, we examined whether any characteristic differences exist in CAM users. Given the interests of the authors and recent trends that focus on heart health in women,31—33 specific gender differences were of focus. While a number of the studies have assess for gender differences and found none,1,34 our interest stems from emerging data that indicates women may have a different cardiovascular course and that illness/health related behavior around cardiovascular disease may also differ by gender.32,33,35 Lastly we sought to determine the degree of disclosure and dialogue this sample of patients had with treating physician’s regarding CAM.
Materials and methods Subjects All consecutive patients ≥18 years admitted to the cardiac care units of Oakwood Hospital and Medical Center during a 3 month period with suspected acute coronary syndrome patients (N = 846) were screened for eligibility (except for 57 patients who were discharged before they could be screened). The 3-month recruitment period was based primarily on the pragmatics of available research resources. Because this study was exploratory rather than designed to test an a priori hypothesis there was no effect size estimates upon which to base a power calculation. The sample size for this study
36
D. Barraco et al.
was based upon previously published works in the area.1,21,34 However, this is a potential limitation of the current study methodology. This study was conducted at the Oakwood Hospital and Medical Center (OHMC) with IRB approval. OHMC is the flagship hospital (620 beds) for the Oakwood Healthcare System. The Medical Center is a full service tertiary care, teaching hospital. Oakwood maintains a Cardiology Center of Excellence, does over 900 open-heart surgeries annually, over 6000 other cardiovascular interventions and has been awarded a Top 100 Cardiovascular hospital by Solucient® five out of the last 6 years. Patients were included if they had a chief complaint of chest pain, prior history of documented coronary artery disease and received a diagnosis of unstable angina, myocardial infarction, or with planned coronary revascularization in the Coronary Care Unit or step-down units. Screened patients were excluded if they were without prior history of cardiac problems, did not speak English, were unable to be interviewed due to hemodynamic in-
stability, cognitive dysfunction, or sensory deficits, were scheduled for CABG, had a history of heart failure, had chest pain of a non-cardiac origin, psychiatric history, or signed out against medical advise (N = 566). Fig. 1 illustrates the recruitment and inclusion/exclusion of patients to the study, including the reasons for exclusion. A final sample of 223 patients completed the data collection process.
Procedures Standardized semi-structured interviews were conducted either by a cardiac research nurse, a research assistant with a medical degree, or a trained internal medicine resident. The research assistant and resident were trained to a standard (i.e. the cardiac research nurse) but no reliability data is available. The interviews assessed CAM use for general health purposes, CAM use specific to cardiovascular disease, types and frequency of physician visits, past medical history, and communications
Figure 1 Patient recruitment flow chart.
Complementary and alternative medicine use patterns and disclosure in ACS patients
Table 1 List of complementary and alternative medicine therapies queried. Acupuncture Anthroposophical medicine Antioxidant therapy Aroma therapy Ayurvedic medicine Biofeedback Chelation therapy Chiropractic Colonics Energy healing (including crystals) Exercise Folk remedies Herbal therapy Holistic medicine Homeopathy Hypnosis Imagery Lifestyle diets (i.e. macrobiotics, Pritikin) Magnetics Megavitamin therapy (not a daily vitamin) Minerals (trace; not calcium or iron supplements) Native American medicine Naturopathic medicine Physiotherapist or physical therapist Prayer Massage therapy Meditation Qi Gong Reflexology Relaxation techniques Elf-help group Shiatsu Spiritual healing Tai chi Therapeutic touch Tibetan medicine Traditional chinese medicine Visits to an alternative medicine practitioner Visits to a medical practitioner (MD, DO, nurse practitioner, physician assistant, nurse midwife) Yoga Other (please list)
about CAM use with treating physicians. Table 1 lists the CAM therapies that were specifically queried. The emphasis was to be comprehensive despite the argument that some of these therapies are more ‘‘conventional’’ than others.
Results Sample characteristics Demographic and descriptive data on the 223 participants are presented in Table 2, including the
Table 2
37
Sociodemographic sample data (N = 223).
Gender Male Female Age (mean in years) Race Caucasian African American Middle Eastern Hispanic Asian Other Marital status Married Divorced Single Widowed Education High school graduate Some high school Some college College graduate Post graduate degree Clinical presentation Unstable angina Chest pain Myocardial infarction Coronary artery disease Status post stent Arrhythmia/atrial fibrillation MVD Planned catheterisation
136 (61%) 87 (39%) 66.2 (S.D. = 13.4) 175 (78.5%) 29 (13%) 11 (4.9%) 4 (1.8%) 2 (.9%) 2 (.9%) 125 (56.1%) 68 (30.5%) 25 (11.2%) 5 (2.2%) 83 (37.2%) 56 (25.1%) 49 (22%) 17 (7.6%) 9 (4%) 89 (39.9%) 81 (36.3%) 30 (13.5%) 14 (6.3%) 3 (1.3%) 3 (1.3%) 2 (.9%) 1 (.4%)
primary reason for admission. The vast majority of patients (i.e. 76%) were admitted for chest pain or unstable angina. Sixty-one percent of the participants were males and 39% females. The sample was predominantly Caucasians (79%). Fifty-six percent were married, 31% formerly married, 11% single, and 2% widowed. Nearly 75% of the sample had completed high school and beyond and 77% of patients reported a household income under US$ 50,000.
CAM therapy use Sixty three percent of the sample reported using at least one of the listed CAM therapies in the year prior to the index hospitalization for any health condition or purpose. Fig. 2 graphically depicts the most common CAM therapies used for general purpose and Fig. 3 presents the same data for cardiovascular disease (CAM categories not endorsed by any patient have been omitted). The most common CAM therapies used for general health
38
Figure 2 Most commonly used complimentary and alternative therapies.
purposes were prayer (33.2%), non-prescribed exercise (22.4%), chiropractic manipulation (14%), physical therapy (12.6%), herbals (5%), antioxidants (3.6%), and minerals (2.7%). Surprisingly, only 11.7% of patients reported using CAM for cardiac specific reasons despite the fact that they all had documented cardiovascular disease. The following CAM therapies were most frequently reported as interventions for cardiac specific reasons: non-prescribed exercise (57.7%), physical therapy (30.8%), Megavitamins (19.2%), herbals (19.2%), and antioxidants (15.4%).
Profile of CAM users Interestingly, CAM users did not differ significantly from non-users in terms of ethnicity, marital status, education, or income. Nor did they differ in terms of age, BMI, number of treating physicians, number of physician visits or number of comorbidities. Gender comparisons indicated that men and women did not differ significantly in age, nor did they differ significantly in the number of doctors seen in the year prior to the index admission. However, there was a trend for women
D. Barraco et al. to report more doctor visits (women, mean = 8.5 (S.D. = 3.8) versus men, mean = 7.5 (S.D. = 4.1), p = .08) (t = 1.9 (d.f. = 221), p < .057) and women reported significantly more co-morbid conditions relative to men (mean = 10.83 (S.D. = 4.9) versus mean = 9 (S.D. = 4) (t = 1.8 (d.f. = 221), p < .066). A Chi square (2 ) analysis used to examine differences between female and male in their use of CAM therapy for any reason or for cardiovascular disease indicated that women were more likely to use CAM therapies generally (2 = 4.09 (d.f. = 1), p < .05). A t-test for independent samples also indicated that women tended to use a greater number of different CAM therapies (t = 1.9 (d.f. = 221), p < .05). More specifically, women had a greater tendency to use meditation (2 = 6.62, p < .01) and prayer (2 = 10.53, p < .001) more frequently than men. Men and women did not differ significantly in their use of other CAM therapy categories.
Physician awareness More than one third (35.9%) of the sample that used CAM reported they had not informed their physician about their use of CAM. Physician not inquiring about CAM use was the most frequently cited reason for the lack of disclosure (48%). The other reasons such as the patient felt it was not important, the patient forgot, or the patient felt uneasy talking about it accounted for a very small percentage of the endorsed barriers to reporting CAM use. Of those CAM users that did have a dialogue with their physician about, the patient’s belief that it might make a difference in medical care was most frequently endorsed reason for disclosure followed by the physician asking and the physician being receptive to the idea of CAM. Men and women did not differ in their disclosure to their physician about CAM use.
Discussion
Figure 3 Most commonly used complimentary and alternative therapies for cardiac purposes.
This study found that the frequency of CAM use in patients presenting with acute coronary syndromes was comparable to that reported by others sampling CAM use from a more general population.3,4 Interestingly, only a small fraction of patients used CAM specifically for cardiovascular health. This is somewhat surprising given that there are a number of CAM therapies that has received some attention as potentially benefiting patients with established cardiovascular disease. For example, the often cited work of Dean Ornish28,29 on lifestyle change has included meditation, yoga, relaxation, imagery and
Complementary and alternative medicine use patterns and disclosure in ACS patients other forms of psychophysiological self-regulation as part of the stress management module. The intensive lifestyle interventions package (that included CAM therapies) was shown to arrest and even reversed atherosclerosis. The data reported here indicate that women were more likely than men to have ever used a CAM therapy and were more likely to have used a greater number of CAM therapies relative to men. More specifically, women were more likely to use meditation and prayer when compared to men. Women in this sample also had greater numbers of co morbid conditions and there was a trend toward greater healthcare utilization as operationalized by physician visits. Importantly, a significant proportion of patients in this sample did not communicate their use of these therapies to their physicians and physicians seldom ask about CAM use. This is potentially problematic as some CAM therapies could undermine other medical treatments already instituted or planned. Several caveats must be acknowledged. The sample represents a highly selected and relatively small group of ACS patients. Therefore, generalization to other cardiac populations should be done cautiously. In addition, some potentially interesting findings may have been missed by under-powered significance testing. The pragmatics of clinical care made further data collection prohibitive. Nevertheless these provide a baseline for further comparisons and estimates of sample size. They also underscore the need for heightened awareness on the part of clinician’s regarding CAM use in their patients. Second, inter-rater reliability between interviewers was not obtained and therefore some rater differences may have influence disclosure. However, raters were trained to a standard and information gleaned from the interviews required minimal subjective consideration with all items focusing on factual information. Finally, some readers may take issue with some of the therapies listed in Table 1. Given that our primary aim was exploratory in nature, it was decided a priori to be over-inclusive so long as the activity was no prescribed by an acknowledged healthcare professional. Complementary and alternative medicine therapies hold great appeal for the general population and such therapies are becoming more readily available. There is much interest in CAM interventions and these treatments must undergo the same rigorous testing that is required of other medical treatments, if they are to become a part of mainstreamed evidence-based medicine. In addition they appears to be great variability in who uses CAM
39
and for what purpose CAM is used. Finally, physicians will need to query patients about CAM use and help patients make informed decisions regarding the risks and benefits of any course of CAM care in ways that are non-judgmental and fact based.
References 1. Ai AI, Bolling SF. The use of complementary and alternative therapies among middle-aged and older cardiac patients. Am J Qual Care 2002;17(1):21—7. 2. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: prevalence, costs, and patterns of use. New England J Med 1993;328:246—52. 3. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States 1990-1997: results of a follow-up national survey. J Am Med Assoc 1998;280:1569—75. 4. Kessler RC, Davis RB, Foster DF, et al. Long-term trends in the use of complementary and alternative medicine therapies in the United States. Ann Intern Med 2001;135:262—8. 5. Pelletier KR, Marie A, Krasner M, Haskell WL. Current trends in the integration and reimbursement of complementary and alternative medicine by managed care, insurance carriers, and hospital providers. Am J Health Promot 1997;12:112—22. 6. Wootton JC, Sparber A. Surveys of complementary and alternative medicine: Part I. General trends and demographic groups. J Alternative Complementary Med 2001;7:195—208. 7. Barnes VA, Davis H, Murzynowski JB, Treiber FA. Impact of meditation on resting and ambulatory blood pressure and heart rate in youth. Psychosomatic Med 2004;66:909—14. 8. Henderson RJ, Hart MG, Lal SKL, Hunyor SN. The effects of home training with direct blood pressure biofeedback of hypertensives: a placebo-controlled study. 9. Jayasinghe SR. Yoga in cardiac health (a review). Eur J Cardiovasc Prevent Rehabil 2004;11:369—75. 10. Lehrer PM, Vaschillo E, Vaschillo B, Lu SE, et al. Heart rate variability biofeedback increases baroreflex gain and peak expiratory flow. Psychosomatic Med 2003;65:796—805. 11. Cupp MJ. Herbal remedies: adverse effects and drug interactions. Am Fam Physician 1999;59:1239—47. 12. Miller KE. Is herbal therapy safe in cardiovascular disease? Am Fam Physician 2002;66(7):1318. 13. Vogelzang JL. Alternative and complementary nutrition in chronic heart disease. Home Healthcare Nurse 2004;22:85—7. 14. Avina RL, Schneiderman LJ. Why patients choose homeopathy. West Med J 1978;128:366—9. 15. Furnham A, Bhagrath R. A comparison of health and behaviours of clients of orthodox and complementary medicine. Br J Clin Psychol 1993;32:237—46. 16. Furnham A, Smith C. Choosing complementary medicine: a comparison of the beliefs of patients visiting a GO and a homeopath. Soc Sci Med 1988;26:653—87. 17. Jensen P. Alternative therapy for atopic dermatitis and psoriasis: patient-reported motivation, information source and effect. Acta Derm Venereol 1990;70:425—8. 18. Marquis MS, Davis AR, Ware JE. Patient satisfaction and change in medical-care provider: a longitudinal study. Med Care 1983;21:821—9.
40 19. Sutherland LR, Verhoef MJ. Why do patients seek a second opinion or alternative medicine? J Clin Gastroenterol 1994;19:194—7. 20. Astin JA. Why patients use alternative medicine: results of a national survey. J Am Med Assoc 1998;279:1548—53. 21. Liu EH, Turner LM, Lin SX, et al. Use of alternative medicine by patients undergoing cardiac surgery. J Thorac Cardiovasc Surg 2000;120:335—41. 22. Sikland A, Laken M. Pediatricians’ experience with and attitudes toward complementary/alternative medicine. Arch Pediatr Adolesc Med 1998;152:1059—64. 23. Linden W. Psychological treatments in cardiac rehabilitation: review of rationales and outcomes. J Psychosomatic Med 2000;48:443—54. 24. Luskin FM, Newell KA, Griffith M, et al. A review of mindbody therapies in the treatment of cardiovascular disease. Part 1: implications for the elderly. Alternative Ther 1998;4:46—61. 25. Field JZ, Walton KG, Schneider RH, et al. Effect of a multimodality natural medicine program on carotid atherosclerosis in older subjects: a pilot trial of Maharishi Vedic Medicine. Am J Cardiol 2002;89:952—8. 26. King MS, Carr T, D’Cruz C. Transcendental meditation, hypertension and heart disease. Austr Fam Physician 2002;31:164—8. 27. Krucoff MW, Crater SW, Green CL, et al. Integrative noetic therapies as adjuncts to percutaneous intervention during unstable coronary syndromes: monitoring and actualization of noetic training (MANTRA) feasibility pilot. Am Heart J 2001;142:760—7.
D. Barraco et al. 28. Ornish D, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary heart disease: the lifestyle heart trial. The Lance 1990;336:128—33. 29. Ornish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. The Lance 1990;336:128—33; Ornish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. J Am Med Assoc 1998;280:2001—7. 30. Kreitzer MJ, Snyder M. Healing the heart: Integrating complementary therapies and healing practices into the care of cardiovascular patients. Prog Cardiovasc Nurs 2002;17(2):73—80. 31. Charney P. Presenting symptoms and diagnosis of coronary heart disease in women. J Cardiovasc Risk 2002;9: 303—7. 32. Mosca L. Heart disease prevention in women. Circulation 2004;109(10):e158—60. 33. Mosca L., for the Expert Panel/Writing Group. Summary of the American Heart Association’s evidencebased guidelines for cardiovascular disease prevention in women. Arteriosc Thromb Vasc Biol 2004;24(3):394— 96. 34. Wood MJ, Steward RL, Merry H, Johnstone DE, Cox JL. Use of complementary and alternative medical therapies in patients with cardiovascular disease. Am Heart J 2003;145:806—12. 35. Tesch BJ. Herbs commonly used by women: an evidencebased review. Am J Obstet Gynecol 2003;188(5):S44— 55.
Complementary and alternative medicine (CAM) use patterns and disclosure to physicians in acute coronary syndromes patients Debra Barraco a, Gretchen Valencia a, Arthur L. Riba a, Suneetha Nareddy b, Cathy B.S.N. Draus a, Steven M. Schwartz c,∗ a
Cardiology Education and Research, USA Medical Education, Internal Medicine, USA c Research Office, Suite 126, Oakwood Healthcare System, 18101 Oakwood Blvd., Dearborn, MI 48123-2500, USA b
KEYWORDS Acute coronary syndromes; CAM use; Communications with physicians
Summary This study assessed the frequency and types of CAM therapies used by patients hospitalized with acute coronary syndromes for general health purposes and cardiac reasons. We profiled CAM users including gender differences and degree of disclosure with treating physicians’. Data collection occurred via semi-structured interview and included demographics, past medical history, CAM use, physician visits, and patient—physician communications. Eight hundred and forty-six patients were screened for eligibility with 223 patients meeting eligibility criteria and completing data collection. Sixty-three percent of this sample used at least one CAM therapy for general health purposes in the year prior to the index hospitalization. Only 11.7% of patients reported using CAM for cardiac specific reasons. Women were more likely to use CAM relative to men and also tended to use a greater number of CAM therapies. More than one third (35.9%) of the patients that used CAM therapies did not inform their physician. Only a small fraction of CAM use was specific to cardiovascular health. These data suggest that a significant portion of patients do not report CAM use to their physicians and physicians seldom ask. © 2005 Elsevier Ltd. All rights reserved.
Introduction There continues to be growing interest in the use of complementary and alternative medicine (CAM)
* Corresponding author. Tel.: +1 313 436 2783; fax: +1 313 593 5931. E-mail address: [email protected] (S.M. Schwartz).
therapies for a wide array of common health concerns. A number of studies (e.g.1—6 ) have documented a significant and increasing trend towards CAM use in the U.S. adult population. For example, Kessler et al. (2001) found that nearly 68% of respondents to their telephone survey had used at least one CAM therapy in their lifetime. Further, there has been a concomitant increase in healthcare expenditures for CAM therapies with out of
0965-2299/$ — see front matter © 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctim.2005.02.003
Complementary and alternative medicine use patterns and disclosure in ACS patients pocket expenditures estimated at approximately 27 million dollars for 1997.3,5 Despite the popularity of CAM among the general public, mainstream medicine has been slow to embrace many of its concepts and techniques. The credibility of CAM relative to mainstream Western medicine has been hampered by several factors. First, there is a vast and heterogeneous array of practices being lumped under the rubric of CAM. These practices can range widely from various forms of ‘‘folk medicine’’ to sophisticated computerized biofeedback systems. Second, some of these practices have supporting data and show promise as viable treatment options (both as primary and adjuvant therapies), while others may show little or no promise and may even be harmful under certain clinical circumstances. In support of CAM therapies, there is growing support for the role of various forms of relaxation training and biofeedback in clinical practice to control anxiety, pain and other manifestations of sympathetic drive like hypertension (e.g.7—10 ). In other circumstances CAM use may interfere or complicate care (e.g.11—13 ). Because of (or perhaps in spite of) these factors, there has been increased attention to CAM efficacy, prompting the National Institutes of Health to establish the National Center for complementary and alternative medicine in 1998 in an attempt to bring greater methodological rigor and financial resources to CAM research endeavors. The use of CAM therapies has important implications for Western Medicine. First, it has been argued that one aspect of the rise in CAM popularity is dissatisfaction with certain aspects of Western Medicine.14—19 Astin20 examined why patients use CAM therapies and found that among other things, respondents felt a distrust of conventional practices, greater congruence of CAM with their personal values, and greater control over health matters when using CAM. A second, more clinical implication is that treating physicians may not be informed of their patient’s use of CAM (e.g.21 ) and/or may underestimate the use of CAM in their patient population.22 Because there is a perception that many CAM therapies are more natural, less invasive, and safer than conventional medical treatments, many patients may feel it is not necessary to discuss these practices with their doctor and many doctors may not inquire. Others may feel that their physician may have a ‘‘closed’’ attitude towards such practices and wish to avoid that interaction. Because the use of some CAM therapies may complicate or compromise more traditional treatments it is important to identify barriers to open discussion of CAM use with treating physicians.
35
Until very recently there had been a paucity of data concerning the use of CAM therapies in patients with established cardiovascular disease (CVD). One of the most often cited study by Eisenberg2 only queried respondents about hypertension. Importantly, there is reason to believe that particular CAM therapies, such as relaxation training, mindfulness or other forms of stress management might provide important therapeutic benefit (e.g.9,23,24 ). Several outcomes studies have now been published lending initial support for certain CAM therapies in cardiovascular disease (e.g.8,25—29 ) and Kreitzer and Snyder30 have recently provided models for integration of CAM into more traditional cardiovascular care. Given these trends and the emerging data on CAM use for CVD, the following study was undertaken to develop a benchmark profile for CAM use in patients presenting with acute coronary syndromes (ACS). The primary purpose of the study was to take a cross-sectional ‘‘snap-shot’’ of the frequency and types of CAM therapies used by ACS patients for both general health purposes and heart disease specifically. Secondarily, we examined whether any characteristic differences exist in CAM users. Given the interests of the authors and recent trends that focus on heart health in women,31—33 specific gender differences were of focus. While a number of the studies have assess for gender differences and found none,1,34 our interest stems from emerging data that indicates women may have a different cardiovascular course and that illness/health related behavior around cardiovascular disease may also differ by gender.32,33,35 Lastly we sought to determine the degree of disclosure and dialogue this sample of patients had with treating physician’s regarding CAM.
Materials and methods Subjects All consecutive patients ≥18 years admitted to the cardiac care units of Oakwood Hospital and Medical Center during a 3 month period with suspected acute coronary syndrome patients (N = 846) were screened for eligibility (except for 57 patients who were discharged before they could be screened). The 3-month recruitment period was based primarily on the pragmatics of available research resources. Because this study was exploratory rather than designed to test an a priori hypothesis there was no effect size estimates upon which to base a power calculation. The sample size for this study
36
D. Barraco et al.
was based upon previously published works in the area.1,21,34 However, this is a potential limitation of the current study methodology. This study was conducted at the Oakwood Hospital and Medical Center (OHMC) with IRB approval. OHMC is the flagship hospital (620 beds) for the Oakwood Healthcare System. The Medical Center is a full service tertiary care, teaching hospital. Oakwood maintains a Cardiology Center of Excellence, does over 900 open-heart surgeries annually, over 6000 other cardiovascular interventions and has been awarded a Top 100 Cardiovascular hospital by Solucient® five out of the last 6 years. Patients were included if they had a chief complaint of chest pain, prior history of documented coronary artery disease and received a diagnosis of unstable angina, myocardial infarction, or with planned coronary revascularization in the Coronary Care Unit or step-down units. Screened patients were excluded if they were without prior history of cardiac problems, did not speak English, were unable to be interviewed due to hemodynamic in-
stability, cognitive dysfunction, or sensory deficits, were scheduled for CABG, had a history of heart failure, had chest pain of a non-cardiac origin, psychiatric history, or signed out against medical advise (N = 566). Fig. 1 illustrates the recruitment and inclusion/exclusion of patients to the study, including the reasons for exclusion. A final sample of 223 patients completed the data collection process.
Procedures Standardized semi-structured interviews were conducted either by a cardiac research nurse, a research assistant with a medical degree, or a trained internal medicine resident. The research assistant and resident were trained to a standard (i.e. the cardiac research nurse) but no reliability data is available. The interviews assessed CAM use for general health purposes, CAM use specific to cardiovascular disease, types and frequency of physician visits, past medical history, and communications
Figure 1 Patient recruitment flow chart.
Complementary and alternative medicine use patterns and disclosure in ACS patients
Table 1 List of complementary and alternative medicine therapies queried. Acupuncture Anthroposophical medicine Antioxidant therapy Aroma therapy Ayurvedic medicine Biofeedback Chelation therapy Chiropractic Colonics Energy healing (including crystals) Exercise Folk remedies Herbal therapy Holistic medicine Homeopathy Hypnosis Imagery Lifestyle diets (i.e. macrobiotics, Pritikin) Magnetics Megavitamin therapy (not a daily vitamin) Minerals (trace; not calcium or iron supplements) Native American medicine Naturopathic medicine Physiotherapist or physical therapist Prayer Massage therapy Meditation Qi Gong Reflexology Relaxation techniques Elf-help group Shiatsu Spiritual healing Tai chi Therapeutic touch Tibetan medicine Traditional chinese medicine Visits to an alternative medicine practitioner Visits to a medical practitioner (MD, DO, nurse practitioner, physician assistant, nurse midwife) Yoga Other (please list)
about CAM use with treating physicians. Table 1 lists the CAM therapies that were specifically queried. The emphasis was to be comprehensive despite the argument that some of these therapies are more ‘‘conventional’’ than others.
Results Sample characteristics Demographic and descriptive data on the 223 participants are presented in Table 2, including the
Table 2
37
Sociodemographic sample data (N = 223).
Gender Male Female Age (mean in years) Race Caucasian African American Middle Eastern Hispanic Asian Other Marital status Married Divorced Single Widowed Education High school graduate Some high school Some college College graduate Post graduate degree Clinical presentation Unstable angina Chest pain Myocardial infarction Coronary artery disease Status post stent Arrhythmia/atrial fibrillation MVD Planned catheterisation
136 (61%) 87 (39%) 66.2 (S.D. = 13.4) 175 (78.5%) 29 (13%) 11 (4.9%) 4 (1.8%) 2 (.9%) 2 (.9%) 125 (56.1%) 68 (30.5%) 25 (11.2%) 5 (2.2%) 83 (37.2%) 56 (25.1%) 49 (22%) 17 (7.6%) 9 (4%) 89 (39.9%) 81 (36.3%) 30 (13.5%) 14 (6.3%) 3 (1.3%) 3 (1.3%) 2 (.9%) 1 (.4%)
primary reason for admission. The vast majority of patients (i.e. 76%) were admitted for chest pain or unstable angina. Sixty-one percent of the participants were males and 39% females. The sample was predominantly Caucasians (79%). Fifty-six percent were married, 31% formerly married, 11% single, and 2% widowed. Nearly 75% of the sample had completed high school and beyond and 77% of patients reported a household income under US$ 50,000.
CAM therapy use Sixty three percent of the sample reported using at least one of the listed CAM therapies in the year prior to the index hospitalization for any health condition or purpose. Fig. 2 graphically depicts the most common CAM therapies used for general purpose and Fig. 3 presents the same data for cardiovascular disease (CAM categories not endorsed by any patient have been omitted). The most common CAM therapies used for general health
38
Figure 2 Most commonly used complimentary and alternative therapies.
purposes were prayer (33.2%), non-prescribed exercise (22.4%), chiropractic manipulation (14%), physical therapy (12.6%), herbals (5%), antioxidants (3.6%), and minerals (2.7%). Surprisingly, only 11.7% of patients reported using CAM for cardiac specific reasons despite the fact that they all had documented cardiovascular disease. The following CAM therapies were most frequently reported as interventions for cardiac specific reasons: non-prescribed exercise (57.7%), physical therapy (30.8%), Megavitamins (19.2%), herbals (19.2%), and antioxidants (15.4%).
Profile of CAM users Interestingly, CAM users did not differ significantly from non-users in terms of ethnicity, marital status, education, or income. Nor did they differ in terms of age, BMI, number of treating physicians, number of physician visits or number of comorbidities. Gender comparisons indicated that men and women did not differ significantly in age, nor did they differ significantly in the number of doctors seen in the year prior to the index admission. However, there was a trend for women
D. Barraco et al. to report more doctor visits (women, mean = 8.5 (S.D. = 3.8) versus men, mean = 7.5 (S.D. = 4.1), p = .08) (t = 1.9 (d.f. = 221), p < .057) and women reported significantly more co-morbid conditions relative to men (mean = 10.83 (S.D. = 4.9) versus mean = 9 (S.D. = 4) (t = 1.8 (d.f. = 221), p < .066). A Chi square (2 ) analysis used to examine differences between female and male in their use of CAM therapy for any reason or for cardiovascular disease indicated that women were more likely to use CAM therapies generally (2 = 4.09 (d.f. = 1), p < .05). A t-test for independent samples also indicated that women tended to use a greater number of different CAM therapies (t = 1.9 (d.f. = 221), p < .05). More specifically, women had a greater tendency to use meditation (2 = 6.62, p < .01) and prayer (2 = 10.53, p < .001) more frequently than men. Men and women did not differ significantly in their use of other CAM therapy categories.
Physician awareness More than one third (35.9%) of the sample that used CAM reported they had not informed their physician about their use of CAM. Physician not inquiring about CAM use was the most frequently cited reason for the lack of disclosure (48%). The other reasons such as the patient felt it was not important, the patient forgot, or the patient felt uneasy talking about it accounted for a very small percentage of the endorsed barriers to reporting CAM use. Of those CAM users that did have a dialogue with their physician about, the patient’s belief that it might make a difference in medical care was most frequently endorsed reason for disclosure followed by the physician asking and the physician being receptive to the idea of CAM. Men and women did not differ in their disclosure to their physician about CAM use.
Discussion
Figure 3 Most commonly used complimentary and alternative therapies for cardiac purposes.
This study found that the frequency of CAM use in patients presenting with acute coronary syndromes was comparable to that reported by others sampling CAM use from a more general population.3,4 Interestingly, only a small fraction of patients used CAM specifically for cardiovascular health. This is somewhat surprising given that there are a number of CAM therapies that has received some attention as potentially benefiting patients with established cardiovascular disease. For example, the often cited work of Dean Ornish28,29 on lifestyle change has included meditation, yoga, relaxation, imagery and
Complementary and alternative medicine use patterns and disclosure in ACS patients other forms of psychophysiological self-regulation as part of the stress management module. The intensive lifestyle interventions package (that included CAM therapies) was shown to arrest and even reversed atherosclerosis. The data reported here indicate that women were more likely than men to have ever used a CAM therapy and were more likely to have used a greater number of CAM therapies relative to men. More specifically, women were more likely to use meditation and prayer when compared to men. Women in this sample also had greater numbers of co morbid conditions and there was a trend toward greater healthcare utilization as operationalized by physician visits. Importantly, a significant proportion of patients in this sample did not communicate their use of these therapies to their physicians and physicians seldom ask about CAM use. This is potentially problematic as some CAM therapies could undermine other medical treatments already instituted or planned. Several caveats must be acknowledged. The sample represents a highly selected and relatively small group of ACS patients. Therefore, generalization to other cardiac populations should be done cautiously. In addition, some potentially interesting findings may have been missed by under-powered significance testing. The pragmatics of clinical care made further data collection prohibitive. Nevertheless these provide a baseline for further comparisons and estimates of sample size. They also underscore the need for heightened awareness on the part of clinician’s regarding CAM use in their patients. Second, inter-rater reliability between interviewers was not obtained and therefore some rater differences may have influence disclosure. However, raters were trained to a standard and information gleaned from the interviews required minimal subjective consideration with all items focusing on factual information. Finally, some readers may take issue with some of the therapies listed in Table 1. Given that our primary aim was exploratory in nature, it was decided a priori to be over-inclusive so long as the activity was no prescribed by an acknowledged healthcare professional. Complementary and alternative medicine therapies hold great appeal for the general population and such therapies are becoming more readily available. There is much interest in CAM interventions and these treatments must undergo the same rigorous testing that is required of other medical treatments, if they are to become a part of mainstreamed evidence-based medicine. In addition they appears to be great variability in who uses CAM
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and for what purpose CAM is used. Finally, physicians will need to query patients about CAM use and help patients make informed decisions regarding the risks and benefits of any course of CAM care in ways that are non-judgmental and fact based.
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