- Email: [email protected]
Patient experience of acupuncture provision in a GP practice
Complementary Therapies in Clinical Practice 18 (2012) 140e144
Contents lists available at SciVerse ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Patient experience of acupuncture provision in a GP practice M. Fixler a, C. Ogden b, F. Moir b, M.J. Polley b, * a b
Highgate Acupuncture Practice, 82 Priory Gardens, London N6 5QS, UK School of Life Sciences, University of Westminster, 115 New Cavendish Street, London W1W 6UW, UK
a b s t r a c t Keywords: Acupuncture GP Evaluation Patient experience MYMOP
Patient experience of acupuncture at a GP surgery was evaluated over 18 months. Patients were referred for six acupuncture treatments of 45 min by 10 practising GPs. Measure Your Medical Outcome Profile (MYMOP), was completed before the first treatment and at the start of the final consultation. A patient experience survey was completed immediately after the patient’s last appointment. Results: A statistically and clinically significant improvement in the mean MYMOP profile score (1.6 SD 1.3, p < 0.0000) (n ¼ 47); reduction in medication usage; a reduction in pain and stress and improved quality of life. Conclusions: Acupuncture provision was beneficial to patients with predominately chronic conditions. Further studies are needed to assess the cost effectiveness and long term benefit of acupuncture in the NHS. Ó 2012 Elsevier Ltd. All rights reserved.
1. Introduction Increasing numbers of Primary Care Organisations are providing access to CAM1,2 with acupuncture being the most widely provided therapy on the NHS over the last decade.2 Studies have indicated the cost effectiveness of acupuncture versus routine medical care, for headache3,4 and neck pain5 as well as general musculoskeletal complaints.6 The NICE guideline development group responsible for the recent low back pain guidance7 considered a study by Ratcliffe et al. which demonstrated strong evidence of the cost effectiveness of acupuncture treatment.8 Furthermore, acupuncture has been shown to reduce prescription and referral costs.9 Significant support has been demonstrated among GPs for acupuncture provision on the NHS yet provision of acupuncture in GP surgeries falls considerably short of demand.10,11 Although no data has been published evaluating traditional acupuncture services in a GP setting, audits of acupuncture provision in primary care have reported favourable conclusions.12e19 Evaluations of multiple CAM therapies in primary care20e23 have solicited GP as well as patient opinion of the services and found positive feedback on both accounts. Data suggested that acupuncture used in primary care can help prevent worsening of patient conditions while on waiting lists for conventional treatment as well as reducing the need for referrals to secondary care.17
* Corresponding author. Tel.: þ44 (0) 20 7911 64627; fax: þ44 (0) 20 7911 5028. E-mail address: [email protected] (M.J. Polley). 1744-3881/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctcp.2012.03.003
An increase in patient involvement in the NHS has led to commissioners actively seeking patients’ views.24 The aim of this evaluation was to inform the practice GPs regarding patient reported outcomes and patient experience of an acupuncture service in their surgery. 2. Methods 2.1. The acupuncture service The acupuncture service was provided at a busy North London GP practice (patient population of 14,700), representing many ethnic groups. The GP practice had an acupuncture service for approximately six years until 1999, when the funding structure within GP practices changed and fund holding was terminated. Through practice based commissioning, however, 18 months of funding was made available to re-establish this acupuncture provision which ran from September 2009 until March 2010. Patients were seen by an experienced acupuncturist using Traditional East Asian Medicine diagnostic and treatment techniques and received individualised treatments tailored to their needs. The acupuncture provision ran for one, 3 h session each week, during which four patients could be seen. Patients were referred by ten practising GPs for six, 45 min acupuncture treatments (inclusive of initial consultation). No inclusion or exclusion criteria were set and GPs could seek the advice of the practitioner regarding the appropriateness of the referral. Patients could also request a referral by the GP. GPs were required to complete
M. Fixler et al. / Complementary Therapies in Clinical Practice 18 (2012) 140e144
a referral form which was processed by the acupuncture practitioner ensuring patients were guaranteed weekly appointment intervals to maximise clinical efficiency. All patients referred for acupuncture were recruited into the service evaluation using continuous sampling. Informed written consent was obtained from all participants and ethics approval was obtained from the University of Westminster Research Ethics Committee. 2.2. Data collection The quantitative patient data was collected using the validated Measure Yourself Medical Outcome Profile (MYMOP 2).25 Baseline data was collected at the first consultation before treatment. If patients presented with more than one complaint a separate MYMOP form was used for each complaint. MYMOP requires the patient to identify a primary symptom which is then scored on a seven point scale. Patients also provide a score for their general ‘wellbeing’ on this scale. Two optional scores may be provided for a second related symptom, and a daily activity. The MYMOP form also records information on the type and frequency of medication use. Follow-up MYMOP data was recorded at the start of the final consultation by rescoring the symptoms, activity and wellbeing sections and documenting current medication usage again. Finally, the follow up form invited the patient to detail anything else affecting their problem other than the acupuncture treatment received. Participants also completed a patient experience survey in the surgery waiting room after their last appointment, which collected data on patients’ experiences and opinions of the acupuncture service. The first question asked patients to rate the efficiency of the service on a scale from 1 (excellent) to 5 (poor) with room for open comments. Question two asked about their experience of having acupuncture at the practice. The third question asked patients to say if they had found acupuncture to be beneficial, and if so how they felt it had helped them, and the final question asked for any other comments and suggestions regarding the acupuncture service. Patients who were not competent with writing English or who had difficulty completing the patient questionnaire due to poor eyesight dictated their responses to the acupuncture practitioner, who completed the questionnaire verbatim and read the answers back to confirm accuracy.
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category, an exhaustive list of categories (to facilitate full definition of the data) was produced.26 3. Results 3.1. Participant data The evaluation was conducted on 46 patients. 33 patients received 6 acupuncture sessions, 8 patients received between 3 & 5 treatments and 5 patients received 7 treatments. Patients who received less than the recommended 6 sessions either had an improvement in their condition that did not warrant further treatment, or other life events stopped them attending. One participant only received 3 treatments due to the termination of the service. Irrespective of treatment length all participants completed the pre and post treatment MYMOP forms and 42 participants completed the patient experience survey. Participants had a mean age of 50 years (SD 17, range 22e86 yrs); 38 were female (82.5%) and 8 were male (17.5%). 41% of referrals were requested by the GP, and 13% were requested jointly by GP and patient. Interestingly the majority of referrals were requested by the patient (46%) as awareness of the acupuncture service grew. Mean waiting time from referral to the initial consultation was 58 days (range 8e140 days, SD 38 days) and the mean duration of treatment was 46 days (range 14e77 days, SD 17 days). Patients seen after the first six months had the longest wait due to the increase in volume of referrals at this time. A high proportion of chronic conditions were treated. The duration of symptoms ranged from 3 months to 13 years with 74% of participants (n ¼ 34) having experienced their condition for over one year and 26 participants (56%) for over 5 years. Only 15 patients (24%) had their symptoms for less than 1 year. Fifty-eight separate symptoms were recorded on the MYMOP form (some patients presented with more than one condition) which were classified using the International Classification of Primary Care process codes. Of the 58 symptoms recorded, 42 (72%) were musculoskeletal, 5 (9%) were neurological, three (5%) were psychological, and two (3.5%) were in each of the following categories: digestive, ear related, urological and respiratory conditions. 3.2. Patient outcomes
2.3. Data analysis Data analysis was carried out using Microsoft excel 2007. Mean changes in MYMOP scores were calculated and the statistical significance calculated using a Wilcoxon sign rank test (statistical significance set at 5%). A problem specific profile score was calculated for each patient’s MYMOP form(s), which comprised the average of the symptom(s), activity and wellbeing scores.23 The mean change in profile scores was calculated and statistical significance tested using a Wilcoxon sign rank test at the 5% significance level. The change in medication use was calculated for patients who had recorded this data. Qualitative data from the patient experience questionnaire was analysed using content analysis.26 All qualitative data was transcribed and read through repeatedly to get a feel for the content. A list of themes and a coding framework using a large proportion of the data was initially developed.27 The themes and coding framework were then applied to the whole data by a second researcher to test the reproducibility of the coding criteria for the data by ensuring a high level of concurrence.28 The final themes and coding framework were then debated and agreed. To ensure that no data fell between two categories or was applied to more than one
The MYMOP profile showed a statistically significant mean improvement in score of 1.6 (p > 0.000) (see Table 1). In fact, all of the components of the profile (Symptom 1, Activity 1, Symptom 2 and Wellbeing) had statistically significant mean improvements of scores (see Table 1). Fig. 1 shows the breakdown in scores changes for the participants. There was an overwhelmingly positive response to the acupuncture treatments. For Symptom 1, 85% of participants (n ¼ 46) had an improvement. Only 5 participants had no change in their score and 3 scored Symptom 1 as worse at the end of
Table 1 Mean changes to MYMOP scores.
Symptom 1 Symptom 2 Activity 1 Wellbeing Profile
Mean change
SD
n
p
1.8 1.8 1.7 1.2 1.6
1.4 1.6 1.5 1.9 1.3
58 54 54 54 58
>0.0000 >0.0000 >0.0000 >0.0000 >0.0000
The MYMOP guidelines suggest that a mean score change of 1 or above represents a clinically significant change.28
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M. Fixler et al. / Complementary Therapies in Clinical Practice 18 (2012) 140e144
Fig. 1. Distribution of changes in MYMOP scores. Fig. 1 demonstrates the degree of change in participants MYMOP scores where a change of 1 or over is clinically significant changes in those participants, 0 represents no detectable change by the participant and a minus score represents deterioration in symptom or wellbeing.
treatment. Results were similar for Symptom 2, as 72% of participants scored an improvement, 21% had no change and 3 participants’ scores were worse. Wellbeing scores improved in 55% (n ¼ 30) of participants. 31% (n ¼ 17) of participants scored no change in wellbeing and 7 (14%) scored wellbeing as worse. Medication usage was recorded for 21 participants (46%) at referral to the acupuncture service, typically including paracetamol, ibruprofen and codeine based analgesics, sleeping tablets and antidepressants. At the end of the acupuncture treatment, 43% of these participants had stopped taking medication and 52% had substantially reduced their intake. When asked if there was anything else important such as changes made or other things happening in their lives that may affect their treatment, 52% of participants responded. Of the respondents, 19 (79%) experienced negative events such as stressful personal circumstances, or other illnesses which they felt negatively affected their follow-up scores. Three participants noted beneficial changes that they had made (e.g. long over due holidays and taking up exercise). Two participants reported no change for this category and four participants noted the improvement of other conditions that they were not specifically treated for.
3.3. Patient experience of the service 42 of the 46 participants completed the patient experience survey. All were satisfied with the efficiency of the service: 81% (n ¼ 34) rated the service as excellent; 17% (n ¼ 7) rated it as good; 2% (n ¼ 1) rated it as satisfactory. Patient responses to the open questions were consistently positive. Content analysis of these responses produced 6 overall categories each encompassing between 2 and 3 codes, with 14 separate codes in total. The three most frequently cited codes, or aspects of treatment valued by patients, were a reduction in pain (n ¼ 29 patients), a reduction in stress levels (n ¼ 27 patients) and improvements in quality of life (n ¼ 22 patients). “Not had any pain on right knee since this was treated. Pain levels have halved ”(F, 69) “Relaxed and de-stressed me physically and mentally ”(F, 34)
“I feel more pro-active e better equipped to deal with life generally. I feel physically & emotionally stronger. I have been exercising regularly, lost some weight & emotionally/ mentally highs and lows are not so severe”(F, 41) Patients also appreciated the opportunity to access acupuncture in an NHS setting, in some cases owing to the reassurance that the practitioner was legitimate and trustworthy: “It has been brilliant being on the NHS, which means it’s recommended; one can have complete trust in the practitioner” (F, 38) NHS affiliation also meant that treatment was free. For a number of patients this service provided a unique opportunity to access acupuncture which they would never be able to afford privately. “I would have struggled to pay for this service privately as I am not earning much at present” (F, 37) Six patients mentioned a reduced need for their conventional medication as a result of treatment, with one patient remarking on the prophylactic effects of acupuncture: “The alternative was anti-depressants and now I do not feel like I need them” (F, 41) The analysis produced a whole category termed practitioner qualities. Overall, 31 comments noted the affability and professionalism of the practitioner and patients particularly appreciated feeling listened to and understood. “Marian understands things I’m saying; I found her caring and she explains things nicely” (F, 38)
4. Discussion The aim of this service evaluation was to gather data on patient outcomes and experience of the acupuncture service for the GPs who commissioned it. The majority of patients had musculoskeletal complaints which would be anticipated given the high proportion of adults affected by MSK pain in GP surgeries29 and the publication of NICE guidelines recommending acupuncture for persistent low back pain.7
M. Fixler et al. / Complementary Therapies in Clinical Practice 18 (2012) 140e144
Furthermore, there is a recognised effectiveness gap in treating patients with MSK on the NHS,30,31 hence a new referral route for GP’s has been shown to be welcomed.23 Findings from this evaluation and previous studies also support a broader use of acupuncture including mental health22 and psycho-social problems,21 IBS and eczema14 as well as ear, nose and throat disorders.32 Having an acupuncture service at this GP surgery was a great success. Referred patients had a high degree of chronicity to their symptoms (56% experienced symptoms for over 5 years). This represents a large group of patients that do not appear to be responding or improving with current NHS treatment and who are living with a reduced quality of life, often with high levels of pain which require frequent analgesia. The MYMOP scores showed highly statistically significant positive changes to the patients’ Symptom, Activity, Wellbeing and Profile scores (Table 1). The mean change in profile scores was 1.6 (SD 1.3) which is above the threshold of detecting clinically significant changes in patients.33 It is particularly noticeable that there is a high level of improvement in the wellbeing scores in comparison to other studies using acupuncture.34,35 At the end of the acupuncture treatments all but one patient on prescribed medication had either stopped or substantially reduced their usage. The acupuncture practitioner was not involved in any clinical decisions regarding change in medication, and advised patients to return to their GP to discuss medication issues. Patients that decreased prescribed medication therefore, either made a personal decision in the case of analgesics, or made the decision in collaboration with their GP. Interestingly, Cheshire et al.23 also report a statistically significant reduction in analgesic use (82%e 68.7% p < 0.003) after a course of acupuncture or osteopathy for 102 patients. When contextualising the MYMOP scores changes and changes in medication usage with the degree of chronic conditions treated, the current improvements in scores are even more impressive. It is important to consider all outcomes significant to patients when evaluating the success of complex interventions such as acupuncture. Collecting qualitative and quantitative data is therefore advocated36e38 to reflect the holistic contribution of acupuncture and address the complexity of healthcare research.39 Two aspects of this service evaluation collected qualitative data to complement the quantitative scores. Firstly the MYMOP follow-up form asked patients to report any other changes they had made or events occurring in their lives that they feel may affect their reported symptom or wellbeing. Previous research40 using Measure Yourself Concerns and Wellbeing (MYCAW), demonstrated a statistically significant relationship between the scores changes of patients with cancer and the ‘other events’ that were occurring in their life at the time. Patients with positive life events (e.g. holiday, increase in social support) had better score changes than patients experiencing negative life events (e.g. bereavement, forced early retirement, low social support).40 This data highlights the need to contextualise patient score changes with other aspects of the patient’s life. Events recorded by patients on the MYMOP follow up form in this evaluation were coded as positive, negative or nothing significant mentioned. The majority of patients with negative symptom and wellbeing scores changes reported negative events occurring in their lives (e.g. acute infection at time of evaluation, moving house, or ending a relationship). Interestingly, half of the patients who reported negative events still showed improvements in their symptom, activity and wellbeing scores. By contextualising the score changes with qualitative data it is possible to draw more accurate conclusions about success of the acupuncture service. The patient experience survey collected mainly qualitative data. When asked how the patients felt they benefited from the acupuncture service, three main themes emerged e reduction in
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pain, reduction in stress levels and improvement in quality of life. Interestingly, no patients came specifically to reduce stress or improve quality of life, yet they felt the need to report this additional improvement. It is a common ‘added extra’ to patients receiving complementary therapies that conditions other than the one being treated for also improve.23,35,41 Patients were asked to give ‘any other comments about the acupuncture service’, to give the researchers insight into patients’ values and perceptions of the acupuncture service. Patients were extremely positive and expressed their appreciation of being able to access acupuncture in an NHS setting as an alternative treatment option, their desire for more treatment, their willingness to have more acupuncture in the future and to recommend the treatment to family and friends. Very similar points have been reported elsewhere.20e23 All patients receiving acupuncture were referred by the GP. Interestingly, as the awareness of the acupuncture service grew, 46% of referrals were initiated at the request of the patient. Cheshire et al.23 also report a rise of patient initiated referrals to the acupuncture and osteopathy service. To enhance external validity, patients represented the general surgery population therefore maintaining differences that exist in actual clinical practice. All patients were seen in order of referral, and the practitioner had autonomy over the delivery of acupuncture.42 5. Conclusion and recommendations The proposed changes to commissioning by the UK government awaiting implementation have significant consequences for the NHS and healthcare in general. Future research should address the limitations of this service evaluation and compare the clinical and economic effectiveness of acupuncture treatment to other treatment options such as physiotherapy, with a larger sample of patients. Providing an extended treatment period would be beneficial given the chronicity of the conditions referred, and follow-up data at 6e12 months would provide an indication of duration of effects from acupuncture. Qualitative feedback from referring practitioners would also provide their valuable opinion of the service. This evaluation using MYMOP to measure symptom and wellbeing changes coupled with patient experience data demonstrates the benefits to the patient of providing acupuncture treatment in this GP practice. Competing interests The authors declare that they have no competing interests. Sources of support This evaluation was supported by a grant from the TCM (Traditional Chinese Medicine) Development Trust. Writing of the manuscript for CS was supported by a bursary from the University of Westminster. Acknowledgements We would like thank Prof Damien Ridge for his contribution in the research process and Dr Anna Cheshire for discussion and critical reading of the draft manuscript. Thank you to all staff at the GP surgery and all patients who participated in the service evaluation. References 1. Thomas K, Coleman P, Weatherley-Jones E, Luff D. Developing integrated CAM services in Primary Care Organisations. Complementary Therapies in Medicine 2003;11:261e7.
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2. Smallwood C. The role of complementary and alternative medicine in the NHS. London: Get Well UK; 2005. 3. Wonderling D, Vickers A, Grieve R, MaCarney R. Cost effectiveness analysis of a randomised trial of acupuncture for chronic headache in primary care. British BMJ 2004;328(7442):747 [Epub 2004 Mar 15]. 4. Witt C, Reinhold T, Jena S, Brinkhaus B, Willich S. Cost-effectiveness of acupuncture treatment in patients with headache. Cephalagia 2008;28: 334e45. 5. Willich S, Reinhold T, Selim D, Jena S, Brinkhaus B, Witt C. Cost-effectiveness of acupuncture treatment in patients with chronic neck pain. Pain 2006;125(1e2): 107e13. 6. Lindall S. Is acupuncture for pain relief in general practice cost-effective? Acupuncture in Medicine 1999;17(2):97e100. 7. National Collaborating Centre for Primary Care In: National Institute for Health and Clinical Excellence, editor. Low back pain: early management of persistent non-specific low back pain. London: National Institute for Health and Clinical Excellence; 2009. 8. Ratcliffe J, Thomas K, MacPherson H, Brazier J. A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis. British Medical Journal 2006;333(7569):611e2. 9. Johnson G, White A, Livingstone R. Do general practices which provide an acupuncture service have low referral rates and prescription costs? A pilot survey. Acupuncture in Medicine 2008;26(4):205e13. 10. Perry R, Dowrick CF. Complementary medicine and general practice: an urban perspective. Complementary Therapies in Medicine 2000;8:71e5. 11. Lipman L, Dale J, MacPherson H. Attitudes of GPs towards the provision of acupuncture on the NHS. Complementary Therapies in Medicine 2003;11: 110e4. 12. Harborow P, Ogden J. The effectiveness of an acupuncturist working in general practice: an audit. Acupuncture in Medicine 2004;22(4):214e20. 13. Stellon A. An audit of acupuncture in a single-handed general practice over one year. Acupuncture in Medicine 2001;19(1):36e42. 14. Freedman J. An audit of 500 acupuncture patients in general practice. Acupuncture in Medicine 2002;20:30e4. 15. Joseph P. A survey of acupuncture treatments in general practice. Acupuncture in Medicine 2002;20:100e1. 16. Kam E, Eslick G, Campbell I. An audit of the effectiveness of acupuncture on musculoskeletal pain in primary health care. Acupuncture in Medicine 2002;20(1):35e8. 17. Day A, Kingsbury-Smith R. An audit of acupuncture in general practice. Acupuncture in Medicine 2004;22(2):87e92. 18. Bevis M. How to set up and outcomes-focused acupuncture service. Pulse Today [online], http://www.pulsetoday.co.uk/story.asp? sectioncode¼40&storycode¼4123655&c¼3; 2009. 19. Lim JH. Provision of medical acupuncture service in general practice under practice-based commissioning (Letter). Acupuncture in Medicine 2010;28:103e4. 20. Robinson N. Does it work? A pilot project investigating the integration of complementary medicine into primary care. London: Get Well UK; 2005. 21. Peters D, Andrews H, Hills D. Integrating complementary medicine into primary care. An audit of five months referrals to the Get Well UK complementary therapy service in South Islington. London: Get Well UK; 2006. 22. McDade D. Evaluation of a CAM pilot project in northern Ireland. London: Get Well UK; 2008. 23. Cheshire A, Polley M, Peters D, Ridge D. Is it feasible and effective to provide osteopathy and acupuncture for patients with musculoskeletal problems in a GP setting? A service evaluation. BMC Family Practice 2011;12(1):49 [Epub ahead of print].
24. Department of Health. World class commissioning competencies. NHS [online]. Available from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_ digitalassets/documents/digitalasset/dh_080954.pdf; 2008. 25. Paterson C. Measuring outcomes in primary care: a patient generated measure, MYMOP, compared with the SF-36 health survey. British Medical Journal 1996;312:1016e20. 26. Cavanagh S. Content analysis: concepts, methods and applications. Nurse Researcher 1997;4(3):5e16. 27. Hickey G, Kipping C. A multi-stage approach to the coding of data from openended questions. Nurse Researcher 1996;4(1):81e92. 28. Weber RP. Basic content analysis. 2nd ed. Sage Publications; 1990. 29. Parsons S, Breen A, Foster N, Letley L, Pincus T, Vogel S, et al. Prevalence and comparative troublesomeness by age of musculoskeletal pain in different body locations. Family Practice 2007;24(4):308e16. 30. Smallwood C. The role of complementary and alternative medicine in the NHS: an investigation into the potential contribution of mainstream complementary therapies to healthcare in the UK. Freshminds; 2005. 31. Fisher P, Van Haselen R, Hardy K, Berkovitz S, McCarney R. Effectiveness gaps: a new concept for evaluating health service and research needs applied to complementary and alternative medicine. Journal of Alternative & Complementary Medicine 2004;10(4):627e32. 32. Chapman R, Norton R, Paterson C. A descriptive outcome study of 291 acupuncture patients. European Journal of Oriental Medicine 2001;3(5): 48e53. 33. Guyatt GH, Juniper EF, Walter S, Griffith L, Goldstein RS. Interpreting treatment effects in randomised trials. British Medical Journal 1998;316:690e3. 34. Huang W, Howie J, Taylor A, Robinson N. An investigation into the effectiveness of traditional Chinese acupuncture (TCA) for chronic stress in adults: a randomised controlled pilot study. Complementary Therapies in Clinical Practice 2011;17(1):16e21. 35. Paterson C, Unwin J, Joire D. Outcomes of traditional Chinese medicine (traditional acupuncture) treatment for people with long-term conditions. Complementary Therapies in Clinical Practice 2010;16(1):3e9. 36. Merkouris A, Papathanassogloub E, Lemonidou C. Evaluation of patient satisfaction with nursing care: quantitative or qualitative approach? International Journal of Nursing Studies 2004;41:355e67. 37. O’Cathain A, Murphy E, Nicholl J. Why, and how, mixed methods research is undertaken in health services research in England: a mixed methods study. BMC Health Services Research 2007;85; Seers H, Gale N, Patterson C, Cooke H, Hoffman C, Polley M. How to summarise and report written qualitative data from patients: a method for use in cancer support care. Supportive Care in Cancer. 2007;15:963e971. 38. Paterson C, Baarts C, Launsø L, Verhoef MJ. Evaluating complex health interventions: a critical analysis of the ‘outcomes’ concept. BMC Complementary and Alternative Medicine 2009;9:18. 39. Robinson N, Donaldson J, Watt H. Auditing outcomes and costs of integrated complementary medicine provision e the importance of length of follow up. Complementary Therapies in Clinical Practice 2006;12(4):249e57 [Epub 2006 Sep 27]. 40. Seers H, Gale N, Patterson C, Cooke H, Hoffman C, Polley M. How to summarise and report written qualitative data from patients: a method for use in cancer support care. Supportive Care in Cancer 2007;15:963e71. 41. Paterson C. Evaluating the effect of treatment from the patient’s perspective. European Journal of Oriental Medicine 2010;6(4):36e9. 42. Godwin M, Ruhland L, Casso I, MacDonald S, Delva D, Birtwhistle R, et al. Pragmatic controlled clinical trials in primary care: the struggle between external and internal validity. BMC Medical Research Methodology 2003; 3:28.
Contents lists available at SciVerse ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Patient experience of acupuncture provision in a GP practice M. Fixler a, C. Ogden b, F. Moir b, M.J. Polley b, * a b
Highgate Acupuncture Practice, 82 Priory Gardens, London N6 5QS, UK School of Life Sciences, University of Westminster, 115 New Cavendish Street, London W1W 6UW, UK
a b s t r a c t Keywords: Acupuncture GP Evaluation Patient experience MYMOP
Patient experience of acupuncture at a GP surgery was evaluated over 18 months. Patients were referred for six acupuncture treatments of 45 min by 10 practising GPs. Measure Your Medical Outcome Profile (MYMOP), was completed before the first treatment and at the start of the final consultation. A patient experience survey was completed immediately after the patient’s last appointment. Results: A statistically and clinically significant improvement in the mean MYMOP profile score (1.6 SD 1.3, p < 0.0000) (n ¼ 47); reduction in medication usage; a reduction in pain and stress and improved quality of life. Conclusions: Acupuncture provision was beneficial to patients with predominately chronic conditions. Further studies are needed to assess the cost effectiveness and long term benefit of acupuncture in the NHS. Ó 2012 Elsevier Ltd. All rights reserved.
1. Introduction Increasing numbers of Primary Care Organisations are providing access to CAM1,2 with acupuncture being the most widely provided therapy on the NHS over the last decade.2 Studies have indicated the cost effectiveness of acupuncture versus routine medical care, for headache3,4 and neck pain5 as well as general musculoskeletal complaints.6 The NICE guideline development group responsible for the recent low back pain guidance7 considered a study by Ratcliffe et al. which demonstrated strong evidence of the cost effectiveness of acupuncture treatment.8 Furthermore, acupuncture has been shown to reduce prescription and referral costs.9 Significant support has been demonstrated among GPs for acupuncture provision on the NHS yet provision of acupuncture in GP surgeries falls considerably short of demand.10,11 Although no data has been published evaluating traditional acupuncture services in a GP setting, audits of acupuncture provision in primary care have reported favourable conclusions.12e19 Evaluations of multiple CAM therapies in primary care20e23 have solicited GP as well as patient opinion of the services and found positive feedback on both accounts. Data suggested that acupuncture used in primary care can help prevent worsening of patient conditions while on waiting lists for conventional treatment as well as reducing the need for referrals to secondary care.17
* Corresponding author. Tel.: þ44 (0) 20 7911 64627; fax: þ44 (0) 20 7911 5028. E-mail address: [email protected] (M.J. Polley). 1744-3881/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctcp.2012.03.003
An increase in patient involvement in the NHS has led to commissioners actively seeking patients’ views.24 The aim of this evaluation was to inform the practice GPs regarding patient reported outcomes and patient experience of an acupuncture service in their surgery. 2. Methods 2.1. The acupuncture service The acupuncture service was provided at a busy North London GP practice (patient population of 14,700), representing many ethnic groups. The GP practice had an acupuncture service for approximately six years until 1999, when the funding structure within GP practices changed and fund holding was terminated. Through practice based commissioning, however, 18 months of funding was made available to re-establish this acupuncture provision which ran from September 2009 until March 2010. Patients were seen by an experienced acupuncturist using Traditional East Asian Medicine diagnostic and treatment techniques and received individualised treatments tailored to their needs. The acupuncture provision ran for one, 3 h session each week, during which four patients could be seen. Patients were referred by ten practising GPs for six, 45 min acupuncture treatments (inclusive of initial consultation). No inclusion or exclusion criteria were set and GPs could seek the advice of the practitioner regarding the appropriateness of the referral. Patients could also request a referral by the GP. GPs were required to complete
M. Fixler et al. / Complementary Therapies in Clinical Practice 18 (2012) 140e144
a referral form which was processed by the acupuncture practitioner ensuring patients were guaranteed weekly appointment intervals to maximise clinical efficiency. All patients referred for acupuncture were recruited into the service evaluation using continuous sampling. Informed written consent was obtained from all participants and ethics approval was obtained from the University of Westminster Research Ethics Committee. 2.2. Data collection The quantitative patient data was collected using the validated Measure Yourself Medical Outcome Profile (MYMOP 2).25 Baseline data was collected at the first consultation before treatment. If patients presented with more than one complaint a separate MYMOP form was used for each complaint. MYMOP requires the patient to identify a primary symptom which is then scored on a seven point scale. Patients also provide a score for their general ‘wellbeing’ on this scale. Two optional scores may be provided for a second related symptom, and a daily activity. The MYMOP form also records information on the type and frequency of medication use. Follow-up MYMOP data was recorded at the start of the final consultation by rescoring the symptoms, activity and wellbeing sections and documenting current medication usage again. Finally, the follow up form invited the patient to detail anything else affecting their problem other than the acupuncture treatment received. Participants also completed a patient experience survey in the surgery waiting room after their last appointment, which collected data on patients’ experiences and opinions of the acupuncture service. The first question asked patients to rate the efficiency of the service on a scale from 1 (excellent) to 5 (poor) with room for open comments. Question two asked about their experience of having acupuncture at the practice. The third question asked patients to say if they had found acupuncture to be beneficial, and if so how they felt it had helped them, and the final question asked for any other comments and suggestions regarding the acupuncture service. Patients who were not competent with writing English or who had difficulty completing the patient questionnaire due to poor eyesight dictated their responses to the acupuncture practitioner, who completed the questionnaire verbatim and read the answers back to confirm accuracy.
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category, an exhaustive list of categories (to facilitate full definition of the data) was produced.26 3. Results 3.1. Participant data The evaluation was conducted on 46 patients. 33 patients received 6 acupuncture sessions, 8 patients received between 3 & 5 treatments and 5 patients received 7 treatments. Patients who received less than the recommended 6 sessions either had an improvement in their condition that did not warrant further treatment, or other life events stopped them attending. One participant only received 3 treatments due to the termination of the service. Irrespective of treatment length all participants completed the pre and post treatment MYMOP forms and 42 participants completed the patient experience survey. Participants had a mean age of 50 years (SD 17, range 22e86 yrs); 38 were female (82.5%) and 8 were male (17.5%). 41% of referrals were requested by the GP, and 13% were requested jointly by GP and patient. Interestingly the majority of referrals were requested by the patient (46%) as awareness of the acupuncture service grew. Mean waiting time from referral to the initial consultation was 58 days (range 8e140 days, SD 38 days) and the mean duration of treatment was 46 days (range 14e77 days, SD 17 days). Patients seen after the first six months had the longest wait due to the increase in volume of referrals at this time. A high proportion of chronic conditions were treated. The duration of symptoms ranged from 3 months to 13 years with 74% of participants (n ¼ 34) having experienced their condition for over one year and 26 participants (56%) for over 5 years. Only 15 patients (24%) had their symptoms for less than 1 year. Fifty-eight separate symptoms were recorded on the MYMOP form (some patients presented with more than one condition) which were classified using the International Classification of Primary Care process codes. Of the 58 symptoms recorded, 42 (72%) were musculoskeletal, 5 (9%) were neurological, three (5%) were psychological, and two (3.5%) were in each of the following categories: digestive, ear related, urological and respiratory conditions. 3.2. Patient outcomes
2.3. Data analysis Data analysis was carried out using Microsoft excel 2007. Mean changes in MYMOP scores were calculated and the statistical significance calculated using a Wilcoxon sign rank test (statistical significance set at 5%). A problem specific profile score was calculated for each patient’s MYMOP form(s), which comprised the average of the symptom(s), activity and wellbeing scores.23 The mean change in profile scores was calculated and statistical significance tested using a Wilcoxon sign rank test at the 5% significance level. The change in medication use was calculated for patients who had recorded this data. Qualitative data from the patient experience questionnaire was analysed using content analysis.26 All qualitative data was transcribed and read through repeatedly to get a feel for the content. A list of themes and a coding framework using a large proportion of the data was initially developed.27 The themes and coding framework were then applied to the whole data by a second researcher to test the reproducibility of the coding criteria for the data by ensuring a high level of concurrence.28 The final themes and coding framework were then debated and agreed. To ensure that no data fell between two categories or was applied to more than one
The MYMOP profile showed a statistically significant mean improvement in score of 1.6 (p > 0.000) (see Table 1). In fact, all of the components of the profile (Symptom 1, Activity 1, Symptom 2 and Wellbeing) had statistically significant mean improvements of scores (see Table 1). Fig. 1 shows the breakdown in scores changes for the participants. There was an overwhelmingly positive response to the acupuncture treatments. For Symptom 1, 85% of participants (n ¼ 46) had an improvement. Only 5 participants had no change in their score and 3 scored Symptom 1 as worse at the end of
Table 1 Mean changes to MYMOP scores.
Symptom 1 Symptom 2 Activity 1 Wellbeing Profile
Mean change
SD
n
p
1.8 1.8 1.7 1.2 1.6
1.4 1.6 1.5 1.9 1.3
58 54 54 54 58
>0.0000 >0.0000 >0.0000 >0.0000 >0.0000
The MYMOP guidelines suggest that a mean score change of 1 or above represents a clinically significant change.28
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Fig. 1. Distribution of changes in MYMOP scores. Fig. 1 demonstrates the degree of change in participants MYMOP scores where a change of 1 or over is clinically significant changes in those participants, 0 represents no detectable change by the participant and a minus score represents deterioration in symptom or wellbeing.
treatment. Results were similar for Symptom 2, as 72% of participants scored an improvement, 21% had no change and 3 participants’ scores were worse. Wellbeing scores improved in 55% (n ¼ 30) of participants. 31% (n ¼ 17) of participants scored no change in wellbeing and 7 (14%) scored wellbeing as worse. Medication usage was recorded for 21 participants (46%) at referral to the acupuncture service, typically including paracetamol, ibruprofen and codeine based analgesics, sleeping tablets and antidepressants. At the end of the acupuncture treatment, 43% of these participants had stopped taking medication and 52% had substantially reduced their intake. When asked if there was anything else important such as changes made or other things happening in their lives that may affect their treatment, 52% of participants responded. Of the respondents, 19 (79%) experienced negative events such as stressful personal circumstances, or other illnesses which they felt negatively affected their follow-up scores. Three participants noted beneficial changes that they had made (e.g. long over due holidays and taking up exercise). Two participants reported no change for this category and four participants noted the improvement of other conditions that they were not specifically treated for.
3.3. Patient experience of the service 42 of the 46 participants completed the patient experience survey. All were satisfied with the efficiency of the service: 81% (n ¼ 34) rated the service as excellent; 17% (n ¼ 7) rated it as good; 2% (n ¼ 1) rated it as satisfactory. Patient responses to the open questions were consistently positive. Content analysis of these responses produced 6 overall categories each encompassing between 2 and 3 codes, with 14 separate codes in total. The three most frequently cited codes, or aspects of treatment valued by patients, were a reduction in pain (n ¼ 29 patients), a reduction in stress levels (n ¼ 27 patients) and improvements in quality of life (n ¼ 22 patients). “Not had any pain on right knee since this was treated. Pain levels have halved ”(F, 69) “Relaxed and de-stressed me physically and mentally ”(F, 34)
“I feel more pro-active e better equipped to deal with life generally. I feel physically & emotionally stronger. I have been exercising regularly, lost some weight & emotionally/ mentally highs and lows are not so severe”(F, 41) Patients also appreciated the opportunity to access acupuncture in an NHS setting, in some cases owing to the reassurance that the practitioner was legitimate and trustworthy: “It has been brilliant being on the NHS, which means it’s recommended; one can have complete trust in the practitioner” (F, 38) NHS affiliation also meant that treatment was free. For a number of patients this service provided a unique opportunity to access acupuncture which they would never be able to afford privately. “I would have struggled to pay for this service privately as I am not earning much at present” (F, 37) Six patients mentioned a reduced need for their conventional medication as a result of treatment, with one patient remarking on the prophylactic effects of acupuncture: “The alternative was anti-depressants and now I do not feel like I need them” (F, 41) The analysis produced a whole category termed practitioner qualities. Overall, 31 comments noted the affability and professionalism of the practitioner and patients particularly appreciated feeling listened to and understood. “Marian understands things I’m saying; I found her caring and she explains things nicely” (F, 38)
4. Discussion The aim of this service evaluation was to gather data on patient outcomes and experience of the acupuncture service for the GPs who commissioned it. The majority of patients had musculoskeletal complaints which would be anticipated given the high proportion of adults affected by MSK pain in GP surgeries29 and the publication of NICE guidelines recommending acupuncture for persistent low back pain.7
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Furthermore, there is a recognised effectiveness gap in treating patients with MSK on the NHS,30,31 hence a new referral route for GP’s has been shown to be welcomed.23 Findings from this evaluation and previous studies also support a broader use of acupuncture including mental health22 and psycho-social problems,21 IBS and eczema14 as well as ear, nose and throat disorders.32 Having an acupuncture service at this GP surgery was a great success. Referred patients had a high degree of chronicity to their symptoms (56% experienced symptoms for over 5 years). This represents a large group of patients that do not appear to be responding or improving with current NHS treatment and who are living with a reduced quality of life, often with high levels of pain which require frequent analgesia. The MYMOP scores showed highly statistically significant positive changes to the patients’ Symptom, Activity, Wellbeing and Profile scores (Table 1). The mean change in profile scores was 1.6 (SD 1.3) which is above the threshold of detecting clinically significant changes in patients.33 It is particularly noticeable that there is a high level of improvement in the wellbeing scores in comparison to other studies using acupuncture.34,35 At the end of the acupuncture treatments all but one patient on prescribed medication had either stopped or substantially reduced their usage. The acupuncture practitioner was not involved in any clinical decisions regarding change in medication, and advised patients to return to their GP to discuss medication issues. Patients that decreased prescribed medication therefore, either made a personal decision in the case of analgesics, or made the decision in collaboration with their GP. Interestingly, Cheshire et al.23 also report a statistically significant reduction in analgesic use (82%e 68.7% p < 0.003) after a course of acupuncture or osteopathy for 102 patients. When contextualising the MYMOP scores changes and changes in medication usage with the degree of chronic conditions treated, the current improvements in scores are even more impressive. It is important to consider all outcomes significant to patients when evaluating the success of complex interventions such as acupuncture. Collecting qualitative and quantitative data is therefore advocated36e38 to reflect the holistic contribution of acupuncture and address the complexity of healthcare research.39 Two aspects of this service evaluation collected qualitative data to complement the quantitative scores. Firstly the MYMOP follow-up form asked patients to report any other changes they had made or events occurring in their lives that they feel may affect their reported symptom or wellbeing. Previous research40 using Measure Yourself Concerns and Wellbeing (MYCAW), demonstrated a statistically significant relationship between the scores changes of patients with cancer and the ‘other events’ that were occurring in their life at the time. Patients with positive life events (e.g. holiday, increase in social support) had better score changes than patients experiencing negative life events (e.g. bereavement, forced early retirement, low social support).40 This data highlights the need to contextualise patient score changes with other aspects of the patient’s life. Events recorded by patients on the MYMOP follow up form in this evaluation were coded as positive, negative or nothing significant mentioned. The majority of patients with negative symptom and wellbeing scores changes reported negative events occurring in their lives (e.g. acute infection at time of evaluation, moving house, or ending a relationship). Interestingly, half of the patients who reported negative events still showed improvements in their symptom, activity and wellbeing scores. By contextualising the score changes with qualitative data it is possible to draw more accurate conclusions about success of the acupuncture service. The patient experience survey collected mainly qualitative data. When asked how the patients felt they benefited from the acupuncture service, three main themes emerged e reduction in
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pain, reduction in stress levels and improvement in quality of life. Interestingly, no patients came specifically to reduce stress or improve quality of life, yet they felt the need to report this additional improvement. It is a common ‘added extra’ to patients receiving complementary therapies that conditions other than the one being treated for also improve.23,35,41 Patients were asked to give ‘any other comments about the acupuncture service’, to give the researchers insight into patients’ values and perceptions of the acupuncture service. Patients were extremely positive and expressed their appreciation of being able to access acupuncture in an NHS setting as an alternative treatment option, their desire for more treatment, their willingness to have more acupuncture in the future and to recommend the treatment to family and friends. Very similar points have been reported elsewhere.20e23 All patients receiving acupuncture were referred by the GP. Interestingly, as the awareness of the acupuncture service grew, 46% of referrals were initiated at the request of the patient. Cheshire et al.23 also report a rise of patient initiated referrals to the acupuncture and osteopathy service. To enhance external validity, patients represented the general surgery population therefore maintaining differences that exist in actual clinical practice. All patients were seen in order of referral, and the practitioner had autonomy over the delivery of acupuncture.42 5. Conclusion and recommendations The proposed changes to commissioning by the UK government awaiting implementation have significant consequences for the NHS and healthcare in general. Future research should address the limitations of this service evaluation and compare the clinical and economic effectiveness of acupuncture treatment to other treatment options such as physiotherapy, with a larger sample of patients. Providing an extended treatment period would be beneficial given the chronicity of the conditions referred, and follow-up data at 6e12 months would provide an indication of duration of effects from acupuncture. Qualitative feedback from referring practitioners would also provide their valuable opinion of the service. This evaluation using MYMOP to measure symptom and wellbeing changes coupled with patient experience data demonstrates the benefits to the patient of providing acupuncture treatment in this GP practice. Competing interests The authors declare that they have no competing interests. Sources of support This evaluation was supported by a grant from the TCM (Traditional Chinese Medicine) Development Trust. Writing of the manuscript for CS was supported by a bursary from the University of Westminster. Acknowledgements We would like thank Prof Damien Ridge for his contribution in the research process and Dr Anna Cheshire for discussion and critical reading of the draft manuscript. Thank you to all staff at the GP surgery and all patients who participated in the service evaluation. References 1. Thomas K, Coleman P, Weatherley-Jones E, Luff D. Developing integrated CAM services in Primary Care Organisations. Complementary Therapies in Medicine 2003;11:261e7.
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2. Smallwood C. The role of complementary and alternative medicine in the NHS. London: Get Well UK; 2005. 3. Wonderling D, Vickers A, Grieve R, MaCarney R. Cost effectiveness analysis of a randomised trial of acupuncture for chronic headache in primary care. British BMJ 2004;328(7442):747 [Epub 2004 Mar 15]. 4. Witt C, Reinhold T, Jena S, Brinkhaus B, Willich S. Cost-effectiveness of acupuncture treatment in patients with headache. Cephalagia 2008;28: 334e45. 5. Willich S, Reinhold T, Selim D, Jena S, Brinkhaus B, Witt C. Cost-effectiveness of acupuncture treatment in patients with chronic neck pain. Pain 2006;125(1e2): 107e13. 6. Lindall S. Is acupuncture for pain relief in general practice cost-effective? Acupuncture in Medicine 1999;17(2):97e100. 7. National Collaborating Centre for Primary Care In: National Institute for Health and Clinical Excellence, editor. Low back pain: early management of persistent non-specific low back pain. London: National Institute for Health and Clinical Excellence; 2009. 8. Ratcliffe J, Thomas K, MacPherson H, Brazier J. A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis. British Medical Journal 2006;333(7569):611e2. 9. Johnson G, White A, Livingstone R. Do general practices which provide an acupuncture service have low referral rates and prescription costs? A pilot survey. Acupuncture in Medicine 2008;26(4):205e13. 10. Perry R, Dowrick CF. Complementary medicine and general practice: an urban perspective. Complementary Therapies in Medicine 2000;8:71e5. 11. Lipman L, Dale J, MacPherson H. Attitudes of GPs towards the provision of acupuncture on the NHS. Complementary Therapies in Medicine 2003;11: 110e4. 12. Harborow P, Ogden J. The effectiveness of an acupuncturist working in general practice: an audit. Acupuncture in Medicine 2004;22(4):214e20. 13. Stellon A. An audit of acupuncture in a single-handed general practice over one year. Acupuncture in Medicine 2001;19(1):36e42. 14. Freedman J. An audit of 500 acupuncture patients in general practice. Acupuncture in Medicine 2002;20:30e4. 15. Joseph P. A survey of acupuncture treatments in general practice. Acupuncture in Medicine 2002;20:100e1. 16. Kam E, Eslick G, Campbell I. An audit of the effectiveness of acupuncture on musculoskeletal pain in primary health care. Acupuncture in Medicine 2002;20(1):35e8. 17. Day A, Kingsbury-Smith R. An audit of acupuncture in general practice. Acupuncture in Medicine 2004;22(2):87e92. 18. Bevis M. How to set up and outcomes-focused acupuncture service. Pulse Today [online], http://www.pulsetoday.co.uk/story.asp? sectioncode¼40&storycode¼4123655&c¼3; 2009. 19. Lim JH. Provision of medical acupuncture service in general practice under practice-based commissioning (Letter). Acupuncture in Medicine 2010;28:103e4. 20. Robinson N. Does it work? A pilot project investigating the integration of complementary medicine into primary care. London: Get Well UK; 2005. 21. Peters D, Andrews H, Hills D. Integrating complementary medicine into primary care. An audit of five months referrals to the Get Well UK complementary therapy service in South Islington. London: Get Well UK; 2006. 22. McDade D. Evaluation of a CAM pilot project in northern Ireland. London: Get Well UK; 2008. 23. Cheshire A, Polley M, Peters D, Ridge D. Is it feasible and effective to provide osteopathy and acupuncture for patients with musculoskeletal problems in a GP setting? A service evaluation. BMC Family Practice 2011;12(1):49 [Epub ahead of print].
24. Department of Health. World class commissioning competencies. NHS [online]. Available from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_ digitalassets/documents/digitalasset/dh_080954.pdf; 2008. 25. Paterson C. Measuring outcomes in primary care: a patient generated measure, MYMOP, compared with the SF-36 health survey. British Medical Journal 1996;312:1016e20. 26. Cavanagh S. Content analysis: concepts, methods and applications. Nurse Researcher 1997;4(3):5e16. 27. Hickey G, Kipping C. A multi-stage approach to the coding of data from openended questions. Nurse Researcher 1996;4(1):81e92. 28. Weber RP. Basic content analysis. 2nd ed. Sage Publications; 1990. 29. Parsons S, Breen A, Foster N, Letley L, Pincus T, Vogel S, et al. Prevalence and comparative troublesomeness by age of musculoskeletal pain in different body locations. Family Practice 2007;24(4):308e16. 30. Smallwood C. The role of complementary and alternative medicine in the NHS: an investigation into the potential contribution of mainstream complementary therapies to healthcare in the UK. Freshminds; 2005. 31. Fisher P, Van Haselen R, Hardy K, Berkovitz S, McCarney R. Effectiveness gaps: a new concept for evaluating health service and research needs applied to complementary and alternative medicine. Journal of Alternative & Complementary Medicine 2004;10(4):627e32. 32. Chapman R, Norton R, Paterson C. A descriptive outcome study of 291 acupuncture patients. European Journal of Oriental Medicine 2001;3(5): 48e53. 33. Guyatt GH, Juniper EF, Walter S, Griffith L, Goldstein RS. Interpreting treatment effects in randomised trials. British Medical Journal 1998;316:690e3. 34. Huang W, Howie J, Taylor A, Robinson N. An investigation into the effectiveness of traditional Chinese acupuncture (TCA) for chronic stress in adults: a randomised controlled pilot study. Complementary Therapies in Clinical Practice 2011;17(1):16e21. 35. Paterson C, Unwin J, Joire D. Outcomes of traditional Chinese medicine (traditional acupuncture) treatment for people with long-term conditions. Complementary Therapies in Clinical Practice 2010;16(1):3e9. 36. Merkouris A, Papathanassogloub E, Lemonidou C. Evaluation of patient satisfaction with nursing care: quantitative or qualitative approach? International Journal of Nursing Studies 2004;41:355e67. 37. O’Cathain A, Murphy E, Nicholl J. Why, and how, mixed methods research is undertaken in health services research in England: a mixed methods study. BMC Health Services Research 2007;85; Seers H, Gale N, Patterson C, Cooke H, Hoffman C, Polley M. How to summarise and report written qualitative data from patients: a method for use in cancer support care. Supportive Care in Cancer. 2007;15:963e971. 38. Paterson C, Baarts C, Launsø L, Verhoef MJ. Evaluating complex health interventions: a critical analysis of the ‘outcomes’ concept. BMC Complementary and Alternative Medicine 2009;9:18. 39. Robinson N, Donaldson J, Watt H. Auditing outcomes and costs of integrated complementary medicine provision e the importance of length of follow up. Complementary Therapies in Clinical Practice 2006;12(4):249e57 [Epub 2006 Sep 27]. 40. Seers H, Gale N, Patterson C, Cooke H, Hoffman C, Polley M. How to summarise and report written qualitative data from patients: a method for use in cancer support care. Supportive Care in Cancer 2007;15:963e71. 41. Paterson C. Evaluating the effect of treatment from the patient’s perspective. European Journal of Oriental Medicine 2010;6(4):36e9. 42. Godwin M, Ruhland L, Casso I, MacDonald S, Delva D, Birtwhistle R, et al. Pragmatic controlled clinical trials in primary care: the struggle between external and internal validity. BMC Medical Research Methodology 2003; 3:28.