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Patients' self-treatment with alternative treatment before presenting to the ED
Patients’ Self-Treatment With Alternative Treatment Before Presenting to the ED LESLIE S. ZUN, MD, MBA,* WILLIAM GOSSMAN, MD,* DAVID LILIENSTEIN,† AND LAVONNE DOWNEY, PHD† This study examined the frequency of patients using alternative medicine to treat their condition before presenting to an emergency department (ED). This was a prospective randomized, consecutive survey conducted at a level I 24-bed inner-city trauma center. Patients were eligible for enrollment if they were at least 18 years old and able to consent. Exclusion criteria included patients delivered by an ambulance and patients unable or unwilling to consent. The questionnaire collected information about sociodemographic variables, alternative treatment used, why was it used, who prescribed the treatment, route, treatment satisfaction, and past history of alternative treatment and medication use. A total of 189 patients were surveyed. Of these, 10.6% of the surveyed patients used alternative treatment. The most common reason for using alternative medicine was “I wanted to try the simplest treatment first” (55%). These treatment options were self-prescribed by 55%, advice from a friend or family member by 40% and other health professional in 5%. The alternative medicines included massage (35%), home remedies (20%), prayer (20%), chiropractor (15%), herbal medicines (5%) and other methods (5%). The treatment was administered orally (20%) or topically (80%). Most said that the alternative therapy was helpful (60%). The use of alternative therapy versus no use of alternative therapy was correlated with gender (P ⴝ .05), treatment (P ⴝ .025) and how it was administered (P ⴝ .021). A small but significant number of inner-city patients use alternative treatments before presenting to an ED. Emergency physicians need to consider the use of alternative treatment and medicine by patients presenting to the ED for treatment. (Am J Emerg Med 2002;20: 473-475. Copyright 2002, Elsevier Science (USA). All rights reserved.)
Alternative treatment is defined as those treatments, medications and health care practices not taught in medical schools, not generally used in hospitals, and not usually reimbursed by medical insurance.1 This form of treatment has become very popular with use increasing from 33.8% in 1991 to 42.1% in 1997. During that time, out-of-pocket expenditures for alternative medicine professional services increased 45% to $12.2 billion.2 The use of alternative treatment by certain ED ethnic groups has been evaluated. Of 43 Mexican Americans pediatric patients who received treatment before coming to the ED, 13 used an herbal folk remedy prescribed by a family member. Twenty-eight percent of these parents used folk healers for their children’s illness for an imbalance of hot
From the *Department of Emergency Medicine, Finch University/ Chicago Medical School, Department of Emergency Medicine, Mount Sinai Hospital Medical Center, Chicago, IL, and †Finch University/Chicago Medical School, Chicago, IL. Manuscript received July 14, 2001, accepted October 14, 2001. Address reprint requests to Leslie S. Zun, MD, MBA, Chairman, Department of Emergency Medicine, Mount Sinai Hospital Medical Center, 15th and California, Chicago, IL 60608. Key Words: Alternative medicine, self-treatment, ED. Copyright 2002, Elsevier Science (USA). All rights reserved. 0735-6757/02/2005-0005$35.00/0 doi:10.1053/ajem.2002.34963
and cold (26%).3 Allen and others investigated the use of complementary and alternative medicine in Dominican ED patients. They found that 24% used alternative medicines for their presenting complaint to the ED. Most of these patients used infused tea or other drinks (92%) and used prayer or religion (40%) for a health problem.4 Pearl, Lee, and Tsang found that Chinese therapies were frequently used by first and second generation immigrants presenting to an ED.5 There are no prior studies evaluating the use of alternative treatment use by an unselected population to an ED for the treatment. This study examined the frequency of undifferentiated ED patients using alternative treatment to treat their presenting condition. We also studied the demographic characteristics of use, types of alternative treatment, and medicines used and incidence of use on a regular basis. MATERIALS AND METHODS This study was a prospective, consecutive randomized survey conducted at a Midwestern, level I, inner-city 24-bed ED with 45,000 visits per year. The ED population is 54.9% African American, 35.9% Hispanic, 4.8% Caucasian, 4.2% unknown and 3.2% Asian. Eligible patients were determined by random number generation to a ratio of 1:4 and approached by a research assistant who obtained informed consent. Data were collected 24 hours a day from June 10 to July 8, 2000 and this investigation was approved by the hospital’s human subjects committee. Patients were eligible for enrollment if they were at least 18 years old and able to consent. Exclusion criteria included patients delivered by an ambulance, trauma and patients unable or unwilling to consent. The research assistants administered the questionnaire that included sociodemographic variables such as age, education level, race, and gender. Respondents were asked about alternative treatments or medicines used, why was it used, who recommended the treatment, route, satisfaction with use, past use and regular use of alternative therapies. The data were analyzed with a commercial software statistical program (SPSS, Chicago, IL, version 10). Descriptives, frequencies, correlations and chi-squared analysis were performed on the data. RESULTS A total of 346 were randomized into the study meeting the study criteria. Of this number, 195 were enrolled into the study and 2 patients had data sheets that were incomplete or unusable. There were 151 were excluded because 65 who were not able to consent (DOA, incoherent, incompetent, CVA, unable to communicate), 52 refused to consent, 20 473
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AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 20, Number 5 ■ September 2002
left without treatment, 11 patients left before being surveyed, and 3 did not speak English or Spanish. The mean age was 37.9 years old with the range from 18 to 89. The racial make-up was African American 63.0%, Hispanic 29.1%, Caucasian 6.9%, and other 1.1%. There were 41.8% men and 58.2% women. The education level varied: 8th grade or less (13.5%), some high school (20.8%), complete high school (34.4%), some college (20.8%), bachelors degree (5.0%), unknown (4.2%) and masters degree (0.5%). The most frequent chief complaints reported by the patients were discomfort in the chest (22.0%), extremity (19.0%), abdomen (15.0%) and head (16.0%). Of the surveyed patients, 10.6% used alternative treatments or medicines (20 patients); 12 African Americans (10.4% of all African Americans), 6 Hispanic (10.7% of all Hispanic), and 2 Caucasians (15.4% of all Caucasians). The reason for using these other options included “I wanted to try the simplest treatment first” (55.0%), other reason (25.0%), no insurance (10.0%), “it costs less than going to the doctor” (5.0%) and “it is better than that I can get at the ED” (5.0%). These treatment options were self-prescribed by 55.0%, advice from a friend or family member by 40% and other health professional by 5%. The alternative medicines included massage (29.2%), home remedies (29.2%), prayer (29.2%), other method (16.7%), chiropractor (12.5%), and herbal medicines (4.2%). Before presenting to the ED 25% of the patients used more than one alternative medicine treatment. The treatment was administered orally (20%) or topically (80%). The use of alternative therapies was correlated with gender (Pearson coefficient 4.23, P ⫽ .040), type of alternative therapy used (Pearson coefficient 12.84, P ⫽ .025) and means of administration (Pearson coefficient 7.72, P ⫽ .021). The use of alternative therapies was not correlated with education, the reason patient’s used alternative therapies, chief complaint, who prescribed the treatment, age, or race (P ⬍ .05). Many of the patients surveyed had used alternative therapies in the past (43%) and a significant number used these alternative therapies on a regular basis (27.7%). Many patients who use alternative methods on a regular basis do so daily (46.3%). Of the 53 who stated they used alternative medicines regularly, their use ranged from daily (46.3%) to less than one time per month (14.6%). Most used prayer (81.1%), some used home remedies (17.0%), a few used herbal medicine (13.2%) and a small number used vitamins (9.4%). The alternative therapy most commonly used in the past was prayer (51.2%), home remedies (33.3%), and herbal medicine (25%). DISCUSSION This is the first study to examine the use of alternative medications by an undifferentiated set of patients presenting to the ED for treatment. Although the study examined one unselected population of patients, the use of alternative therapies is small but significant percentage. It is important to consider the widespread use in the ED patients and possible problems that this use may cause. The use of alternative medicine is widespread in the general population. Gulla found that 56% of ED patients
used some form of alternative medicine sometime in the past and 87% believed the treatment was effective.6 Eisenberg found that use of alternative medicine increased in the United States from 33.8% in 1990 to 42.1% in 1997. These therapies were used most frequently for back problems, anxiety, depression, and headaches. The most frequently used techniques were relaxation, herbal medicine, and message.2 Druss and Rosenheck found that 1.8% of the population that they surveyed used only unconventional therapy and 59.9% use only conventional care. The most frequently used unconventional therapies were chiropractic, herbal, massage, and spiritual. They found that the rate of ED visits did not differ significantly between those that use both unconventional and conventional therapy and those that use only conventional medicine.7 Astin found that the predictors of the use of alternative medicines were more education, poorer health status, holistic orientation to health and a transformational experience that changed the person’s worldview. Most of the time these patients had back problems, anxiety, chronic pain, or urinary tract problems.8 It is important to identify the alternative treatments that patients’ use before presenting to the ED because these therapies might have caused, complicated or exacerbated their problem.9-18 Blanc and others found that asthma patients frequently self-medicate with herbs, coffee, or black tea and over-the-counter epinephrine or ephedrine.9 The use of these products was associated with an increased hospitalization rate. The Physicians’ Desk Reference (PDR) notes over 100 categories of potentially adverse drug/herb combinations.16 The interaction of Rauwolfia serpentina and digitalis preparations causing severe bradycardia and Tanacetum pathenium and aspirin causing increased antithrombotic effect are 2 examples of such interaction. Murphy has recommended inquiring about the use of herbal medicines as part of a medical assessment.18 This study was limited by a number of factors. Those who were unable or unwilling to consent to the study, trauma patients or were brought to the ED by ambulance may have skewed the data. The study did not examine parents’ use of alternative treatments for their children. The data were also limited by the population studied and may not reflect a cross section of the American population. Although the study did enroll patients all day during the study period, we did not account for seasonal variations. We did not examine whether the use of alternative therapy delayed presentation to an ED. In conclusion, a small but significant percentage of patients use alternative medications before presenting to the ED. Most of those who used alternative treatment used a generally benign therapy, massage. A larger number of patients used alternative medicine on a regular basis. Again, the most common method was benign—prayer. But a portion of the population use home remedies and food supplements on a regular basis. Agents that can cause or complicate the patients condition or interfere with the planned treatment may be in the patients system when the patient presents to the ED. It is essential to better understand the role of alternative treatments in the care of the emergency patients.
ZUN ET AL ■ ALTERNATIVE TREATMENT
REFERENCES 1. National Center for Complementary and Alternative Medicine: National Institutes of Health, Internet site. March 1, 2000. Available at: http://nccam.nihgov/fcp/faq/index. Accessed June 20, 2000 2. Eisenberg DM, David RB, Ettner SL, et al: Trends in alternative medicine use in the United States. 1990-1997, results of a follow-up national survey. JAMA 1998;280:1568-1575 3. Sandler AP, Chan LS: Mexican-American folk belief in pediatric emergency room. Med Care 1978;16:778-784 4. Allen R, Cushman LF, Morris S, et al: Use of complementary and alternative medicine among Dominican emergency department patients. Am J Emerg Med 2000;18:51-54 5. Pearl WS, Lee P, Tsang WO: Use of Chinese therapies among Chinese patients seeking emergency department care. Ann Emerg Med 1995;26:735-738 6. Gulla J, Singer AJ: Use of alternative therapies among emergency department patients, Ann Emerg Med 2000;35:226-228 7. Druss BG, Rosenheck RA: Association between use of unconventional therapies and conventional medical services. JAMA 1999; 282,651-656 8. Astin JA: Why patients use alternative medicine: results of a national study. JAMA 1998;279:1548-1553 9. Blanc PD, Kuschner WG, Katz PP, et al: Use of herbal prod-
475
ucts, coffee or black tea, and over the counter medications as self-treatments among adults with asthma. J Allergy Clin Immunol 1997;100:789-791 10. Larkin M: Surgery patients at risk for herb-anesthesia interaction. Lancet 1999;354:1362 11. Ko R: Adverse reactions to watch for in patients using herbal remedies. West J Med 1999;171:181-186 12. Windrum P, Hull DR, Morris TCM: Herb-drug interactions. Lancet 2000;355:1019-1020 13. Miller G: Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions. Arch Intern Med 1998;158:2200-2211 14. Cupp MJ: Herbal remedies: adverse effects and drug interactions. Am Fam Physician 1999;59:1239-1245 15. D’Arcy PF: Adverse reactions with herbal medicines: part 2, drug interactions. Adverse Drug React Toxicol Rev 1993;12:147162 16. Gruenwald J, Brendler T, Jaenicke C: PDR for Herbal Medicines. Montvale, NJ, Medical Economics, 1998 17. Miller G: Herbal medicinals. Arch Intern Med 1998;158:22002210 18. Murphy JM: Preoperative considerations with herbal medicines. AORN 1999;69:173-183
Alternative treatment is defined as those treatments, medications and health care practices not taught in medical schools, not generally used in hospitals, and not usually reimbursed by medical insurance.1 This form of treatment has become very popular with use increasing from 33.8% in 1991 to 42.1% in 1997. During that time, out-of-pocket expenditures for alternative medicine professional services increased 45% to $12.2 billion.2 The use of alternative treatment by certain ED ethnic groups has been evaluated. Of 43 Mexican Americans pediatric patients who received treatment before coming to the ED, 13 used an herbal folk remedy prescribed by a family member. Twenty-eight percent of these parents used folk healers for their children’s illness for an imbalance of hot
From the *Department of Emergency Medicine, Finch University/ Chicago Medical School, Department of Emergency Medicine, Mount Sinai Hospital Medical Center, Chicago, IL, and †Finch University/Chicago Medical School, Chicago, IL. Manuscript received July 14, 2001, accepted October 14, 2001. Address reprint requests to Leslie S. Zun, MD, MBA, Chairman, Department of Emergency Medicine, Mount Sinai Hospital Medical Center, 15th and California, Chicago, IL 60608. Key Words: Alternative medicine, self-treatment, ED. Copyright 2002, Elsevier Science (USA). All rights reserved. 0735-6757/02/2005-0005$35.00/0 doi:10.1053/ajem.2002.34963
and cold (26%).3 Allen and others investigated the use of complementary and alternative medicine in Dominican ED patients. They found that 24% used alternative medicines for their presenting complaint to the ED. Most of these patients used infused tea or other drinks (92%) and used prayer or religion (40%) for a health problem.4 Pearl, Lee, and Tsang found that Chinese therapies were frequently used by first and second generation immigrants presenting to an ED.5 There are no prior studies evaluating the use of alternative treatment use by an unselected population to an ED for the treatment. This study examined the frequency of undifferentiated ED patients using alternative treatment to treat their presenting condition. We also studied the demographic characteristics of use, types of alternative treatment, and medicines used and incidence of use on a regular basis. MATERIALS AND METHODS This study was a prospective, consecutive randomized survey conducted at a Midwestern, level I, inner-city 24-bed ED with 45,000 visits per year. The ED population is 54.9% African American, 35.9% Hispanic, 4.8% Caucasian, 4.2% unknown and 3.2% Asian. Eligible patients were determined by random number generation to a ratio of 1:4 and approached by a research assistant who obtained informed consent. Data were collected 24 hours a day from June 10 to July 8, 2000 and this investigation was approved by the hospital’s human subjects committee. Patients were eligible for enrollment if they were at least 18 years old and able to consent. Exclusion criteria included patients delivered by an ambulance, trauma and patients unable or unwilling to consent. The research assistants administered the questionnaire that included sociodemographic variables such as age, education level, race, and gender. Respondents were asked about alternative treatments or medicines used, why was it used, who recommended the treatment, route, satisfaction with use, past use and regular use of alternative therapies. The data were analyzed with a commercial software statistical program (SPSS, Chicago, IL, version 10). Descriptives, frequencies, correlations and chi-squared analysis were performed on the data. RESULTS A total of 346 were randomized into the study meeting the study criteria. Of this number, 195 were enrolled into the study and 2 patients had data sheets that were incomplete or unusable. There were 151 were excluded because 65 who were not able to consent (DOA, incoherent, incompetent, CVA, unable to communicate), 52 refused to consent, 20 473
474
AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 20, Number 5 ■ September 2002
left without treatment, 11 patients left before being surveyed, and 3 did not speak English or Spanish. The mean age was 37.9 years old with the range from 18 to 89. The racial make-up was African American 63.0%, Hispanic 29.1%, Caucasian 6.9%, and other 1.1%. There were 41.8% men and 58.2% women. The education level varied: 8th grade or less (13.5%), some high school (20.8%), complete high school (34.4%), some college (20.8%), bachelors degree (5.0%), unknown (4.2%) and masters degree (0.5%). The most frequent chief complaints reported by the patients were discomfort in the chest (22.0%), extremity (19.0%), abdomen (15.0%) and head (16.0%). Of the surveyed patients, 10.6% used alternative treatments or medicines (20 patients); 12 African Americans (10.4% of all African Americans), 6 Hispanic (10.7% of all Hispanic), and 2 Caucasians (15.4% of all Caucasians). The reason for using these other options included “I wanted to try the simplest treatment first” (55.0%), other reason (25.0%), no insurance (10.0%), “it costs less than going to the doctor” (5.0%) and “it is better than that I can get at the ED” (5.0%). These treatment options were self-prescribed by 55.0%, advice from a friend or family member by 40% and other health professional by 5%. The alternative medicines included massage (29.2%), home remedies (29.2%), prayer (29.2%), other method (16.7%), chiropractor (12.5%), and herbal medicines (4.2%). Before presenting to the ED 25% of the patients used more than one alternative medicine treatment. The treatment was administered orally (20%) or topically (80%). The use of alternative therapies was correlated with gender (Pearson coefficient 4.23, P ⫽ .040), type of alternative therapy used (Pearson coefficient 12.84, P ⫽ .025) and means of administration (Pearson coefficient 7.72, P ⫽ .021). The use of alternative therapies was not correlated with education, the reason patient’s used alternative therapies, chief complaint, who prescribed the treatment, age, or race (P ⬍ .05). Many of the patients surveyed had used alternative therapies in the past (43%) and a significant number used these alternative therapies on a regular basis (27.7%). Many patients who use alternative methods on a regular basis do so daily (46.3%). Of the 53 who stated they used alternative medicines regularly, their use ranged from daily (46.3%) to less than one time per month (14.6%). Most used prayer (81.1%), some used home remedies (17.0%), a few used herbal medicine (13.2%) and a small number used vitamins (9.4%). The alternative therapy most commonly used in the past was prayer (51.2%), home remedies (33.3%), and herbal medicine (25%). DISCUSSION This is the first study to examine the use of alternative medications by an undifferentiated set of patients presenting to the ED for treatment. Although the study examined one unselected population of patients, the use of alternative therapies is small but significant percentage. It is important to consider the widespread use in the ED patients and possible problems that this use may cause. The use of alternative medicine is widespread in the general population. Gulla found that 56% of ED patients
used some form of alternative medicine sometime in the past and 87% believed the treatment was effective.6 Eisenberg found that use of alternative medicine increased in the United States from 33.8% in 1990 to 42.1% in 1997. These therapies were used most frequently for back problems, anxiety, depression, and headaches. The most frequently used techniques were relaxation, herbal medicine, and message.2 Druss and Rosenheck found that 1.8% of the population that they surveyed used only unconventional therapy and 59.9% use only conventional care. The most frequently used unconventional therapies were chiropractic, herbal, massage, and spiritual. They found that the rate of ED visits did not differ significantly between those that use both unconventional and conventional therapy and those that use only conventional medicine.7 Astin found that the predictors of the use of alternative medicines were more education, poorer health status, holistic orientation to health and a transformational experience that changed the person’s worldview. Most of the time these patients had back problems, anxiety, chronic pain, or urinary tract problems.8 It is important to identify the alternative treatments that patients’ use before presenting to the ED because these therapies might have caused, complicated or exacerbated their problem.9-18 Blanc and others found that asthma patients frequently self-medicate with herbs, coffee, or black tea and over-the-counter epinephrine or ephedrine.9 The use of these products was associated with an increased hospitalization rate. The Physicians’ Desk Reference (PDR) notes over 100 categories of potentially adverse drug/herb combinations.16 The interaction of Rauwolfia serpentina and digitalis preparations causing severe bradycardia and Tanacetum pathenium and aspirin causing increased antithrombotic effect are 2 examples of such interaction. Murphy has recommended inquiring about the use of herbal medicines as part of a medical assessment.18 This study was limited by a number of factors. Those who were unable or unwilling to consent to the study, trauma patients or were brought to the ED by ambulance may have skewed the data. The study did not examine parents’ use of alternative treatments for their children. The data were also limited by the population studied and may not reflect a cross section of the American population. Although the study did enroll patients all day during the study period, we did not account for seasonal variations. We did not examine whether the use of alternative therapy delayed presentation to an ED. In conclusion, a small but significant percentage of patients use alternative medications before presenting to the ED. Most of those who used alternative treatment used a generally benign therapy, massage. A larger number of patients used alternative medicine on a regular basis. Again, the most common method was benign—prayer. But a portion of the population use home remedies and food supplements on a regular basis. Agents that can cause or complicate the patients condition or interfere with the planned treatment may be in the patients system when the patient presents to the ED. It is essential to better understand the role of alternative treatments in the care of the emergency patients.
ZUN ET AL ■ ALTERNATIVE TREATMENT
REFERENCES 1. National Center for Complementary and Alternative Medicine: National Institutes of Health, Internet site. March 1, 2000. Available at: http://nccam.nihgov/fcp/faq/index. Accessed June 20, 2000 2. Eisenberg DM, David RB, Ettner SL, et al: Trends in alternative medicine use in the United States. 1990-1997, results of a follow-up national survey. JAMA 1998;280:1568-1575 3. Sandler AP, Chan LS: Mexican-American folk belief in pediatric emergency room. Med Care 1978;16:778-784 4. Allen R, Cushman LF, Morris S, et al: Use of complementary and alternative medicine among Dominican emergency department patients. Am J Emerg Med 2000;18:51-54 5. Pearl WS, Lee P, Tsang WO: Use of Chinese therapies among Chinese patients seeking emergency department care. Ann Emerg Med 1995;26:735-738 6. Gulla J, Singer AJ: Use of alternative therapies among emergency department patients, Ann Emerg Med 2000;35:226-228 7. Druss BG, Rosenheck RA: Association between use of unconventional therapies and conventional medical services. JAMA 1999; 282,651-656 8. Astin JA: Why patients use alternative medicine: results of a national study. JAMA 1998;279:1548-1553 9. Blanc PD, Kuschner WG, Katz PP, et al: Use of herbal prod-
475
ucts, coffee or black tea, and over the counter medications as self-treatments among adults with asthma. J Allergy Clin Immunol 1997;100:789-791 10. Larkin M: Surgery patients at risk for herb-anesthesia interaction. Lancet 1999;354:1362 11. Ko R: Adverse reactions to watch for in patients using herbal remedies. West J Med 1999;171:181-186 12. Windrum P, Hull DR, Morris TCM: Herb-drug interactions. Lancet 2000;355:1019-1020 13. Miller G: Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions. Arch Intern Med 1998;158:2200-2211 14. Cupp MJ: Herbal remedies: adverse effects and drug interactions. Am Fam Physician 1999;59:1239-1245 15. D’Arcy PF: Adverse reactions with herbal medicines: part 2, drug interactions. Adverse Drug React Toxicol Rev 1993;12:147162 16. Gruenwald J, Brendler T, Jaenicke C: PDR for Herbal Medicines. Montvale, NJ, Medical Economics, 1998 17. Miller G: Herbal medicinals. Arch Intern Med 1998;158:22002210 18. Murphy JM: Preoperative considerations with herbal medicines. AORN 1999;69:173-183