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Disclosure of Complementary and Alternative Medicine to Conventional Medical Providers: Variation by Race/Ethnicity and Type of CAM
Maria T Chao, DrPH, MPA; Christine Wade, MPH; and Fredi Kronenberg, PhD
Financial support: This research was supported by grant R21-AT02852 from the National Center for Complementary and Alternative Medicine NCCAM, National Institutes of Health NIH Study analyses and interpretations presented here do not necessarily reflect the views or opinions of NCCAM or the NIH Background: Complementary and alternative medicine CAM is often used alongside conventional medical care, yet fewer than half of patients disclose CAM use to medical doctors CAM disclosure is particularly low among racial/ ethnic minorities, but reasons for differences, such as type of CAM used or quality of conventional healthcare, have not been explored Objective: We tested the hypotheses that disclosure of CAM use to medical
doctors is higher for provider-based CAM and among non-Hispanic whites, and that access to and quality of conventional medical care account for racial/ ethnic differences in CAM disclosure Methods: Bivariate and multiple variable analyses of the 2002 National Health Interview Survey and 2001 Health Care Quality Survey were performed Results: Disclosure of CAM use to medical providers was higher for provider-based than self-care CAM Disclosure of any CAM was associated with access to and quality of conventional care and higher among non-Latino whites relative to minorities Having a regular doctor and quality patient provider relationship mitigated racial/ethnic differences in CAM disclosure Conclusion: Insufficient disclosure of CAM use to conventional providers, particularly for self-care practices and among minority populations, represents a serious challenge in medical encounter communications Efforts to improve disclosure of CAM use should be aimed at improving consistency of care
and patientphysician communication across racial/ethnic groups Key words: complementary and alternative medicine n race/ethnicity n communication n access n quality of care
2008 From Richard and Hinda Rosenthal Center for Complementary and Alternative Medicine, College of Physicians and Surgeons, Columbia University, New York, NY Send correspondence and reprint requests for J Natl Med Assoc 2008;100:13411349 to: Dr Maria T Chao, Osher Center for Integrative Medicine, University of California, San Francisco, Box 1726, San Francisco, CA 94143; e-mail: chaom@ocimucsfedu
IntroductIon
M
ore than two-thirds of the US population has used complementary and alternative medicine CAM, defined as healthcare systems, practices and products not currently considered part of conventional medicine1,2 Most Americans use CAM as an adjunct to, rather than a substitute for, conventional medical care3,4 Yet, 6372 of CAM users do not discuss use with doctors;5 and CAM disclosure is particularly low
among racial/ethnic minorities6-10 CAM utilization can affect treatment outcomes, including adverse herbdrug interactions,11,12 underscoring the need for patientprovider communication about CAM13,14 Reasons patients give for nondisclosure of CAM use include doctors not asking about CAM use, beliefs that doctors do not need to know or would not understand, and doctors potentially negative responses to CAM5,1517 Perceived legitimacy of CAM treatments also affects disclosure In a qualitative study of self-treatment practices originating from popular, folk and professional sectors, Stevenson et al found that patients most likely discussed treatments from the professional sector with physicians because they were perceived as legitimate and medically acceptable18 Research suggests disclosure differs by type of CAM used,15 but a systematic examination of disclosure rates for specific CAM modalities, provider based and self-care, has not been conducted Patients may more willingly disclose use
of providerbased CAM eg, chiropractic or acupuncture relative to self-care CAM eg, vitamins and herbal medicine if the former is perceived as more legitimate CAM disclosure also varies by subpopulation African Americans, Latinos and Asian Americans are less likely than non-Latino whites to tell doctors about using
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CAM,6-9 but reasons for differences are not understood Minorities face multiple barriers to receiving adequate healthcare–including cost, communication, insurance and suboptimal sources of care eg, hospital emergency room19,20–which may result in medical encounters that do not facilitate disclosure of CAM use One study found that Asian Americans who discussed CAM use with a health provider rated their quality of healthcare higher than those that did not discuss CAM use10 Healthcare factors that may limit opportunity to disclose CAM use
include number and length of medical encounters, continuity of care and medical charting conventions A remaining question is whether disparities in access to quality conventional care contribute to racial/ ethnic differences in CAM disclosure We addressed the following research questions: 1 Does disclosure of CAM use to conventional medical providers differ by type of CAM and race/ethnicity? 2 Are access to and quality of conventional care associated with CAM disclosure? 3 Are racial/ethnic differences in CAM disclosure mitigated by access to and quality of conventional healthcare received? We hypothesized that disclosure is higher for provider-based CAM because professional care is perceived to have greater legitimacy; and that CAM disclosure is lower among racial/ ethnic minorities relative to non-Latino whites, but that access to and quality of conventional care account for racial/ethnic differences in CAM disclosure
vider-based natural herbs, homeopathic treatment, special diets,
high-dose or megavitamin therapy, yoga/tai chi/qi gong and relaxation techniques Of the domains that could be self-care or provider based, only 8 of users saw a provider for those domains when yoga/tai chi/qi gong classes were excluded These domains generally involve self-care maintenance beyond treatment from a provider eg, regularly taking herbs or adhering to a specific diet Thus, we refer to these therapies as self-care CAM Respondents who had used a CAM domain were asked, During the past 12 months, did you let any of these conventional medical professionals know about your use of [CAM domain]? We coded disclosure of CAM use dichotomously disclosure versus no disclosure for each domain and created 3 summary measures: 1 disclosure of 1 of 16 CAM domains, 2 disclosure of 1 of 10 provider-based CAM domains, and 3 disclosure of 1 of 6 self-care CAM domains In the HCQS, respondents who used 1 alternative therapy were asked, Have you told your doctor that you use [herbal medicines,
acupuncture, a chiropractor, a traditional healer]? A dichotomous variable was created to indicate any disclosure versus no disclosure
Independent Variables
Race/ethnicity was classified by: 1 whether respondents were of Latino or Hispanic origin or descent and; 2 what race they considered themselves In each data set, we created 4 dichotomous variables: non-Latino white, nonLatino African American, Latino regardless of race and non-Latino Asian American Due to small sample sizes and uncertain heterogeneity, those who responded as other, American Indian, dont know or refused the race inquiry and were not Latino were excluded from study analyses Access to and quality of conventional care were examined through 5 NHIS measures Health insurance status was measured in 3 dichotomous variables: no insurance, public insurance, private insurance Three additional dichotomous measures of access to conventional care included whether respondents: 1 had postponed medical care in the past year due to
cost; 2 experienced any changes in their place of care; and 3 experienced delays in getting medical care such as transportation difficulties, getting an appointment and waiting time prior to seeing the doctor A proxy measure of quality of care was created from 2 questions: 1 Is there a particular clinic, health center, doctors office or other place that you usually go to if you are sick or need advice about your health? and 2 if so, where their usual place of healthcare was A usual source of conventional care variable was created with higher scores estimating greater quality of care 1 no usual place, 2 hospital emergency room, 3 hospital outpatient department, 4 clinic or health center, 5 doctors office or HMO Previous health services research has used similar measures22
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Methods data sources
We utilized national data from the 2002 National Health Interview Survey NHIS and the Commonwealth Funds 2001 Health Care Quality Survey HCQS Both surveys employ
a complex multistage design to oversample minority populations and, with appropriate weighting, are representative of adults age 18 in the continental United States Detailed survey methodology has been previously reported6,21 The 2002 NHIS includes disclosure of specific CAM domains but limited measures of quality of conventional care The HCQS includes detailed information on quality of conventional care and a general measure of CAM disclosure For this study, each data set was analyzed separately
Measures dependent Variables
In 2002, NHIS included a supplement on CAM implemented as part of the Sample Adult Core Respondents were asked if, in the past 12 months, they employed any of 10 provider-based domains acupuncture, ayurveda, biofeedback, chelation therapy, chiropractic care, energy healing therapy, folk medicine, hypnosis, massage and naturopathy and 6 domains that may be self-care or pro1342 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
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Seven measures of access to and quality of conventional care were created from the HCQS Health insurance status, postponing care due to cost and usual source of care were coded in the same way as data from NHIS Additionally, a dichotomous variable indicated whether respondents had a regular doctor or other health professional, such as a nurse or a midwife that they usually go to when sick or in need of health care yes/no A fifth measure was based on respondents satisfaction with the quality of healthcare they received during the previous 2 years very satisfied, somewhat satisfied, somewhat dissatisfied or very dissatisfied coded with higher values indicating greater satisfaction Another question documented whether respondents or any family member had been given the wrong medication or dose when filling a prescription at a pharmacy or while hospitalized yes/no HCQS included 11 items regarding participant perceptions of patientprovider communication and provider cultural
competency used to create a scale for patientprovider relationship Based on a factor analysis, 2 items with low interitem reliability were excluded Nine remaining items included: 1 if the doctor listened to everything the respondent had to say; 2 if the respondent understood everything the doctor said; 3 whether the respondent had questions about care or treatment that
table 1a disclosure of complementary and alternative medicine caM use by specific domain: results from the 2002 national health Interview survey of users Who disclosed
they wanted to discuss; 4 level of confidence and trust in the doctor; 5 if the doctor treated the respondent with respect and dignity; 6 if the doctor involved the respondent in decisions about their care as much as the respondent wanted; 7 if the doctor spent as much time with the respondent as respondent wanted; and 8 whether the respondent felt judged unfairly or treated with disrespect by the doctor or medical staff because of: ability to pay,
insurance coverage, English proficiency, race/ethnicity, or gender; and 9 how strongly respondent agreed with the statement I feel that my doctor understands my background and values These measures are consistent with recommendations from the Agency for Healthcare Research and Quality in the National Healthcare Disparities Report23 Items were coded with higher scores indicating a more favorable relationship; then, mean scores were calculated based on valid responses Respondents with 5 valid responses were coded as missing The patientprovider relationship scale had high reliability alpha083 Factors assessed as confounders included: age; marital status; region of residence; self-reported health status; number of health conditions; household income; education; current employment status; and, in the HCQS, length of time in the United States
B disclosure of caM use by race/ethnicity: results from the 2002 national health Interview survey of no of users Who odds ratio users disclosed 95 cI
Any CAM Non-Latino whites 7,767 African Americans 1,152 Latinos Asian Americans 1,459 381 411 345 311 267 100 075 065, 087 065 056, 075 052 040, 068 100 139 101, 192 101 075, 137 086 052, 143 100 075 064, 087 062 053, 073 045 033, 061
no of users Summary CAM Measures Any CAM Provider-based CAM Self-care CAM Provider-Based CAM Domains Acupuncture Ayurveda Biofeedback Chelation therapy Chiropractic Energy therapy Folk medicine Hypnosis Massage Naturopathy Self-Care CAM Domains Natural herbs Homeopathy Special diets Megavitamins Yoga, tai chi, qi gong Relaxation therapies
10,759 391 3,453 468 9,365 342 327 19 44 10 2,146 154 36 74 1,476 82 5,732 514 1,030 838 1,792 4,374 540 532 724 747 522 308 333 418 305 405 333 346 384 483 247 233
Provider-Based CAM Non-Latino whites 2,814 African Americans 216 Latinos Asian Americans 328 95
465 547 468 429 365 301 262 204
Self-Care CAM Non-Latino whites 6,603 African Americans 1,071 Latinos Asian Americans 1,332 359
Statistically significant
odds ratios p005 are indicated in boldface; CI: Confidence interval
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statistical analyses
Data preparation, descriptive analyses, prevalence estimates, and regression analyses were conducted using Stata Version 9024 Due to oversampling minority populations, both data sets require adjustment for complex multistage sampling procedures, including probability sampling units, weights and strata All analyses utilized Stata survey estimation techniques, which account for design effects when calculating standard errors Chi-squared tests were used to examine disclosure by CAM type and race/ethnicity in the NHIS Chi-square for
categorical variables and Ftests for continuous variables were performed to assess bivariate associations between access to and quality of conventional medical care measures, race/ethnicity and CAM disclosure in the NHIS and HCQS In each
data set, 2 multiple variable logistic regression models were run to test the mediating effects of access to and quality of conventional care: model 1 included race/ ethnicity controlling for confounding variables; model 2 replicated model 1 with the addition of access to and quality of care measures Changes in the adjusted odds ratios for race/ethnicity between the 2 models were compared
table 2 access to and quality of conventional care of complementary and alternative medicine caM users by race/ethnicity and disclosure of caM use disclosed non-Latino african asian all caM any caM Whites americans Latinos americans users use Percents 2002 National Health Interview Survey Health Insurance Private Public None Postponed Care Due to Cost: No Yes Delayed Medical Care: No Yes Changed Place of Care: No Yes Usual Source of Conventional Care No usual place Hospital emergency room Hospital outpatient Clinic or health center Doctors office or HMO 2001 Health Care Quality Survey Health
Insurance Private Public None Postponed Care Due to Cost: No Yes Given Wrong Medicine or Dose: No Yes Has a Regular Doctor: No Yes Usual Source of Conventional Care No usual care Emergency room Hospital outpatient Clinic or health center Doctors office or HMO Satisfaction with Conventional Care Mean PatientProvider Relationship Mean
803 166 108 835 165 869 131 874 126 104 054 11 140 740
676 179 167 752 248 844 156 892 108 119 25 34 157 665
530 182 307 772 228 850 150 877 123 215 13 18 171 583
761 115 138 892 108 845 156 819 181 174 0 14 122 691
767 166 131 824 176 864 136 874 126 118 08 13 143 718
406 478 246 389 402 382 451 415 458 169 324 327 382 434
729 143 128 740 260 773 227 178 822 21 30 28 74 847 321 208
685 130 185 784 216 755 245 247 753 12 108 111 81 687 314 205
582 99 319 753 247 805 195 437 563 73 63 29 187 649 287 176
731 142 127 753 247 913 87 268 732 10 47 66 43 834 270 163
712 138 150 746 254 780 220 212 789 24 41 36 84 815 315 203
734 743 499 701 693 689
733 494 753 384 601 565 546 742 328 215
Asterisks in this column indicate statistically significant differences between racial/ethnic groups; Asterisks in this column indicate statistically significant differences between those who disclosed CAM use and those who did not disclose CAM use; Percents may total to more than 100 because respondents may have both public and private insurance; Possible reasons for delays in getting medical care included transportation difficulties, getting an appointment and waiting time prior to seeing the doctor; p005; p001; p0001
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resuLts
To assess race/ethnicity and CAM disclosure to conventional medical providers, this study was restricted to non-Latino whites, African Americans, Latinos and Asian Americans who had used 1 CAM domain 10,759 respondents in the NHIS and 2003 respondents in the HCQS Sample
sociodemographics are previously reported8,25
caM disclosure by type of caM and race/ethnicity
Table 1A shows disclosure of any CAM 39, provider-based CAM 47, self-care CAM 34 and specific CAM domains For 5 of 10 provider-based CAM, at least half of users disclosed use to medical providers Though based on small samples, disclosure of biofeedback and chelation therapy was particularly high, at 72 and 75, respectively For energy therapies, folk medicine, and massage, one-third or less of users disclosed these therapies 31, 33 and 31, respectively Among self-care domains, disclosure of mega-
vitamins was the highest 48 One-quarter or fewer of those who had used yoga, tai, chi, qi gong or relaxation therapies told their medical providers about their use Table 1A We examined disclosure of any CAM, provider-based and self-care CAM by race/ethnicity Table 1B Disclosure of any CAM use was lowest among Asian Americans 27 and highest among non-Latino whites 41 Relative to non-Latino whites,
African-Americans, Latinos and Asian Americans were significantly less likely to disclose any CAM [odds ratio OR075, 065, 052, respectively] or self-care CAM OR075, 062, 045, respectively Compared to non-Latino whites, African Americans were more likely to discuss using provider-based CAM OR139 Latinos, Asian Americans and non-Latino whites did not differ in provider-based CAM disclosure
access to and Quality of conventional care, race/ethnicity and caM disclosure
Access to and quality of conventional care were
table 3 adjusted odds ratios and 95 confidence intervals of disclosure of complementary and alternative medicine to medical practitioner based on 2002 national health Interview survey data Model 1 aor 95 cI 101 100101 122 124 106 096 094 131 099 135 080 067 057 100 100 112134 108142 092122 084109 089098 124137 089110 122149 068093 057079 044073 Model 2 aor 95 cI 100 100101 115 116 101 095 092 126 093 125 077 074 056 100 104127 100 101134 088116 083109 087096 120133 082106 100
113140 100 066091 062088 045079
Age Marital Status Not married Married Region of Residence West Northeast Midwest South Self-Reported Health Status Number of Health Conditions Employment Sex Male Female Race/Ethnicity Non-Latino white African American Latino Asian American Access to and Quality of Biomedical Care Health Insurance None Private Public Changed Place of Care No Yes Usual Source of Conventional Medical Care
100 100
115 098 120 116
100 100132 082116 100 103140 105129
Model 1 assessed the association of race/ethnicity and CAM disclosure controlling for confounding variables; model 2 included access to and quality-of-care measures to assess their mediating effects on the association between race/ethnicity and CAM disclosure Statistically significant AORs p005 are indicated in boldface; AOR: Adjusted odds ratio; CI: Confidence interval
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examined among CAM users by race/ethnicity and by any CAM disclosure Table 2 NHIS data indicate that, relative to CAM users of other race/ethnicities, Latino CAM users had the highest rate of uninsured 31, p0001 African-American and Latino CAM users 25 and 23, respectively were more likely to postpone medical care due to cost, compared to non-Latino white or Asian-American CAM users 17 and 11, respectively No racial/ethnic differences in delaying medical care due to transportation difficulties, getting an appointment or waiting time were observed Among CAM users, Latinos 22 and Asian Americans 17 were more likely not to have a usual source of medical care compared to non-Latino whites p0001 Disclosure of any CAM use was associated with some aspects of access to and quality of conventional medical care in the NHIS Respondents with no usual source of care were the least likely to disclose CAM use 17, while those whose usual source of care was a doctors office or HMO were most
likely to disclose 43, p0001 The uninsured were least likely to disclose 25, compared to privately and publicly insured individuals 41 and 48, respectively, p0001
In the HCQS, disclosure of any CAM use was significantly associated with having private health insurance 73 vs 50 for no insurance, p0001, having a regular doctor 75 vs 49, p0001, quality usual source of conventional care 74 for doctors office vs 38 for no usual source of care, p0001, higher satisfaction with conventional care 328 vs 287, p0001 and higher scores on the patientprovider relationship scale 215 vs 177, p0001
Multiple Variable Logistic regression analyses of any caM disclosure
We examined potential confounding effects of age, marital status, region of residence, self-reported health status, number of health conditions, education, income, employment and sex Variables not associated with CAM disclosure in bivariate analyses were excluded from subsequent analyses ie, education and household income in NHIS,
self-reported health status and sex in HCQS In multiple variable logistic regression analyses, we included measures of access to and quality of conventional care that were significantly associated with both race/ethnicity and any CAM disclosure
table 4 adjusted odds ratios and 95 confidence intervals of disclosure of complementary and alternative medicine to medical practitioner based on 2001 health care Quality survey data Model 1 aor 101 190 196 129 101 139 115 114 062 057 084 100 100 Model 2 aor 099 188 189 130 105 130 111 102 064 063 081 100 100
Age Marital Status Not married Married Region of Residence West Northeast Midwest South Number of Health Conditions Education Length of Time in the United States Race/Ethnicity Non-Latino white African American Latino Asian American Access to and Quality of Biomedical Care Health Insurance None Private Public No Regular Doctor Regular Doctor Usual Source of Care Satisfaction with Conventional Care PatientProvider Relationship
95 cI
099101 140257 124311 081207 069149 115167 102131 086150 040095 036090 046154
95 cI 098101 136262 116309 078217 070157 107158 097126 075140 040101 037106 042157
100
100
138 180 190 108 094 137
100 100
086220 099325 128282 089130 074120 103182
Model 1 assessed the association of race/ethnicity and CAM disclosure controlling for confounding variables; model 2 included access to and quality-of-care measures to assess their mediating effects on the association between race/ethnicity and CAM disclosure Statistically significant AORs are indicated in boldface; AOR: Adjusted odds ratio; CI: Confidence interval
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Model 1 of Table 3 presents adjusted odds ratios AORs of confounding variables and race/ethnicity on CAM disclosure based on 2002 NHIS data Controlling for sociodemographics and health status, African Americans, Latinos and Asian Americans were
significantly less likely to disclose any CAM use to medical providers compared to non-Latino whites AOR080, 067 and 057, respectively] Disclosure was also associated with being married, living in the northeast, having worse health and being female Model 2 of Table 3 reports odds of CAM disclosure when access to and quality of care are considered In contrast to bivariate findings, health insurance was no longer associated with CAM disclosure Those who changed their place of care AOR120 or had a higher quality of usual source of conventional care AOR116 were more likely to disclose CAM use when sociodemographics, health status and insurance were controlled Access to and quality of conventional care did not, however, eliminate racial/ethnic differences in CAM disclosure–compared to non-Latino whites, disclosure remained significantly lower for African Americans, Latinos and Asian Americans AORs077, 074 and 056, respectively Similar analyses using the 2001 HCQS, which had additional
measures of quality of care, are shown in Table 4 Model 1 indicates racial/ethnic differences when sociodemographic and health factors are controlled African Americans and Latinos were less likely to disclose CAM use AORs062 and 057, compared to non-Latino whites In Model 2, accounting for sociodemographics and health conditions, having a regular doctor and higher scores on the patientprovider relationship scale were significantly associated with CAM disclosure AORs190 and 137 In contrast to bivariate results, insurance, usual source of care and satisfaction with conventional care were not associated with CAM disclosure Race/ethnicity was no longer associated with CAM disclosure when access to and quality of conventional care were controlled
dIscussIon
Prior research estimates that two-thirds of CAM users do not disclose CAM practices to conventional healthcare providers5,15 Disclosure in this study, although sometimes higher than previously reported, was often 50 for many CAM
practices Findings confirmed our hypothesis of higher disclosure for provider-based than for self-care CAM Patients may have an easier time discussing provider-based CAM treatments because of a perception that they are more legitimate and acceptable to a conventional medical provider18 Domains with 50 disclosure have licensing requirements eg, acupuncture and chiropractic or greater perceived integration with conventional medicine eg, biofeedback, chelation therapy that likely add to their perceived validity
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Disclosure of self-care CAM ranged from fewer than a quarter of those using relaxation therapies to nearly half of those using megavitamins Self-care is the most widely used CAM26,27 Simultaneous use of vitamins, herbs and homeopathic remedies with over-the-counter and prescription medications is common,28,29 but often users are unaware of possible interactions between drugs and biologically based CAM therapies17 Patients may consider it
unimportant to report using herbs and other treatments readily available over the counter, as they often do not discuss pharmaceutical over-the-counter medications, such as analgesics, cold and allergy products and antacids30 Low patient disclosure of yoga, tai chi, qi gong and relaxation therapies is not surprising since patients may not see the use of these therapies as interacting with medical treatments and may not consider the medical encounter as a good source of information about these practices Corroborating previous research,6-10 we found that African Americans, Latinos and Asian Americans were less likely to disclose any CAM use to healthcare providers relative to non-Latino whites Our hypothesis that racial/ethnic differences in disclosure are mitigated by access to and quality of conventional healthcare was partially confirmed Using 2 national data sets, we examined specific factors of access to and quality of conventional care and patient disclosure of CAM use When
sociodemographics were considered, access issues such as insurance and cost were not associated with disclosure Factors indicative of higher-quality care–including better source of usual conventional care in the NHIS and having a regular doctor and higher patientprovider relationship ratings in the HCQS–were positively associated with greater disclosure and in the HCQS mitigated the effects of race/ethnicity It is not surprising that sequential opportunities and familiar relationships, especially if combined with culturally competent care, foster communication Findings indicate a need for improved quality of conventional medical care vis-รก-vis patient provider communication for minority populations In the NHIS, race/ethnicity contributed to nondisclosure regardless of access to and quality of conventional care, suggesting impediments to open communication between minority patients and their health providers Differential treatment at the medical encounter based on patients
race/ethnicity, such as more information provided to and better questions asked of white patients than of African-American patients,31 is likely to contribute to limited disclosure of CAM in minority groups For some minorities, distrust of conventional medicine–resulting from racial/ethnic injustices, such as the Tuskegee syphilis study and overuse of avoidable invasive procedures in minority populations32–motivates CAM use as a sociopolitical alternative to the shortcomings of the healthcare system33-35 If CAM and conventional treatments are polarized along sociopolitical lines, patients
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may withhold information about treatments they are using when they visit medical doctors For immigrants, disclosure may be further impeded by unavailability of providers who speak their preferred language, different communication norms of medical systems in the country of origin, fear about immigration status
and unfamiliarity with the American healthcare system36,37 Being female, having lower health status, a greater number of health conditions, living in the northeast and being married were also associated with increased likelihood of disclosure Compared to men, women have more medical encounters, have longer appointments and are more engaged at them,38 which provides more opportunity for disclosure Poor health often translates to more frequent medical interactions and perhaps more active medication management, 2 conditions that could invite discussion of CAM use In fact, when women use CAM and see a medical health doctor for the same health concern, disclosure rates are particularly high, ranging from 5296 depending on the health condition28 The associations of place of residence and marital status with disclosure are less clear
based CAM Research on perceptions of legitimacy of CAM treatments and self-care in a medically pluralistic environment should inform professional training for
healthcare providers Disclosure of CAM is associated with better patient physician relationship and quality healthcare across racial/ethnic groups Communication may be improved through patient-oriented interventions aimed at establishing consistent care and trusting rapport with providers Patient education about the usefulness of disclosure should be culturally sensitive and targeted to special populations CAM disclosure can educate physicians about specific cases and populations they serve, thus informing patient-driven clinical care and research
acKnoWLedgeMents
The authors thank the Commonwealth Fund for conducting and providing public access to the Health Care Quality Survey and the National Center for Health Statistics for the National Health Interview Survey
study strengths and Limitations
Using cross-sectional data, we were unable to determine causal relationships among study variables It was not possible to determine, for instance, whether quality care increases disclosure
or if discussion of CAM use improves patients ratings of their patientprovider relationship Second, the broad groupings of race/ethnicity in our analysis obscure cultural heterogeneity within groups that may influence behaviors such as CAM use and communication with medical providers Finally, heterogeneous CAM therapies are not readily characterized as self-care and providerbased care, as the use of homeopathy and herbalism, for instance, can be prescribed by practitioners but are commonly used as self-care The interplay of self-care and provider-based care in health behaviors that affect disclosure opportunities are not captured in these analyses To our knowledge, this is the first study to examine disclosure by specific CAM types and differences between self-care and provider-based CAM The nationally representative samples of NHIS and HCQS coupled with data on sociodemographics and healthcare behaviors facilitated analyses of CAM disclosure in the context of access to and quality of
conventional medical care Oversampling of minorities in these data sets provides valuable information on CAM utilization in populations that have been underresearched
reFerences
concLusIon
Insufficient disclosure of CAM use to conventional providers represents a serious medical encounter communications challenge, particularly for self-treatment and among minority populations Racial/ethnic variation in CAM disclosure seems driven primarily by differences in reporting self-care rather than provider1348 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
1 Kessler R, Davis R, Foster DF, et al Long-term trends in the use of complementary and alternative medical therapies in the United States Ann Intern Med 2001;15:262-268 2 Barnes P, Powell-Griner E, McFann K, et al Complementary and alternative medicine use among adults: United States, 2002 Advance data from vital and health statistics; 2004 Hyattsville, MD: National Center for Health Statistics; no 343 3 Druss BG, Rosenheck RA Association
between use of unconventional therapies and conventional medical services JAMA 1999;282:651-656 4 Kronenberg F, Cushman LF, Wade CM, et al Race/ethnicity and womens use of complementary and alternative medicine in the United States: Results of a national survey Am J Public Health 2006;96:1236-1242 5 Eisenberg DM, Kessler RC, Van Rompay MI, et al Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey Ann Intern Med 2001;135:344-351 6 Collins KS, Hughes DL, Doty MM, et al Diverse communities, common concerns: Assessing health care quality for minority Americans, Findings from the Commonwealth Fund 2001 Health Care Quality Survey; 2002 Commonwealth Fund 7 Kuo GM, Hawley ST, Weiss LT, et al Factors associated with herbal use among urban multiethnic primary care patients: a cross-sectional survey BMC Complement Altern Med 2004;4:18 8 Graham RE, Ahn AC, Davis RD, et al Use of complementary and alternative medical
therapies among racial and ethnic minority adults: Results from the 2002 National Health Interview Survey J Natl Med Assoc 2005;97:535-545 9 Mehta DH, Phillips RS, Davis RB, et al Use of complementary and alternative therapies by Asian Americans Results from the National Health Interview Survey J Gen Intern Med 2007;22:762-767 10 Ahn AC, Ngo-Metzger Q, Legedza ATR, et al Complementary and alternative medical therapy use among Chinese and Vietnamese Americans: Prevalence, associated factors, and effects of patient-clinician communication Am J Public Health 2006;96:647-653 11 Hu Z, Yang X, Ho PC, et al Herb-drug interactions: a literature review Drugs 2005;65:1239-1282 12 Skalli S, Zaid A, Soulaymani R Drug interactions with herbal medicines Ther Drug Monit 2007;29:679-686 13 Coon JT, Ernst E Panax ginseng: a systematic review of adverse effects and drug interactions Drug Saf 2002;25:323-344 14 Piscitelli SC, Burstein AH, Welden N, et al The effect of garlic supplements on the
pharmacokinetics of saquinavir Clin Infect Dis 2002;34:234-238
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DISCLOSURE OF COMPLEMENTARY AND ALTERNATIVE MEDICINE 15 Robinson A, McGrail MR Disclosure of CAM use to medical practitioners: a review of qualitative and quantitative studies Complement Ther Med 2004;12:90-98 16 Tasaki K, Maskarinec G, Shumay DM, et al Communication between physicians and cancer patients about complementary and alternative medicine: exploring patients perspectives Psychooncology 2002;11:212-220 17 Vickers KA, Jolly KB, Greenfield SM Herbal medicine: womens views, knowledge and interaction with doctors: a qualitative study BMC Complement Altern Med 2006;6:40 18 Stevenson FA, Britten N, Barry CA, et al Self-treatment and its discussion in medical consultations: how is medical pluralism managed in practice? Soc Sci Med 2003;57:513-527 19 Institute of Medicine Unequal treatment: Confronting racial and ethnic disparities in health care Washington, DC: National Academies Press;
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