areas of complementary and alternative medicine (CAM). The series was prepared. as part of the National Center for Complementary and Alternative Medicine’s …
Complementary and Alternative Medicine Use among Health Plan Members
A Cross-Sectional Survey
Many health plans have started to cover the cost of complementary and alternative medicine CAM National survey data indicate that CAM use is highly prevalent among adults However, little is known about CAM use among health plan members
CONTEXT OBJECTIVE To describe CAM users, the prevalence of CAM use, and how CAM use relates to utilization of conventional preventive services and health care satisfaction among health plan members DESIGN
ORIGINAL ARTICLE
CAROLYN M GRAY, BSN AGNES WH TAN, PhD
Center for Health Promotion, HealthPartners
NICOLAAS P PRONK, PhD
Center for Health Promotion and HealthPartners Research Foundation, Health Partners
PATRICK J OCONNOR, MD, MPH
HealthPartners Research Foundation, Health Partners Minneapolis, Minn Eff Clin Pract 2002;5:1722
Cross-sectional mail survey in 1997 Managed care organization in Minnesota
SETTING SAMPLE
Random sample of health plan members
aged 40 and older stratified by number of chronic diseases; 4404 86 of the 5107 returned completed questionnaires
MEASURES Use of CAM, patient characteristics eg, chronic diseases, health status, health behaviors eg, smoking, diet, exercise, and interaction with conventional health care eg, use of preventive services, having a primary care doctor, health care satisfaction
Overall, 42 reported the use of at least one CAM therapy; the most common were relaxation techniques 18, massage 12, herbal medicine 10, and megavitamin therapy 9 Perceived efficacy of CAM ranged from 76 hypnosis to 98 energy healing CAM users tended to be female, younger, better educated, and employed Users of CAM reported more physical and emotional limitations, more pain, and more dysthymia but were not more likely to have a chronic condition CAM users were slightly more likely to have a primary care provider 86 vs 82 had chosen a primary care provider; P 0014 and had more favorable healthrelated behaviors CAM
users and nonusers were equally likely to use conventional preventive services and were equally satisfied with their health plan
RESULTS
CAM use is highly prevalent among health plan members CAM users report more physical and emotional limitations than do nonusers CAM does not seem to be a substitute for conventional preventive health care
CONCLUSION
A
ccording to survey data, use of complementary and alternative medicine CAM in the United States is common and growing: CAM use rose from 34 to 42 between 1993 and 19981, 2 In 1998, 425 million visits were made to providers
Edited by James D Sargent, MD
This paper is available at ecpacponlineorg
2002 American College of PhysiciansAmerican Society of Internal Medicine
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of unconventional therapy at a total cost of 137 billion,2 costs that are increasingly being borne by health plans as they begin to cover CAM services3, 4 Given the prevalence of CAM use and its potential interaction with conventional therapies, medical care
providers have an interest in understanding how and why patients seek CAM Little is known about CAM use among health plan members In 1997, HealthPartners, a not-for-profit managed care organization MCO in Minnesota, initiated a blended approach to alternative medicine at two clinics as a pilot to better meet members needs and interests We conducted this study to assess the prevalence of CAM use, to describe who uses CAM, and to determine how CAM use relates to the use of conventional health care preventive service utilization and satisfaction with care
Methods
Study Sample
reported measures of physical limitations, emotional limitations, chronic pain, depression, and perception of improved health since last year, health behaviors exercise, vegetable and fruit intake, fast-food intake, choice of low-fat foods when eating out, alcohol consumption, smoking, and seatbelt use, use of conventional preventive health services having a primary care provider, flu shot within the past year,
mammogram within the past year; preventive use of aspirin; and postmenopausal use of estrogen and calcium for prevention of osteoporosis, and satisfaction with the conventional health system
Analysis
The study was conducted at HealthPartners, a large mixed-model MCO that had approximately 650,000 members in 1997 Study participants were drawn from a stratified sample of the groups members who were 40 years of age and older; the study sample included 3000 members with no chronic conditions, 2500 members with one chronic condition, and 2500 members with two to four chronic conditions Chronic conditions used to stratify the population included diabetes, hypertension, dyslipidemia, and heart disease; the conditions were identified by using ICD-9-CM codes and other data5 We mailed surveys to 5107 members who had responded to previous surveys and received 4404 responses 86 response rate for the survey reported herein We telephoned respondents who did not return the survey after two
mailings
Survey Measures
To assess CAM use, we asked, During the last 12 months have you used any of these therapies for your health? Seventeen therapies, similar to those reported by Eisenberg and colleagues1 in 1993, were listed as response options Although we queried the recipients about use of prayer, we excluded prayer as a CAM method No examples or definitions for each type of therapy were given; therefore, each respondent arrived at his or her selection independently Perceived efficacy of CAM was assessed by using the question, Does/did it help? To describe the characteristics of CAM users, we also asked about demographics gender, age, education, employment, and marital status, health status self18
To account for the stratified sampling according to chronic conditions, we weighted all estimates so that they represented the entire adult population of the health plan The relationship between CAM use and health status, use of conventional preventive services, and member
satisfaction with the health plan was first assessed using the Chi-square test All data were analyzed after adjustment for sample stratification using the formula described in Kahn and Sempos6 In determining the association between CAM use and conventional preventive services, we used multivariate logistic regression models to adjust for the following potential confounders: demographics, health status, physical limitations, dysthymia, marital status, and employment status In each case, a full model was fitted and then variables not found to be significant were removed to obtain the final adjusted odds ratios The final model consisted of gender, age, education, improved health status over the past year, emotional limitations, and having pain The effect of stratified sampling is taken into account by using appropriate sampling weights In Statistical Analysis Software, version 6 SAS Institute, Cary, NC, this is accomplished by using the option of WEIGHT in the procedure of PROC LOGISTIC
Finally, the method of Zhang and Yu7 was used to approximate the relative risk from the odds ratio obtained from the logistic regression
Results
Prevalence of CAM Use
Table 1 shows that the overall rate of use for at least one of the 16 CAM therapies excluding prayer for the study population was 42 The most commonly used alternative therapies were relaxation techniques 18, massage 12, and herbal medicine 10 Among members using CAM, the mean number of therapies used was 19 Most CAM users thought their therapy helped; the percentage of satisfied users ranged from 76 for hypnosis to 98 for energy healing
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TA B L E 1
Prevalence of CAM Use by Health Plan Members and Its Perceived Effectiveness
ALTERNATIVE THERAPY DURING THE PAST 12 MONTHS, HAVE YOU USED ANY OF THESE THERAPIES FOR YOUR HEALTH? YES DOES/DID IT HELP? YES
Relaxation technique Massage Herbal medicine Megavitamin therapy Spiritual healing Chiropractic
adjustment Imagery Self-help groups Lifestyle diets Commercial weight-loss programs Homeopathy Folk remedies Acupuncture Energy healing Biofeedback Hypnosis Prayer At least one therapy excluding prayer
18 12 10 9 8 8 5 4 3 3 2 2 1 1 1 1 52 42
93 93 80 79 94 89 92 91 88 90 84 83 90 98 97 76 89
Responses from the 4404 respondents are weighted to reflect the entire adult population of the health plan
Who Uses CAM?
Table 2 presents CAM use by demographic and healthrelated factors CAM use was higher among female 46 female vs 38 male, younger 55 years, more highly educated college graduate or more, single, and employed health plan members While those with chronic conditions were no more likely to report CAM use, patients with limitations in each of the health status measures were more likely to report CAM use In addition, those who perceived improvement in their general health status over the past year were more likely to have used CAM than those who did not feel their health had
improved 50 vs 41
Health-Related Behaviors
vices A significantly higher proportion of CAM users had chosen a primary care physician 86 vs 82, used supplemental calcium 63 vs 52, had a recent check-up 63 vs 60, and had a recent mammogram 67 vs 62 In all cases, the adjusted relative risk ratios were small never more than 106 CAM users were not more likely to get flu shots, use aspirin to prevent heart disease, or use estrogen
Satisfaction with the Health Plan
With respect to health-related behaviors, patients who reported higher use of CAM also reported more regular exercise 46 of regular exercisers vs 40 of nonregular exercisers reported CAM use, higher vegetable intake 45 vs 40, lower dietary fat intake 48 vs 39, and lower alcohol intake 43 vs 35 but ate more fast food 47 vs 41 Nonsmoking history, receipt of dental care, and use of seatbelts did not relate to CAM use
Use of Conventional Preventive Services
CAM users did not differ from nonusers with respect to satisfaction with the
health plan The satisfaction measures included satisfaction with health plan support of members efforts to improve their health status 42 of users vs 43 nonusers responded excellent or very good and provision of information about staying well and avoiding illness 41 users vs 42 nonusers users responded excellent or very good CAM users were slightly more likely to want a lot more active involvement in their own health care decisions 46 vs 39; P 0002
Discussion
Table 3 presents the association between use of CAM and utilization of various conventional preventive serEffective Clinical Practice
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This study indicates that use of CAM among health plan members mirrored that of a national sample, both in terms of prevalence and types of therapies used1, 2, 4 Our data provide solid evidence that persons likely to use
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TA B L E 2
Characteristics of Health Plan Members According to CAM Use
CHARACTERISTIC OR CONDITION PERCENTAGE REPORTING CAM
USE
P VALUE
Demographics Gender Female Male Age, yr 55 5564 65 Education High school graduate or less Some college College graduate or higher Employment status Unemployed Employed Marital status Never been married, divorced, or separated Married/widowed Health status Diagnosed chronic conditions None One Two or more During the past 30 days How many days was your physical health not good? includes physical illness or injury None 5 days How many days was your mental health not good? includes stress, depression, and emotional problems None 5 days How many days did pain make it hard for you to do your usual activities, such as self-care, work, or recreation? None 5 days Do you often feel sad or depressed? No Yes Compared with 1 year ago, how would you rate your health in general now? Much worse or somewhat worse Much better or somewhat better Health-related behaviors In the past week, have you had a total of 30 minutes or more of physical activity? No Yes Do you eat at least five
servings of vegetables every day? No Always or most of the time In the past week, how many times have you eaten fast food or eaten in a restaurant? None Yes How often do you make a low-fat choice when eating away from home? Never Always or most of the time How many times during the past year did you have five or more drinks on one occasion? None One or more times Have you smoked at least 100 cigarettes in your entire life? No Yes How often do you wear a seatbelt when driving or riding in a car? Never Always
0001 46 38 0001 49 40 32 0001 35 45 46 0001 35 46 0026 49 42
02 43 40 40 0001 40 53 0001 39 57 0001 40 57 0020 42 49 0001 41 50
0008 40 46 0011 40 45 0020 41 47 0001 39 48 0011 43 35 02 42 42 0154 39 43
Responses from the 4404 respondents are weighted to reflect the entire adult population of the health plan
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TA B L E 3
Relationship between CAM Use and Use of Conventional and Preventive
Services
CHARACTERISTIC TOTAL RESPONDENTS CAM USERS n 1807 NONCAM USERS n 2597 ADJUSTED RR 95 CI
Fewer Preventive Services 08 09 10
More Preventive Services 11 12
Primary care provider chosen Regular check-up within past year Flu shot within past year Mammogram within past year Aspirin use–3 or more times a week for prevention of heart disease Estrogen use–has taken hormone replacement therapy women only Calcium use–has taken supplement women only
4255
86
82
4257
63
60
4172 1999
52 67
54 62
4323
31
33
1106
72
70
2045
63
52
08 09 10 11 12
Fewer Preventive Services
More Preventive Services
The percentages are weighted to reflect the entire adult population of the health plan and are based on the numbers shown Adjusted for gender, age, education, impaired health status over the past year, emotional limitations, and having pain
CAM were also likely to utilize traditional care In fact, in our health plan, CAM users were slightly more likely to seek traditional
preventive care and were as satisfied with the health plan as nonusers In addition, CAM users were more likely to want to be actively involved in health care decision making
CAM User Profile
chronic conditions we selected diabetes, dyslipidemia, hypertension, and heart disease; however, other chronic conditions eg, chronic back pain are not as easily treated Patients with the conditions that are more difficult to treat may be the patients who seek CAM
Limitations
CAM use appears to be more prevalent among young women who are educated and employed Surprisingly, CAM users are not more likely to have chronic medical conditions They do, however, report more physical and emotional limitations and have more pain, consistent with previous findings1, 2 These findings are difficult to reconcile One would expect chronic conditions to be associated with higher levels of physical and emotional limitations and perhaps more pain It may be speculated that CAM users look for additional ways to
address their suboptimum functioning In doing so, they become actively engaged in their own care but do not appear to substitute CAM for traditional medicine It could also be true that the traditional medical system adequately addresses the
Effective Clinical Practice
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Several limitations to our study should be acknowledged First, self-reported use of preventive services tends to be higher than what is observed through review of medical records While self-report may affect the magnitude of the rates, it is unlikely to affect the differences between CAM users and nonusers Next, we measured only conventional preventive care It is possible that CAM users feel differently about the use of conventional treatments for active disease Finally, our assessment of the perceived efficacy of therapy is limited to one question
Implications for Health Plans and Health Provider
Our data suggest that CAM utilization may be quite high in some demographic groups Cost per patient will
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increase for health plans that choose to cover CAM alternatives because those who use CAM do not appear to use fewer conventional preventive care services Health plans can play an important role in providing members with access to evidence-based information regarding the safety and effectiveness of various alternative therapies While some health plans are moving in this direction, most have not yet considered the potential implications of CAM use on clinical outcomes, patient satisfaction, and cost of care As attention to patient-centered health care increases,8, 9 CAM will necessarily receive increased attention in the future Since CAM users often have selected a primary care provider, have regular check-ups, and desire active engagement in health care decisions, there is an opportunity to provide information about alternative medicine options812 Such discussions may lead to higher patient satisfaction14 Efficacy data on the more common CAM
modalities are urgently needed to inform discussions between patients and their health providers
References
Take-Home Points
Although many managed care organizations are now providing CAM benefits, little is known about health plan member use of CAM We surveyed a random sample of health plan members to learn the prevalence of CAM use, characteristics of CAM users, and how use relates to interactions with the conventional health care system CAM use among health plan members was high 42 and closely mirrored the level of CAM use observed in the general population Although CAM users did not report more chronic disorders, they were more likely to perceive physical and emotional limitations in daily life and to experience more pain than nonusers CAM users reported slightly higher rates of conventional preventive health care services As a result, coverage of CAM by health plans will probably increase the cost of care Since CAM users want to be actively involved in health care
decisions, there may be an opportunity for health plans to provide patients with information about the efficacy and safety of these therapies
1 Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL Unconventional medicine in the United States Prevalence, costs, and patterns of use N Engl J Med 1993;328:246-52 2 Eisenberg DM, Davis RB, Ettner SL, et al Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey JAMA 1998;280:1569-75 3 Astin JA Why patients use alternative medicine: results of a national study JAMA 1998: 279:1548-53 4 Oldendick R, Coker AL, Wieland D, et al Population-based survey of complementary and alternative medicine usage, patient satisfaction, and physician involvement South Carolina Complementary Medicine Program Baseline Research Team South Med J 2000;93;375-81 5 OConnor PJ, Rush WA, Pronk NP, Cherney LM Identifying diabetes mellitus or heart disease among health maintenance organization members:
sensitivity, specificity, predictive value, and cost of survey and database methods Am J Manag Care 1998;4:335-42 6 Kahn HA, Sempos CT Statistical Methods in Epidemiology New York: Oxford University Pr; 1989 7 Zhang J, Yu KF Whats the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes JAMA 1998;280:1690-1 8 Kohn LT, Corrigan JM, Donaldson MS, eds To Err Is Human: Building a Safer Health System Washington, DC: National Academy Pr; 2000 9 Institute of Medicine Crossing the Quality Chasm: A New Health System for the 21st Century Washington, DC: National Academy Pr; 2001 10 OConnor PJ, Pronk NP, Tan AW, Rush WA, Gray RJ Does professional advice influence aspirin use to prevent heart disease in an HMO population? Eff Clin Pract 1998;1:26-2 11 Gottlieb NH, Green LW Life events, social network, life-style, and health: an analysis of the 1979 national survey of personal health practices and consequences Health Educ Q 1984;11:91105 12 Byrd RC Positive
therapeutic effects of intercessory prayer in a coronary care unit population South Med J1988;81:826-9 13 Dossey L Healing Words: The Power of Prayer and the Practice of Medicine San Francisco: Harper; 1993 14 OConnor PJ, Rush WA, Rardin KA, Isham G Are HMO members willing to engage in two-way communication to improve health? HMO Practice 1996;10:17-9
Correspondence
Nicolaas P Pronk, PhD, HealthPartners, Center for Health Promotion, 8100 34th Avenue South, Minneapolis, MN 554401309; telephone: 952-967-6729; fax: 952-967-6710; e-mail: nicoppronk@healthpartnerscom
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