so, then you have had some experience with alternative medicine. and Alternative Medicine (NCCAM), established by the National Institutes of …
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Should NICE evaluate complementary and alternative medicine?
Linda Franck, Cyril Chantler and Michael Dixon BMJ 2007;334;506 doi:101136/bmj39122512211BE
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Should NICE evaluate complementary and alternative medicine?
Linda Franck professor University College London
Institute of Child Health, London WC1N 1EH Cyril Chantler chair Kings Fund, London W1G 0AN Michael Dixon chair NHS Alliance, Retford, Nottingham DN22 6JD
lfranck@ichuclacuk
The National Institute for Health and Clinical Excellence NICE guidance is built on the rigorous appraisal of scientific evidence and the evaluation of the cost effectiveness of diagnostics and treatments1 2 The Secretary of State for Health refers topics for development of guidance based on national priorities3 NICE has received international recognition for its topic selection and appraisal processes and commitment to using the best available evidence for decision making4 Complementary and alternative medicine covers a heterogeneous group of therapies that share a focus on, or integration of, treatment of mind and spirit as well as body5 The main goals of these treatments are often framed in terms of feeling better that is, relief of symptoms or prevention promotion of general health and wellbeing rather than cure6 7 They may therefore be particularly relevant for patients with long term disease, who account for 80 of general practice consultations and who, by
definition, are unlikely to be cured Furthermore, most people seek complementary therapies as an adjunct rather than substitute for conventional medicine8 Complementary therapies are widely used by the public Around half of general practitioners provide access to complementary medicine,9 and two thirds of Scottish general practitioners prescribe herbal or homoeopathic medicines10 However, NICE has not been asked to develop guidance on these therapies3 Given the high public interest in complementary medicine, we find this surprising
Explanations There are several possible explanations for the lack of investigation The first is that complementary therapies are not relevant to NHS priorities of reducing health inequalities, promoting health and wellbeing, patient choice, and patient involvement Yet
506
Yes
as current usage statistics indicate, patients are choosing complementary therapies to promote health and wellbeing and there are inequalities in terms of access A second reason is
that there are not always adequate methods for evaluating these therapies with the same rigour as applied to conventional medicine Some therapies, such as herbal, nutritional, or homoeopathic remedies, can be evaluated in standard double blind randomised placebo controlled trials11 For other therapies that are heavily dependent on the individual therapist, double blinding may be impossible However, these research design problems are no different from those for conventional therapies such as surgery Research methods used for comparative trials of behavioural interventions offer a way forward1214 In order for alternative therapies to be compared with conventional treatments, more work is needed to define the most important outcomes and to measure them appropriately15
This leaves two final reasons for the absence of NICE guidance There may be an attitudinal bias against complementary therapies or a lack of resources Some people within conventional medicine remain deeply convinced that
alternative medicine cannot have any possible benefit,5 but this is all the more reason that these therapies should be rigorously evaluated The lack of resources for evaluation is equally difficult to defend, but perhaps understandable when there is great pressure to evaluate high cost drugs and technologies
Benefits of review However, failure to evaluate complementary therapies leads to health inequalities because of uneven access and missed opportunities For example, as complementary therapies are often relatively cheap, if shown to be effective they could save money currently spent on costly drugs In summary, NICE already has a systematic review process that takes into account all available evidence, including observational studies18 Recent publicity on the use of complementary medicine in the NHS suggests that it should receive greater priority in topic selection Applying the same standards as we apply to conventional medicine, we simply need to ask is it safe, is it effective in
relieving symptoms compared with no treatment, how effective is it the number needed to treat, how much does it cost, and is it affordable quality adjusted life years? Complementary and alternative therapies deserve a full evaluation from NICE and, if the evaluation is favourable, they should be adopted either on their own or integrated with conventional medicine
competing interests: None declared
Failure to evaluate complementary therapies leads to health inequalities because of uneven access and missed opportunities
A third reason NICE may not have been commissioned to evaluate complementary therapies is that there is insufficient evidence with which to develop guidelines However, there are numerous Cochrane reviews of complementary therapies16 NICE has made some recommendations about benefits or risks of some complementary therapies within condition specific guidelines–for example, pregnancy, multiple sclerosis, Parkinsons disease, hypertension, and depression17 The guidance and
supporting documentation available on its website suggests that these recommendations of a few complementary therapies have not been subjected to the same rigour as those of traditional medical interventions Furthermore, NICE has not addressed the important questions of comparative efficacy or additive value in relation to current treatments being offered in the NHS Where there is insufficient evidence, NICE could draw attention to this in order to stimulate more research
BMJ | 10 March 2007 | VoluMe 334
Source:bmj.com
