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BackgroundThe use of homeopathy is growing in the United States, but little is known about practice patterns of physicians using homeopathy and the patients who seek homeopathic care.Materials and MethodsData for consecutive patient visits to 27 doctors of medicine and doctors of osteopathy using homeopathy in 1992 were collected and compared with the National Ambulatory Medical Care Survey of 1990.ResultsPatients seen by the homeopathic physicians were younger, more affluent, and more likely to present with long-term complaints. Physicians using homeopathic medicine surveyed spent more time with their patients, ordered fewer tests, and prescribed fewer pharmaceutical medications than physicians practicing conventional medicine.ConclusionsWhile definite conclusions cannot be made based on this survey, we have documented that the use of diagnostic testing and conventional medications by physicians who use homeopathy to treat common chronic conditions is well below that of conventional primary care physicians. These findings, if associated with comparable clinical outcomes, suggest a potential for substantial cost savings. Further studies documenting outcomes, cost benefits, physician decision-making, and patient satisfaction will be required to further explore this subject.HOMEOPATHIC medicine was first developed in Germany by Samuel Hahnemann in the late 18th century. By the late 1800s, it was practiced widely in the United States, and today it is used extensively throughout the world, especially in Europe, where surveys have reported that in some countries 30% to 40% of the population has used homeopathic medicine.Homeopathy declined in the United States in the early 20th century, but there has been increasing interest in the field in the past 10 years. In 1990, 4.8 million visits to homeopathic providers were reported in the United States and retail sales of homeopathic medicines increased from $100 million in 1988 to $250 million in 1996.In 1997, worldwide sales of homeopathic products were estimated to be $1.15 billion.Homeopathy is based on the principle of similars, whereby highly diluted preparations of substances that can cause symptoms in healthy volunteers are used to stimulate healing in patients who have similar symptoms when ill.The mechanism of action of homeopathy is not understood, and many doubt the scientific rationale of using such diluted medicines.Nevertheless, a growing body of double-blind, placebo-controlled trials suggest that homeopathy may be clinically effective,and it has been estimated that 2500 medical professionals in the United States use homeopathy to some extent in their practices.A growing number of insurers and managed care plans are offering coverage of alternative therapies ,and it has been suggested that health care costs could be reduced by use of these therapies.A survey done in France, where one third of physicians use homeopathy, found that the annual cost per person to the social security system for a homeopathic physician was 15% less than that of a conventional physician.This savings was attributed to the reduction in the use of diagnostic tests and to the lower cost of homeopathic medications, which cost about one third less than conventional medicines in France.To further our understanding of the use of alternative modalities, information is needed about patients who seek care, the problems for which care is sought, tests and treatments that are provided, and their costs. In this survey, we looked at these factors for a group of physicians using homeopathy and compared the results with similar findings from a group of physicians using conventional medicine.MATERIALS AND METHODSIn early 1992, we sent a letter requesting participation in the survey to all 102 active members of the American Institute of Homeopathy (AIH), a national organization of doctors of medicine and doctors of osteopathy who use homeopathy. Twenty-seven members agreed to participate. Physicians were asked to record data on all patient visits occurring during the week of April 6 through April 10, 1992. This survey was modeled after the National Ambulatory Medical Care Survey (NAMCS), conducted by the National Center for Health Statistics and the US Bureau of the Census. The 1990 NAMCS, which included a representative sample of general and family physicians, was used as a comparison group for the AIH physicians.Data on sequential patient visits were recorded either during or immediately after the visit on a form that was identical to that used in the 1990 NAMCS, with the addition of fields to record costs. Demographic information about the patient, payment sources, principal diagnoses, diagnostic services, medication therapy, and duration of visit was collected in both surveys.RESULTSOf the 27 participating AIH physicians, 22 (81.5%) were men; the average age of the entire group was 46 years. United States geographical distribution was as follows: 7(26%), northeast; 2 (7.4%), south; (3) 11.1%, midwest; and 15 (55.5%), west. This compares with 76 (72.6%), men; 38 (37.4%), northeast; 12 (11.7%), south; 18 (17.5%), midwest; and 34 (33.5%), west of the total AIH membership of 102 physicians in 1992. Twenty-two (80%) of the 27 respondents listed their primary specialty as family practice, general practice, or homeopathic medicine. They had been practicing medicine for a median of 18 years, with an average of 11.5 years' experience using homeopathy in their practices. Twenty-four (85%) said that they used homeopathy in 75% or more of their patient visits. Demographic information about the NAMCS physicians was limited to sex (90%, men) and geographic region (18.4%, northeast; 32.3%, south; 27%, midwest; and 22.3%, west). Information about age was not collected by the NAMCS, but other sources indicate that the median age of all physicians in the United States was 44 years in 1990.A comparison of patient sex and ages showed that the AIH physicians were more likely to treat women, as well as children younger than 15 years and young to middle-aged adults, and were less likely to treat patients older than 65 years (Table 1). These physicians saw a higher percentage of white and Asian patients and a lower proportion of blacks and Hispanics.Table 1. Demographic Characteristics of Patients Seeing Physicians Using Homeopathic Medicine Compared With Physicians Using Conventional Medicine*CharacteristicHomeopathic Medicine, % (n = 1177)Conventional Medicine, % (n = 11,614)SexFemale66.261.0Male33.739.0Age, y<1523.916.615-245.211.625-4432.628.545-6427.822.8>6410.520.5RaceWhite91.584.4Black2.98.5Asian/Pacific Islander5.53.0Unspecified04.0Hispanic2.65.4*For all characteristics P<.001 by χ2test.The average percentage of new patient visits, 15%, was comparable between the 2 groups, although the AIH physicians were more likely to be seeing an old patient for an old problem (Table 2). The patients seeing AIH physicians more commonly had private medical insurance, while the NAMCS patients were more likely to have Medicare or Medicaid, to belong to a health maintenance organization or other managed health care program, or to have no insurance at all. The AIH physicians spent more than twice as much time with their patients, with an average of 30 minutes per visit compared with 12.5 minutes for physicians practicing conventional medicine. This information reflects both returning and new patient visits.Table 2. Visit Type, Insurance Coverage, and Duration of Visit of Patients Seeing Physicians Using Homeopathic Medicine Compared With Physicians Using Conventional MedicineHomeopathic Medicine, % (n = 1177)Conventional Medicine, % (n = 11,614)Type of visitNew patient15.614.6Old patientNew problem21.231.9Old problem63.253.5Insurance coverageSelf-pay18.133.9Medicare10.419.0Medicaid3.312.3Blue Cross/Blue Shield17.58.6Other commercial37.220.1HMO/prepaid plan*6.913.5Other5.76.0Duration of visit, min<52.011.16-107.033.211-1517.232.5>1574.823.2Mean duration, min30.012.5*HMO indicates health maintenance organization.While the AIH physicians spent more time with their patients, they were less likely to order diagnostic services. In the NAMCS survey, physicians ordered 1 or more diagnostic services in 68.3% of all patient visits, compared with 39.9% of visits for the AIH physicians (Table 3). The AIH physicians prescribed homeopathic medications in 79% of visits, and conventional pharmaceutical medications in 27.5% of patients visits. This compared with 68.7% of visits in the NAMCS sample where conventional medications were prescribed.Table 3. Diagnostic Services and Medication Therapy Used by Physicians Using Homeopathic Medicine Compared With Physicians Using Conventional Medicine (Percentage of Visits)Homeopathic Medicine, % (n = 1177)Conventional Medicine, % (n = 11,614)Diagnostic services1 or more39.968.3Laboratory test(s)9.219.6Urinalysis4.012.0Chest x-ray film0.43.7Other diagnostic services6.731.3Therapy usedConventional medication27.568.7Homeopathic medication79.0NA**NA indicates not applicable.A comparison of the 10 most common diagnoses between the 2 groups indicates that the AIH physicians saw more patients for chronic illnesses (Table 4). With the exception of otitis media, which can be acute or chronic, all of the 10 most common diagnoses of the AIH patients were for chronic illnesses, such as asthma, depression, allergies, headaches, and arthritis. In contrast, there were only 3 chronic illnesses represented in the 10 most common diagnoses of the NAMCS physicians—hypertension, diabetes, and chronic sinusitis.Table 4. Ten Most Common Principal Diagnoses of Patients Seeking Care From Physicians Using Homeopathic Medicine Compared With Physicians Using Conventional MedicineHomeopathic Medicine (n = 1177)Cases, %Conventional Medicine (n = 11,614)Cases, %Asthma4.9Hypertension6.4Depression3.5Upper respiratory tract infection3.9Otitis media3.5Otitis media3.1Allergic rhinitis3.4Diabetes mellitus2.9Headache/migraine3.2Acute pharyngitis2.6Neurotic disorders2.9Chronic sinusitis2.6Allergy (nonspecific)2.8Bronchitis2.6Dermatitis, eczema2.6Sprains/strains1.7Arthritis2.5Back disorders1.4Hypertension2.4Allergic rhinitis1.4The average cost for a new patient visit for AIH physicians was $137 and the average time was 59.8 minutes. The average cost for a follow-up visit was $55 and the average time was 25.4 minutes. The cost of visits was not included in the NAMCS.COMMENTThe results of this survey indicate that there are considerable differences in the types of patients seeking care, principal diagnoses, and the practice patterns of physicians using homeopathy when compared with physicians who practice conventional medicine. The finding that physicians using homeopathy see a younger patient population is similar to that of a 1990 surveyin which a larger proportion of young to middle-aged adults (the baby boomers) were found to have used unconventional therapies. The larger number of white and Asian patients is likely due to practice location, since most of the AIH survey physicians practiced in the west, where there is a larger number of Asian patients, while in the south, which was more highly represented in the NAMCS survey, there is a larger number of black and Hispanic patients. The higher percentage of patients with private medical insurance suggests that the AIH patients were in general more affluent. Conversely, the low number of Medicaid, Medicare, and noninsured patients seen by the homeopathic physicians suggests that interest in and access to alternative health care by low-income groups may be limited.The AIH physicians were roughly similar to the NAMCS sample for sex and age distribution. However, major differences in geographical distribution were found, which could have affected some of the results. There was a preponderance of homeopathic physicians in the west and northeast, with a much lower proportion in the south and midwest. Whether regional differences could have affected the case mix and/or practice patterns of the physicians surveyed is unknown.The AIH physicians were more likely to be consulted for chronic illnesses and by patients with psychological and/or functional symptoms, such as anxiety, allergies, and fatigue. These are conditions that are often difficult to treat with conventional medicine, or for which modern medicine offers mostly symptomatic relief, or treatment that does not satisfy patients. Conversely, patients with illnesses such as hypertension, diabetes mellitus, and acute injuries and infections, for which there are effective conventional treatments, were more likely to seek conventional care.Because of the differences in the case mix, including the age and socioeconomic status of the patients and type of illnesses seen by the 2 groups, conclusions about laboratory tests, time spent, and cost per visit should be interpreted with caution. Homeopathic physicians spent more than twice as much time with their patients, which likely reflects the complexity of the homeopathic history-taking and prescribing process. Homeopathic medications are individualized to each patient, based on a wide constellation of physical, general, and mental/emotional symptoms that must be elicited at each visit.The fewer number of diagnostic procedures and laboratory tests ordered by AIH physicians also could reflect the emphasis on history taking and physical examination to determine the diagnosis and course of treatment in homeopathic practice.It is also possible that the patients seeing the AIH physicians generally were less ill and required fewer tests, or that extensive testing had already been done by another physician. The increased number of visits by old patients for old problems could also have contributed to the use of fewer tests by the AIH physicians.As would be expected, the AIH physicians prescribed fewer conventional pharmaceutical drugs, although their use in almost 28% of patient visits suggests the complementary nature of homeopathic treatment as an adjunct to conventional treatment in many cases. In most cases, homeopathic medicines were used alone, and the cost of these medicines, as was found in the French survey, is considerably below that of standard drugs. Since visit costs were not evaluated in the NAMCS, it is difficult to make conclusions about the total cost of health care.There are several limitations to this survey. It is unknown if the AIH members who chose to participate in the survey are representative of all members, or of the larger group of homeopathic practitioners who do not belong to this organization. It is also unknown whether patients seeing AIH members were seeing other physicians simultaneously. The NAMCS physicians recorded visits during a random week of the year, while the AIH survey was conducted in the month of April, which could lead to seasonal differences in illnesses treated. As the use of alternative modalities such as homeopathy increases, the types of patients visiting such physicians could change, affecting costs and practice patterns.The results of this survey suggest that most patients are seen by homeopathic physicians for common, chronic complaints. While homeopathic physicians spend more time with their patients, they order fewer tests and prescribe less conventional medication. These data suggest that the cost of homeopathic care for these patients may be less than that of conventional care, although without comparable data on the actual cost of office visits, this is only speculative. Further research comparing clinical outcomes, costs, and patient satisfaction needs to be done to increase our understanding of the role of homeopathy in the health care system.FBouchayerAlternative medicines: a general approach to the French situation.Complementary Med Res.1990;4:4-8.RWhartonGLewithComplementary medicine and the general practitioner.Br Med J (Clin Res Ed).1986;292:1498-1500.EErnstTJKaptchukHomeopathy revisited.Arch Intern Med.1996;156:2162-2164.DMEisenbergRCKesslerCFosterFENorlockDRCalkinsTLDelbancoUnconventional medicine in the United States.N Engl J Med.1993;328:246-252.HSwanderHomeopathy: medical enigma attracts renewed attention.Am Acad Fam Pract Rep.1994;21:1-2.Not AvailableComplementary therapies: homeopathyHarvard Women's Health Watch.January 1997:4.Information Access CompanyFrance leads world in homeopathy.Marketletter.May 1996.WJonasJJacobsHealing With Homeopathy.New York, NY: Warner Books; 1996.Not AvailableWhen to believe the unbelievable.Nature.1988;333:816-818.JKleijnenPKnipschildGter RietClinical trials of homeopathy.BMJ.1991;302:316-323.DTReillyMATaylorCMcSharryTAitchisonIs homeopathy a placebo response? controlled trial of homeopathic potency, with pollen in hayfever as model.Lancet.1986;2:881-885.PFisherAGreenwoodECHuskissonPTurnerPBelonEffect of homeopathic treatment on fibrositis (primary fibromyalgia).BMJ.1989;299:365-366.JPFerleyDSmirouDD'AdhemarFBalducciA controlled evaluation of a homeopathic preparation in the treatment of influenza-like syndromes.Br J Clin Pharmacol.1989;27:329-335.JJacobsLMJiménezSSGloydJLGaleDCrothersTreatment of acute childhood diarrhea with homeopathic medicine: a randomized clinical trial in Nicaragua.Pediatrics.1994;93:719-725.DTReillyMATaylorNGMBeattieIs evidence of homeopathy reproducible?Lancet.1994;344:1601-1606.BCartonHealth insurers embrace eye-of-newt therapy.Wall Street Journal.January 30, 1995:B1, B4.JFirsheinPicture alternative medicine in the mainstream.Business Health Solutions Managed Care.April 1995:29-33.GCowleyPKingMHagerDRosenbergGoing mainstream.Newsweek.June 26, 1995:56-57.MASwyersLSilversmithAlternative Medicine: Expanding Medical Horizons. A Report to the National Institutes of Health on Alternative Medical Systems and Practices in the United States.Washington, DC: US Government Printing Office; 1995:309-310.Not AvailableHealthcare Professionals in Private Practice in 1990.Paris, France: National Office of Medical Insurance (CNAM); 1991. CNAM publication 61.SMSchappertNational Ambulatory Medical Care Survey: 1990 Summary.Hyattsville, Md: National Center for Health Statistics; 1992. Advance Data From Vital and Health Statistics, No. 213.American Medical Association [brochure]Physicians in the US: Summary Data 1980 to 1993.Chicago, Ill: American Medical Association; 1994.GVithoulkasThe Science of Homeopathy.New York, NY: Grove Press; 1980.Accepted for publication May 28, 1998.This work was done in affiliation with the American Institute of Homeopathy. Financial support was provided to the American Institute of Homeopathy by the Boiron Institute, Newton Square, Pa.Reprints: Jennifer Jacobs, MD, MPH, 23200 Edmonds Way, Suite A, Edmonds, WA 98026.
Archives of Family Medicine – American Medical Association
Published: Nov 1, 1998
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