This study is one of few providing comparative data on use of homeopathy and other types of CAMs compared to conventional primary care in a representative population of patients. The results showed that patients who consult for MSDs were comparable for quality of life and co-morbidities regardless of the physicians' preferences for prescribing homeopathy or CAMs. This corresponds to what has been reported for physical QOL score but not for mental score where patients using CAMs have been found to have a slightly lower mental scores [5
]. Our study also showed that patients with chronic MSDs tended to seek care more often with GPs who prescribe alternatives to conventional medicine, a finding that has been reported in other studies [10
]. Socio-demographic and lifestyle differences between MSD patients in the three groups of physicians could have contributed in part to the results. For instance, patients consulting homeopaths were more often older and more educated women with less lifestyle risk factors than those consulting in conventional primary care. This corresponds to what has been described in other studies of consultations in homeopathy in general [12
]. However, these factors were controlled for in the analyses and the magnitude of the difference with regard to chronicity was too high to be explained by confounding factors alone.
We also found that these chronic MSD patients more often declared their physician as not being their regular treating physician. In France each citizen is required to identify a physician for their regular health care. Therefore, patients who did not declare their physician as their regular physician, could be considered as consulting in second intention, outside of their regular primary care provider. The greater health care load assumed by physicians who prescribe homeopathy and CAMs then comes from two factors, greater proportions of chronic patients and consultations in second intention. This finding has significant bearing on professional practice as almost half of the homeopath clientele in this study was seen as a consultant. This information provided an important complement to what has been reported on the planning of homeopathic practice, particularly as it differs from conventional medicine [16
One strength of the study was that MSD patients were identified from a larger survey of patients consulting for any reason in primary care, thus minimising selection bias related to sampling MSD patients directly. Another strength was the specificity of the data collection for the purposes of this study, combining medical information on diagnoses and patients' information on QOL, drugs and CAMs utilisation, all collected on the day of consultation, ensuring timely compatibility with diagnoses. The large number of participating physicians and patients favoured a fair representativity of clinical practices in primary care in France. A previous analysis of the EPI3-LASER survey showed that the distribution of physicians' individual characteristics differed only slightly from published French national statistics [4
]. SF-12 scores observed in our patients were also not far away from those reported in three European population surveys of MSD patients, with score differences between acute and chronic patients that were also similar [17
The main limitation of this study was the way the three groups of physicians were defined, relying on their own declaration of prescribing CAMs never or rarely (CM) or regularly (Mx). The definition used for defining the group of homeopaths (Ho) was more straightforward, being based on their professional certification. These definitions potentially limit the generalisation of the results as they represent the practice in France. On the other hand, it also represents a strength because it provided a unique opportunity to compare head-to-head primary care practices differing only by preferences for homeopathy and CAMs, all physicians shared similar medical professional status and basic training in conventional medicine. We feel that even if the context of the study was specific to one country, differences between the groups of patients may provide valid information on the differential utilisation of homeopathy and CAMs, meaningful beyond national borders.
Another important difference with studies performed in other countries is that France is unique with Germany to reimburse homeopathy in a national health insurance regime. Therefore, access to this type of medical practice is specific and, unlike what has been reported in the literature, less subjected to economic barriers [13
]. The best illustration of this came from our observation of no apparent differences of access to homeopathy and CAM by employment status. The economic impacts of homeopathy and CAM on health care deserve more attention in future research, particularly in terms of the cost-benefit of complementary approaches for chronic MSD patients who seek alternatives to conventional medicine for the relief of their symptoms.