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This study was done to determine characteristics and management of patients in France visiting allopathic general practitioners (AGPs) and homeopathic general practitioners (HGPs) for influenza-like illness (ILI).
Design: This was a prospective observational study. Settings/location: It was conducted in metropolitan France during the 2009–2010 influenza season. Subjects: Sixty-five HGPs and 124 AGPs recruited a total of 461 patients with ILI. Interventions: Patients were treated for ILI by their GPs. GPs and patients completed questionnaires recording demographic characteristics and patient symptoms when patients were included in the study. Patients reported satisfaction with treatment on day 4. Prescriptions were recorded by the GPs. Outcome measures: Outcome measures were patient characteristics, demographics, and symptoms at baseline; medications prescribed by type of physician; and satisfaction with treatment by type of physician and medication.
Most AGPs (86%), and most patients visiting them (58%) were men; whereas most HGPs (57%; p<0.0001), and most patients visiting them (56%; p=0.006) were women. Patients visiting AGPs were seen sooner after the appearance of symptoms, and they self-treated more frequently with cough suppressants or expectorants (p=0.0018). Patients visiting HGPs were seen later after the appearance of symptoms and they self-treated with homeopathic medications more frequently (p<0.0001). At enrollment, headaches (p=0.025), cough (p=0.01), muscle/joint pain (p=0.049), chills/shivering (p<0.001), and nasal discharge/congestion (p=0.002) were more common in patients visiting AGPs. Of these patients, 37.1% visiting AGPs were prescribed at least one homeopathic medication, and 59.6% of patients visiting HGPs were prescribed at least one allopathic medication. Patient satisfaction with treatment did not differ between AGPs and HGPs but was highest for patients treated with homeopathic medications only.
In France, homeopathy is widely accepted for the treatment of ILI and does not preclude the use of allopathic medications. However, patients treated with homeopathic medications only are more satisfied with their treatment than other patients.
Influenza is a threat to public health, especially in elderly adults, children up to 5 years of age, pregnant women, and people with certain chronic diseases and conditions.1 Worldwide, influenza causes 3–5 million cases of severe illness and 250,000–500,000 deaths each year, mostly in high-risk groups.2–6 Influenza is also a major cause of work absenteeism and lost productivity.7–9 For example, in the United States, the annual economic burden of seasonal influenza is estimated to be $87 billion, of which $17 billion (20%) results from lost productivity.8
Because it is not possible to perform virologic or molecular testing for all cases of influenza, it is monitored according to the appearance of influenza-like symptoms and, therefore, typically recorded as “influenza-like illness” (ILI).10 In France, ILI is defined as “a sudden onset of respiratory symptoms with infection context (fever, headaches), in the absence of other diagnosis.”10 ILI has been monitored in France since 1984 by a sentinel surveillance network of representative general practitioners.11 Data collected between 1984 and 2009 showed that, on average, 2.5 million people suffered from ILI each year.12
In June 2009, the World Health Organization announced the beginning of an influenza pandemic due to an A (H1N1) strain that was highly transmissible and appeared to affect mostly children and young adults.13 In France, by the end of August 2009, an excess in ILI cases, compared to the previous 24 years, had been detected, suggesting a developing pandemic,14 and by the end of the 2009–2010 influenza season, 6.6 million people, or an excess of ~4 million people, were estimated to have had ILI.12
In France, general practitioners (GPs) can prescribe homeopathic or allopathic medicines for ILI, and many of these are partially reimbursed by French National Health Insurance.15 The overall practices of homeopathic GPs (HGPs) in France was examined in 2001.16 However, the management of ILI by HGPs specifically and how their treatment compares to that of allopathic GPs (AGPs) has not been investigated. This article reports the results of a survey on the medical management of ILI by AGPs and HGPs in France during the 2009–2010 influenza season. The characteristics of patients choosing to be treated by AGPs and HGPs were also compared, as well as patients' satisfaction with the treatments they received.
This was a prospective observational study of the characteristics and management of patients in France visiting AGPs and HGPs for ILI. The study was carried out between October 2009 and April 2010. The study was reported to the Comité Consultatif sur le Traitement de l'Information en Matière de Recherche dans le Domaine de la Santé, the Conseil National de l'Ordre des Médecins, and the Commission de l'Informatique et des Libertés of France. All patients were sent a letter describing the purposes and procedures of the study, and all subjects participating in the study (or for children <12 years of age, their parents or legal guardians) provided written informed consent.
Licensed GPs working in metropolitan France were randomly selected from a registry compiled every year (from a telephone directory) and invited by telephone to participate in the study. GPs were considered HGPs if they had a diploma in homeopathy from a French university or a private institute, and, according to their recollection, prescribed more than 50% homeopathic medicines each day. All other general practitioners were considered AGPs. All participating GPs were asked to enroll their first three patients >1 year of age sequentially with ILI as diagnosed by: (1) fever (body temperature >38°C); (2) headache, myalgia, athralgia, chills/shivering, or general malaise; and (3) cough, nasal congestion, nasal discharge, or sore throat. Patients were excluded if they were being treated with antiviral drugs, were included in another study, or were unlikely to complete the questionnaire.
At the beginning of the study, GPs answered questionnaires to collect information about the GPs social/demographic characteristics and the locations of their practices. At enrollment of each patient (day 0), the GPs completed case-report forms to collect information about the patient's social/demographic characteristics, presence of risk factors, previous vaccination, time since appearance of symptoms, presence of individual symptoms, severity of ILI, and self-treatment. The case-report form was also used by GPs to record prescriptions given to patients during the study. Patients (for children <12 years of age, their parents or guardians) completed questionnaires to collect information satisfaction with treatment (not at all/a little satisfied/satisfied/very satisfied) at the end of the study (on day 4).
All statistical analysis was performed using SPSS version 19 (IBM, Armonk, New York) and JMP8 (SAS Institute, Cary, NC). Independent quantitative variables were analyzed using a Student's t-test (parametric tests) or the Kruskal-Wallis test (nonparametric tests). Paired quantitative variables were compared using the Student's t-test (parametric) or the Wilcoxon signed-rank test (nonparametric). Independent qualitative variables were compared using a χ2 test or Fisher's exact test. Paired qualitative variables were compared using McNemar's χ2 test. Missing values were not replaced. Binary logistic regression analysis was performed (1) to compare the presence of symptoms at baseline by type of GP and baseline age, gender, and vaccination for seasonal influenza; and (2) to compare the level of patient satisfaction with treatment by gender, severity of illness at inclusion in the study, and prescription of Oscillococcinum,® paracetamol, and ibuprofen. For all statistical tests, a p-value of <0.05 was considered statistically significant.
The study included 124 AGPs and 65 HGPs. Ages of the 2 groups were not significantly different, but the gender distribution was significantly different: Most AGPs were men (86.3%), whereas most HGPs were women (56.9%;Table 1). Also, compared to AGPs, HGPs were more often in urban areas than rural areas.
A total of 461 patients completed questionnaires, including 310 who were enrolled by AGPs and 151 by HGPs (Table 2). Age and social/professional status and age distribution were not significantly different between the two groups of patients. However, most patients visiting AGPs were men (58.1%), while most patients visiting HGPs were women (56.0%) (p=0.006). Although vaccine coverage in both groups was relatively low, more patients visiting AGPs than visiting HGPs had been vaccinated for seasonal influenza (15.5% versus 6.1%; p=0.007), but there was no difference in the frequency of vaccination for influenza A (H1N1). The presence of risk factors in patients visiting both AGPs and HGPs was comparable (respectively, 18.7% and 17.2%: df was not significant).
The majority of patients visiting both AGPs (73.3%) and HGPs (66.2%) came within 24 hours of the onset of symptoms. However, patients visiting AGPs were seen sooner after the appearance of symptoms than patients visiting HGPs (Table 2)—6.1% of patients visiting AGPs were seen 36 hours or more after the appearance of symptoms versus 15.9% of patients visiting HGPs (p=0.0007).
Most patients in both groups treated themselves before visiting their GPs (75.7% for patients visiting AGPs versus 79.5% for patients visiting HGPs; df was not significant). Approximately three quarters of patients visiting AGPs and HGPs (77.3% versus 72.5%; df was not significant) were self-treated with paracetamol. Nevertheless, patients visiting HGPs self-treated more frequently with homeopathic medications (15.4% versus 47.5%; p<0.0001) and patients visiting AGPs self-treated more frequently with cough suppressants or expectorants (16.7% versus 5.0%; p=0.0018; Table 2).
At inclusion in the study, the cough symptom in patients visiting AGPs was significantly more frequent than in patients visiting HGPs (96.4% versus 90.1%; p=0.01). Most of the ILI symptoms were significantly more common in patients visiting AGPs: headaches (97.2% for AGPs, 92.4% for HGPs; p=0.025), muscle/joint pain (97.6% versus 93.0%; p=0.049), chills/shivering (95.3% versus 85.8%; p<0.001), and nasal discharge/congestion (92.7% versus 82.1%; p=0.002). From a medical perspective, body temperatures were comparable in patients visiting AGPs and in patients visiting HGPs (mean, 39.1°C versus 38.9°C; p=0.002; Table 3). Logistic regression analysis confirmed that these symptoms differed between patients visiting AGPs and HGPs and that baseline age, gender, and vaccination for seasonal influenza had no influence (data not shown).
During this study, HGPs prescribed more medications for ILI than AGPs (4.8±1.7 versus 3.6±1.7; p<0.0001 by Student's t-test). Of the 461 patients in the study, 197 (42.7%) were prescribed only allopathic medications and 72 (15.6%) were prescribed only homeopathic medications, but 192 (41.7%) were prescribed both homeopathic and allopathic medications. Furthermore, 115 of the 310 (37.1%) patients visiting AGPs were prescribed at least one homeopathic medication and 90 of the 151 (59.6%) patients visiting HGPs were prescribed at least one allopathic medication.
AGPs prescribed the following agents more frequently: paracetamol (77.1% versus 38.4%; p<0.0001); ibuprofen (31.6% versus 6.0%; p<0.0001); other nonsteroidal anti-inflammatory drugs (6.1% versus 0.0%; p<0.0001); local antiseptics (12.3% versus 2.6%; p=0.0004); nasal decongestants (26.8% versus 1.3%; p<0.0001); antiemetics (3.6% versus 0.0%; p=0.020); and antivirals (20.3% versus 1.3%; p<0.0001). However, the HGPs prescribed different homeopathic dilutions more frequently as follows: Belladonna (6.1% versus 33.8%; p<0.0001); Eupatorium perfoliatum (5.2% versus 30.5%; p<0.0001); Gelsemium (7.1% versus 22.5%; p<0.0001); Bryonia (0.3% versus 21.2%; p<0.0001); Influenzinum (5.2% versus 15.2%; p=0.0003); and L52® (a mixture of several homeopathic dilutions of ILI medications; 1.6% versus 12.6%; p<0.0001; Table 4). Oscillococcinum®, a homeopathic medication used for ILI, was prescribed at similar rates for patients visiting AGPs and HGPs (19.4% versus 21.9%; not significant). Prescriptions for cough suppressants/expectorants, vitamins, minerals/other supplements, and antibiotics were uncommon (<6% of patients in both groups) and not significantly different between patients visiting AGPs and HGPs.
Patient satisfaction was assessed at the end of the study (day 4). No patients reported being unsatisfied with treatment, and satisfaction scores were not significantly different between patients treated by AGPs and HGPs (Table 5). However, more patients were “very satisfied” than “satisfied” or “somewhat satisfied” when prescribed homeopathic medications only (58.6% versus 41.4%) than when prescribed allopathic medications only (35.3% versus 64.7%) or both allopathic and homeopathic medications (47.0% versus 61.0%; p=0.002).
In addition, logistic analysis (adjusted for gender and severity of illness at enrolment) showed that patients were more likely to be “very satisfied” versus “satisfied” or “somewhat satisfied” when prescribed Oscillococcinum® (odds ratio [OR]=2.4 [95% confidence interval (CI): 1.4–3.9]; p=0.001) and when not prescribed paracetamol (OR=1.7 [95% CI, 1.1–2.5]; p=0.012) or ibuprofen (OR=2.4 [95% CI: 1.5–4.0]; p=0.001).
The current study was the first to compare the clinical management of ILI by AGPs and HGPs in France. Substantial crossover in approaches between AGPs and HGPs were found: more than one third of patients visiting AGPs were prescribed at least one homeopathic medication, and nearly 60% of patients visiting HGPs were prescribed at least one allopathic medication. Oscillococcinum, a homeopathic medication, was prescribed at similar rates (to approximately 1 in 5 patients) by both HGPs and AGPs. Patients also showed substantial crossover in self-treatment approaches. These results show that, in France, homeopathy is widely accepted, is not exclusively prescribed by HGPs, and does not necessarily preclude the use of allopathic medications.
Some differences were found in the frequency of symptoms at enrollment between patients visiting AGPs and patients visiting HGPs. Patients visiting HGPs complained less frequently of headache, cough, muscle/joint pain, shivering/chills, and nasal discharge/congestion than patients visiting AGPs. However, these differences could be explained by the following hypotheses: a significantly greater proportion of patients visiting HGPs were included in the study more than 36 hours after the onset of ILI symptoms; HGPs' patients self-treated more frequently with homeopathic medications before inclusion in the study than AGPs' patients; and, finally, the natural progression of ILI is a decrease of its symptoms.
Patients visiting HGPs were most often women, and conversely, patients visiting AGPs were more often men. This agrees with the findings of a 2001 study in France of patients visiting HGPs.16 A higher frequency of women than men visiting homeopaths has also been found in Switzerland,17 Norway,18 the United States,19 and Brazil.20 Interestingly, the vast majority of AGPs participating in the current study were men (86%), whereas the majority of HGPs were more often women (57%). Finally, in contrast to the previous French study, differences were not found in the distribution of ages of the patients visiting AGPs and HGPs,16 but, in agreement with the previous studies, HGPs were more likely than AGPs to be located in urban areas.16
Patients more often reported being “very satisfied” when treated exclusively with homeopathic medicines than when treated exclusively with allopathic medications or with a combination of allopathic and homeopathic medications. In addition, patients were more likely to report being “very satisfied” when treated with Oscillococcinum®. According to logistic regression, these differences in satisfaction were not linked to differences in baseline characteristics (gender, severity of illness at inclusion in the study, and prescription of Oscillococcinum®, paracetamol, and ibuprofen). An American study in 1996–1997 also found that, of patients treated for respiratory and ear complaints, more were “very satisfied” when treated with homeopathy than with conventional medicine.21 This higher level of satisfaction with homeopathic medicines might be the result of occurrences or perceptions of fewer side-effects with homeopathic medications.17,21,22 These results strengthen the position of homeopathic treatment as a therapeutic option for treating ILI.
The results of this study should be interpreted in light of certain considerations. First, it should be emphasized that this study compared different general approaches to treatment of ILI. This study did not assess or take into account the effects of compliance to the prescriptions, medication dosage, concomitant self-treatments by patients, or whether ILI was caused an influenza virus or other factors. Second, this was not a blinded study. Knowledge of what kind of medications were being prescribed and what kind of general practitioner patients were visiting could have influenced their scoring of satisfaction; however, the current authors expect that any such bias would have been balanced between the two groups. Third, it could be supposed that significant differences may not have been detected because of the number of patients or general practitioners was not sufficient (a statistical precision of 4.52% with 461 patients).
This study examined the clinical management of ILI by AGPs and HGPs during the 2009–2010 influenza season in France. The results show that homeopathy is widely accepted in France for treating ILI and does not preclude the use of allopathic medications. However, patients are more satisfied with their treatment when prescribed exclusively homeopathic medicines, including Oscillococcinum. This difference could be the result of the lower risk and fewer side-effects associated with homeopathic treatments, compared to conventional care.
The authors thank Phillip Leventhal, Ph.D., and Julie Harriague, Ph.D. (4Clinics, Paris, France), for writing assistance and Gérard Duru, Ph.D. for statistical analysis. This study and medical writing assistance were funded by Laboratoires Boiron, Lyon, France.
A.D., D.D., and D.S. received consulting fees from Laboratoires Boiron for participation in this study, and S.V. and M.-F.B. are employees of Laboratoires Boiron. GPs received 50 euros from Laboratoires Boiron for each subject recruited. The total amount received by each GP was approved by the Conseil National de l'Ordre des Médecins or the French National Medical Council, according to the total amount of work performed.