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1.  Questions about complementary and alternative medicine to the Regional Medicines Information and Pharmacovigilance Centres in Norway (RELIS): a descriptive pilot study 
Background
Provision of clinically relevant information about complementary and alternative medicine (CAM) to health care professionals is not well described. The aim of the study was to assess questions about CAM to the Regional Medicines Information and Pharmacovigilance Centres in Norway (RELIS).
Methods
All question-answers pairs (QAPs) in the RELIS database indexed with alternative medicine from 2005-2010 constituted the study material. A randomly selected sample of 100 QAPs was characterized with regard to type of question (category, patient-specific or general), occupation and workplace of enquirer, the type of information search performed (simple or advanced), and if the answers contained information to provide factual or consultative replies (facts about or advice on clinical use of CAM, respectively). Proportions were compared with Fisher’s exact test with significance at the 0.05 level.
Results
One thousand and thirty-eight (7.7%) out of 13 482 questions involved CAM. Eighty-two out of 100 questions concerned products containing one or more herbs, vitamins and minerals as well as other substances. Thirty-eight out of 100 questions concerned the category documentation (substance identification and/or literature reports about clinical effects), 36 interactions, 16 adverse effects, 9 pregnancy and lactation, and 1 question concerned contraindications. Sixty-three questions were patient-specific and 37 general. Fifty-four questions came from physicians, 33 from pharmacists and 13 from others (including nurses, midwives, students, CAM practitioners, and the public). Pharmacists asked more frequently about interactions while physicians asked more frequently about adverse effects (p < 0.05). Seventy-six of the questions came from outside hospital, mainly general practice and community pharmacies. Fifty-nine answers were based on a simple and 41 on an advanced information search. Thirty-three factual and 38 consultative answers were provided. In 29 answers, search provided no information. Lack of information to provide an answer was not significantly different between patient-specific (31.7%) and general questions (24.3%).
Conclusions
General practice and community pharmacies are the main sources for questions about CAM to RELIS. Physicians are concerned about adverse effects while pharmacists are concerned about interactions. Lack of information to provide answers to patient-specific and general questions about CAM represents a problem.
doi:10.1186/1472-6882-14-56
PMCID: PMC3932037  PMID: 24529279
Drug information; Complementary and alternative medicine; Decision support
2.  Intervention development for integration of conventional tobacco cessation interventions into routine CAM practice 
Background
Practitioners of complementary and alternative medicine (CAM) therapies are an important and growing presence in health care systems worldwide. A central question is whether evidence-based behavior change interventions routinely employed in conventional health care could also be integrated into CAM practice to address public health priorities. Essential for successful integration are intervention approaches deemed acceptable and consistent with practice patterns and treatment approaches of different types of CAM practitioners – that is, they have context validity. Intervention development to ensure context validity was integral to Project CAM Reach (CAMR), a project examining the public health potential of tobacco cessation training for chiropractors, acupuncturists and massage therapists (CAM practitioners). This paper describes formative research conducted to achieve this goal.
Methods
Intervention development, undertaken in three CAM disciplines (chiropractic, acupuncture, massage therapy), consisted of six iterative steps: 1) exploratory key informant interviews; 2) local CAM practitioner community survey; 3) existing tobacco cessation curriculum demonstration with CAM practitioners; 4) adapting/tailoring of existing curriculum; 5) external review of adaptations; 6) delivery of tailored curriculum to CAM practitioners with follow-up curriculum evaluation.
Results
CAM practitioners identified barriers and facilitators to addressing tobacco use with patients/clients and saw the relevance and acceptability of the intervention content. The intervention development process was attentive to their real world intervention concerns. Extensive intervention tailoring to the context of each CAM discipline was found unnecessary. Participants and advisors from all CAM disciplines embraced training content, deeming it to have broad relevance and application across the three CAM disciplines. All findings informed the final intervention.
Conclusions
The participatory and iterative formative research process yielded an intervention with context validity in real-world CAM practices as it: 1) is patient/client-centered, emphasizing the practitioner’s role in a healing relationship; 2) is responsive to the different contexts of CAM practitioners’ work and patient/client relationships; 3) integrates relevant best practices from US Public Health Service Clinical Practice Guidelines on treating tobacco dependence; and 4) is suited to the range of healing philosophies, scopes of practice and practice patterns found in participating CAM practitioners. The full CAMR study to evaluate the impact of the CAMR intervention on CAM practitioners’ clinical behavior is underway.
doi:10.1186/s12906-015-0604-9
PMCID: PMC4391469  PMID: 25887742
Context validity; Intervention protocol; Curriculum development; Training; Interprofessional education; Tobacco cessation; Chiropractic; Acupuncture; Massage therapist; Community based participatory research
3.  CAM practitioners in the Australian health workforce: an underutilized resource 
Background
CAM practitioners are a valuable but underutilizes resource in Australian health care. Despite increasing public support for complementary and alternative medicine (CAM) little is known about the CAM workforce. Apart from the registered professions of chiropractic, osteopathy and Chinese medicine, accurate information about the number of CAM practitioners in the workforce has been difficult to obtain. It appears that many non-registered CAM practitioners, although highly qualified, are not working to their full capacity.
Discussion
Increasing public endorsement of CAM stands in contrast to the negative attitude toward the CAM workforce by some members of the medical and other health professions and by government policy makers. The marginalisation of the CAM workforce is evident in prejudicial attitudes held by some members of the medical and other health professions and its exclusion from government policy making. Inconsistent educational standards has meant that non-registered CAM practitioners, including highly qualified and competent ones, are frequently overlooked. Legitimising their contribution to the health workforce could alleviate workforce shortages and provide opportunities for redesigned job roles and new multidisciplinary teams. Priorities for better utilisation of the CAM workforce include establishing a guaranteed minimum education standard for more CAM occupation groups through national registration, providing interprofessional education that includes CAM practitioners, developing courses to upgrade CAM practitioners' professional skills in areas of indentified need, and increasing support for CAM research.
Summary
Marginalisation of the CAM workforce has disadvantaged those qualified and competent CAM practitioners who practise evidence-informed medicine on the basis of many years of university training. Legitimising and expanding the important contribution of CAM practitioners could alleviate projected health workforce shortages, particularly for the prevention and management of chronic health conditions and for health promotion.
doi:10.1186/1472-6882-12-205
PMCID: PMC3528465  PMID: 23116374
4.  Searching for Controlled Trials of Complementary and Alternative Medicine: A Comparison of 15 Databases 
This project aims to assess the utility of bibliographic databases beyond the three major ones (MEDLINE, EMBASE and Cochrane CENTRAL) for finding controlled trials of complementary and alternative medicine (CAM). Fifteen databases were searched to identify controlled clinical trials (CCTs) of CAM not also indexed in MEDLINE. Searches were conducted in May 2006 using the revised Cochrane highly sensitive search strategy (HSSS) and the PubMed CAM Subset. Yield of CAM trials per 100 records was determined, and databases were compared over a standardized period (2005). The Acudoc2 RCT, Acubriefs, Index to Chiropractic Literature (ICL) and Hom-Inform databases had the highest concentrations of non-MEDLINE records, with more than 100 non-MEDLINE records per 500. Other productive databases had ratios between 500 and 1500 records to 100 non-MEDLINE records—these were AMED, MANTIS, PsycINFO, CINAHL, Global Health and Alt HealthWatch. Five databases were found to be unproductive: AGRICOLA, CAIRSS, Datadiwan, Herb Research Foundation and IBIDS. Acudoc2 RCT yielded 100 CAM trials in the most recent 100 records screened. Acubriefs, AMED, Hom-Inform, MANTIS, PsycINFO and CINAHL had more than 25 CAM trials per 100 records screened. Global Health, ICL and Alt HealthWatch were below 25 in yield. There were 255 non-MEDLINE trials from eight databases in 2005, with only 10% indexed in more than one database. Yield varied greatly between databases; the most productive databases from both sampling methods were Acubriefs, Acudoc2 RCT, AMED and CINAHL. Low overlap between databases indicates comprehensive CAM literature searches will require multiple databases.
doi:10.1093/ecam/nep038
PMCID: PMC3137728  PMID: 19468052
5.  Information-seeking behavior in complementary and alternative medicine (CAM): an online survey of faculty at a health sciences campus* 
Background: The amount of reliable information available for complementary and alternative medicine (CAM) is limited, and few authoritative resources are available.
Objective: The objective is to investigate the information-seeking behavior of health professionals seeking CAM information.
Methods: Data were gathered using a Web-based questionnaire made available to health sciences faculty affiliated with the University of California, San Francisco.
Results: The areas of greatest interest were herbal medicine (67%), relaxation exercises (53%), and acupuncture (52%). About half the respondents perceived their CAM searches as being only partially successful. Eighty-two percent rated MEDLINE as a useful resource, 46% personal contacts with colleagues, 46% the Web, 40% journals, and 20% textbooks. Books and databases most frequently cited as useful had information about herbs. The largest group of respondents was in internal medicine (26%), though 15% identified their specialties as psychiatry, psychology, behavioral medicine, or addiction medicine. There was no correlation between specialty and patterns of information-seeking behavior. Sixty-six percent expressed an interest in learning more about CAM resources.
Conclusions: Health professionals are frequently unable to locate the CAM information they need, and the majority have little knowledge of existing CAM resources, relying instead on MEDLINE. Medical librarians need to educate health professionals in the identification and use of authoritative CAM resources.
PMCID: PMC164394  PMID: 12883563
6.  IN-CAM Outcomes Database: Its Relevance and Application in Massage Therapy Research and Practice 
One of the most commonly used complementary and alternative medicine (CAM) modalities in North America is massage therapy (MT). Research to date indicates many potential health benefits of MT, suggesting that ongoing research efforts to further elucidate and substantiate preliminary findings within the massage profession should be given high priority. Central to the development of a sound evidence base for MT are the use of valid, reliable, and relevant outcome measures in research, and practice in assessing the effectiveness of MT. The purpose of the present article is to introduce MT researchers and massage therapists interested in using outcome measures in research and clinical practice to the IN-CAM Outcomes Database website by describing the Outcomes Database and identifying its utility in MT research and practice. The IN-CAM Outcomes Database is a centralized location where information on outcome measures is collected and made accessible to users. Outcome measures are organized in the database within the Framework of Outcome Domains. The Framework includes health domains relevant to conventional medicine and CAM alike, and health domains that have been identified as important to CAM interventions. Users of the website may search for information on a specific outcome measure, plan research projects, and engage in discussions related to outcomes assessment in the CAM field with other users and with members of the CAM research community. As the MT profession continues to evolve and move toward evidence-informed practice, the IN-CAM Outcomes Database website can be a valuable resource for MT researchers and massage therapists.
PMCID: PMC3091455  PMID: 21589721
Massage therapy; research; practice; health outcomes; outcomes database
7.  The application of foraging theory to the information searching behaviour of general practitioners 
BMC Family Practice  2011;12:90.
Background
General Practitioners (GPs) employ strategies to identify and retrieve medical evidence for clinical decision making which take workload and time constraints into account. Optimal Foraging Theory (OFT) initially developed to study animal foraging for food is used to explore the information searching behaviour of General Practitioners. This study is the first to apply foraging theory within this context.
Study objectives were:
1. To identify the sequence and steps deployed in identifiying and retrieving evidence for clinical decision making.
2. To utilise Optimal Foraging Theory to assess the effectiveness and efficiency of General Practitioner information searching.
Methods
GPs from the Wellington region of New Zealand were asked to document in a pre-formatted logbook the steps and outcomes of an information search linked to their clinical decision making, and fill in a questionnaire about their personal, practice and information-searching backgrounds.
Results
A total of 115/155 eligible GPs returned a background questionnaire, and 71 completed their information search logbook.
GPs spent an average of 17.7 minutes addressing their search for clinical information. Their preferred information sources were discussions with colleagues (38% of sources) and books (22%). These were the two most profitable information foraging sources (15.9 min and 9.5 min search time per answer, compared to 34.3 minutes in databases). GPs nearly always accessed another source when unsuccessful (95% after 1st source), and frequently when successful (43% after 2nd source). Use of multiple sources accounted for 41% of searches, and increased search success from 70% to 89%.
Conclusions
By consulting in foraging terms the most 'profitable' sources of information (colleagues, books), rapidly switching sources when unsuccessful, and frequently double checking, GPs achieve an efficient trade-off between maximizing search success and information reliability, and minimizing searching time. As predicted by foraging theory, GPs trade time-consuming evidence-based (electronic) information sources for sources with a higher information reward per unit time searched. Evidence-based practice must accommodate these 'real world' foraging pressures, and Internet resources should evolve to deliver information as effectively as traditional methods of information gathering.
doi:10.1186/1471-2296-12-90
PMCID: PMC3175159  PMID: 21861880
Information Foraging; General Practitioners; Evidence - based medicine; Information Seeking Behavior; Questionnaires.
8.  CAMbase – A XML-based bibliographical database on Complementary and Alternative Medicine (CAM) 
The term "Complementary and Alternative Medicine (CAM)" covers a variety of approaches to medical theory and practice, which are not commonly accepted by representatives of conventional medicine. In the past two decades, these approaches have been studied in various areas of medicine. Although there appears to be a growing number of scientific publications on CAM, the complete spectrum of complementary therapies still requires more information about published evidence. A majority of these research publications are still not listed in electronic bibliographical databases such as MEDLINE. However, with a growing demand by patients for such therapies, physicians increasingly need an overview of scientific publications on CAM. Bearing this in mind, CAMbase, a bibliographical database on CAM was launched in order to close this gap. It can be accessed online free of charge or additional costs.
The user can peruse more than 80,000 records from over 30 journals and periodicals on CAM, which are stored in CAMbase. A special search engine performing syntactical and semantical analysis of textual phrases allows the user quickly to find relevant bibliographical information on CAM. Between August 2003 and July 2006, 43,299 search queries, an average of 38 search queries per day, were registered focussing on CAM topics such as acupuncture, cancer or general safety aspects. Analysis of the requests led to the conclusion that CAMbase is not only used by scientists and researchers but also by physicians and patients who want to find out more about CAM.
Closely related to this effort is our aim to establish a modern library center on Complementary Medicine which offers the complete spectrum of a modern digital library including a document delivery-service for physicians, therapists, scientists and researchers.
doi:10.1186/1742-5581-4-2
PMCID: PMC1853104  PMID: 17407592
9.  The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview 
PLoS Medicine  2011;8(1):e1000387.
Aziz Sheikh and colleagues report the findings of their systematic overview that assessed the impact of eHealth solutions on the quality and safety of health care.
Background
There is considerable international interest in exploiting the potential of digital solutions to enhance the quality and safety of health care. Implementations of transformative eHealth technologies are underway globally, often at very considerable cost. In order to assess the impact of eHealth solutions on the quality and safety of health care, and to inform policy decisions on eHealth deployments, we undertook a systematic review of systematic reviews assessing the effectiveness and consequences of various eHealth technologies on the quality and safety of care.
Methods and Findings
We developed novel search strategies, conceptual maps of health care quality, safety, and eHealth interventions, and then systematically identified, scrutinised, and synthesised the systematic review literature. Major biomedical databases were searched to identify systematic reviews published between 1997 and 2010. Related theoretical, methodological, and technical material was also reviewed. We identified 53 systematic reviews that focused on assessing the impact of eHealth interventions on the quality and/or safety of health care and 55 supplementary systematic reviews providing relevant supportive information. This systematic review literature was found to be generally of substandard quality with regards to methodology, reporting, and utility. We thematically categorised eHealth technologies into three main areas: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. We found that despite support from policymakers, there was relatively little empirical evidence to substantiate many of the claims made in relation to these technologies. Whether the success of those relatively few solutions identified to improve quality and safety would continue if these were deployed beyond the contexts in which they were originally developed, has yet to be established. Importantly, best practice guidelines in effective development and deployment strategies are lacking.
Conclusions
There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies. In addition, there is a lack of robust research on the risks of implementing these technologies and their cost-effectiveness has yet to be demonstrated, despite being frequently promoted by policymakers and “techno-enthusiasts” as if this was a given. In the light of the paucity of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, it is vital that future eHealth technologies are evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle. Such evaluation should be characterised by careful attention to socio-technical factors to maximise the likelihood of successful implementation and adoption.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
There is considerable international interest in exploiting the potential of digital health care solutions, often referred to as eHealth—the use of information and communication technologies—to enhance the quality and safety of health care. Often accompanied by large costs, any large-scale expenditure on eHealth—such as electronic health records, picture archiving and communication systems, ePrescribing, associated computerized provider order entry systems, and computerized decision support systems—has tended to be justified on the grounds that these are efficient and cost-effective means for improving health care. In 2005, the World Health Assembly passed an eHealth resolution (WHA 58.28) that acknowledged, “eHealth is the cost-effective and secure use of information and communications technologies in support of health and health-related fields, including health-care services, health surveillance, health literature, and health education, knowledge and research,” and urged member states to develop and implement eHealth technologies. Since then, implementing eHealth technologies has become a main priority for many countries. For example, England has invested at least £12.8 billion in a National Programme for Information Technology for the National Health Service, and the Obama administration in the United States has committed to a US$38 billion eHealth investment in health care.
Why Was This Study Done?
Despite the wide endorsement of and support for eHealth, the scientific basis of its benefits—which are repeatedly made and often uncritically accepted—remains to be firmly established. A robust evidence-based perspective on the advantages on eHealth could help to suggest priority areas that have the greatest potential for benefit to patients and also to inform international eHealth deliberations on costs. Therefore, in order to better inform the international community, the authors systematically reviewed the published systematic review literature on eHealth technologies and evaluated the impact of these technologies on the quality and safety of health care delivery.
What Did the Researchers Do and Find?
The researchers divided eHealth technologies into three main categories: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. Then, implementing methods based on those developed by the Cochrane Collaboration and the NHS Service Delivery and Organisation Programme, the researchers used detailed search strategies and maps of health care quality, safety, and eHealth interventions to identify relevant systematic reviews (and related theoretical, methodological, and technical material) published between 1997 and 2010. Using these techniques, the researchers retrieved a total of 46,349 references from which they identified 108 reviews. The 53 reviews that the researchers finally selected (and critically reviewed) provided the main evidence base for assessing the impact of eHealth technologies in the three categories selected.
In their systematic review of systematic reviews, the researchers included electronic health records and picture archiving communications systems in their evaluation of category 1, computerized provider (or physician) order entry and e-prescribing in category 2, and all clinical information systems that, when used in the context of eHealth technologies, integrate clinical and demographic patient information to support clinician decision making in category 3.
The researchers found that many of the clinical claims made about the most commonly used eHealth technologies were not substantiated by empirical evidence. The evidence base in support of eHealth technologies was weak and inconsistent and importantly, there was insubstantial evidence to support the cost-effectiveness of these technologies. For example, the researchers only found limited evidence that some of the many presumed benefits could be realized; importantly, they also found some evidence that introducing these new technologies may on occasions also generate new risks such as prescribers becoming over-reliant on clinical decision support for e-prescribing, or overestimate its functionality, resulting in decreased practitioner performance.
What Do These Findings Mean?
The researchers found that despite the wide support for eHealth technologies and the frequently made claims by policy makers when constructing business cases to raise funds for large-scale eHealth projects, there is as yet relatively little empirical evidence to substantiate many of the claims made about eHealth technologies. In addition, even for the eHealth technology tools that have proven to be successful, there is little evidence to show that such tools would continue to be successful beyond the contexts in which they were originally developed. Therefore, in light of the lack of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, the authors say that future eHealth technologies should be evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle, and include socio-technical factors to maximize the likelihood of successful implementation and adoption in a given context. Furthermore, it is equally important that eHealth projects that have already been commissioned are subject to rigorous, multidisciplinary, and independent evaluation.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000387.
The authors' broader study is: Car J, Black A, Anandan C, Cresswell K, Pagliari C, McKinstry B, et al. (2008) The Impact of eHealth on the Quality and Safety of Healthcare. Available at: http://www.haps.bham.ac.uk/publichealth/cfhep/001.shtml
More information is available on the World Health Assembly eHealth resolution
The World Health Organization provides information at the Global Observatory on eHealth, as well as a global insight into eHealth developments
The European Commission provides Information on eHealth in Europe and some examples of good eHealth practice
More information is provided on NHS Connecting for Health
doi:10.1371/journal.pmed.1000387
PMCID: PMC3022523  PMID: 21267058
10.  Real-time EBM: From Bed Board to Keyboard and Back 
Journal of General Internal Medicine  2007;22(12):1656-1660.
Background
To practice Evidence-Based Medicine (EBM), physicians must quickly retrieve evidence to inform medical decisions. Internal Medicine (IM) residents receive little formal education in electronic database searching, and have identified poor searching skills as a barrier to practicing EBM.
Objective
To design and implement a database searching tutorial for IM residents on inpatient rotations and to evaluate its impact on residents’ skill and comfort searching MEDLINE and filtered EBM resources.
Design
Randomized controlled trial. Residents randomized to the searching tutorial met for up to 6 1-hour small group sessions to search for answers to questions about current hospitalized patients.
Participants
Second- and 3rd-year IM residents.
Measurements
Residents in both groups completed an Objective Structured Searching Evaluation (OSSE), searching for primary evidence to answer 5 clinical questions. OSSE outcomes were the number of successful searches, search times, and techniques utilized. Participants also completed self-assessment surveys measuring frequency and comfort using EBM databases.
Results
During the OSSE, residents who participated in the intervention utilized more searching techniques overall (p < .01) and used PubMed’s Clinical Queries more often (p < .001) than control residents. Searching “success” and time per completed search did not differ between groups. Compared with controls, intervention residents reported greater comfort using MEDLINE (p < .05) and the Cochrane Library (p < .05) on post-intervention surveys. The groups did not differ in comfort using ACP Journal Club, or in self-reported frequency of use of any databases.
Conclusions
An inpatient EBM searching tutorial improved searching techniques of IM residents and resulted in increased comfort with MEDLINE and the Cochrane Library, but did not impact overall searching success.
doi:10.1007/s11606-007-0387-x
PMCID: PMC2219829  PMID: 17922170
evidence-based medicine; medical education; internship and residency; searching
11.  Attitudes Toward Antiretroviral Therapy and Complementary and Alternative Medicine in Chinese HIV-Infected Patients 
HIV has become a significant health issue in China, and an increasing number of HIV-infected individuals are in need of care. Current reports confirm more than 230,000 cases of HIV infection and estimate that approximately 700,000 people are now infected with HIV, although approximately 70% of these individuals do not realize they are infected (Gill & Okie, 2007).
China's national antiretroviral therapy (ART) program, Four Frees and One Care, began in 2003, and ART treatment is now widely available in China (Zhang et al., 2007). Under this program, the following services are available to eligible citizens: (a) free ART for all AIDS patients in financial difficulty, (b) free schooling for AIDS orphans and children of AIDS patients, (c) free counseling and prevention measures to prevent mother-to-child-transmission for HIV-infected pregnant women, and (d) free HIV antibody testing and counseling, provided by the Chinese Center for Disease Control and Prevention (China CDC). “One Care” means providing care to AIDS patients and their families (Zhang, Pan, Yu, Wen, & Zhao, 2005). Prior to 2003, only a few people in China had access to ART, and clinical expertise in HIV medicine was limited to the major centers in a few eastern cities (Zhang et al., 2007). When ART is the dominant method of treatment, however, its use is complicated by the presence of complementary and alternative medicine (CAM), which has remained a substitute and supplement for conventional HIV therapy (Hsiao et al., 2003), even after ART became available (Josephs, Fleishman, Gaist, & Gebo, 2007).
CAM is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine (National Institutes of Health, 2008). Commonly, CAM includes a wide range of practices that do not fit within the dominant allopathic model of health care (Bishop, Yardley, & Lewith, 2007), including but not limited to herbalism, traditional Chinese medicine (TCM), acupuncture, and diet-based therapies (Bratman & Steven, 1997). TCM has been used in Chinese society for more than 5,000 years. In the TCM approach, the body is recognized and treated as a whole entity, and diseases are identified as conditions caused by internal imbalances. The role of doctors is to identify imbalances and then correct them; the body is then expected to be able to heal itself (Tsao, Dobalian, Myers, & Zeltzer, 2005). The balancing factors of the yin and yang, or of the cold and hot forces, govern health and modulate some Chinese eating and pain management practices (Wong-Kim & Merighi, 2007). The integration of ART and CAM therefore has important implications in health outcomes, especially in China where the use of CAM is widespread.
Three types of treatment systems are practiced in Chinese society: (a) allopathic Western medicine offered by health care professionals in clinics and hospitals; (b) Buyao, which is over-the-counter popular medicine and includes teas, soups, tablets, herbal preparations, and tonics, which are similar to herb supplements used in some Western countries; and (c) TCM or Zhongyi, provided by trained Chinese herbalists, which incorporates a wide range of theories, therapies, and practices, some of which are medicinal, some physical, and some supernatural (Ma et al., 2008). Many Chinese people use all three types of treatment simultaneously.
In the West, the use of CAM is widespread among HIV-infected individuals. From 1980 to 1996, 27% to 100% of HIV-infected patients used CAM (Ernst, 1997), and the rates of CAM remained steady when compared with the era before highly active ART (Josephs et al., 2007). Some people living with HIV (PLWH) used CAM to replace the prescribed ART treatment regimen (Owen-Smith, Diclemente, & Wingood, 2007), while others used it as a complement to conventional HIV therapy (Hsiao et al., 2003).
A variety of factors influence an individual's decision to use CAM. In Western countries, women who were more educated and who had lived longer with HIV were more likely to use CAM (Owen-Smith et al., 2007). Pain was a strong predictor of CAM use, and increased pain over time was associated with the use of unlicensed or illicit underground drugs that held a potential for harm (Tsao et al., 2005). Overall, the most common source of information about CAM was from patients' friends (Wiwanitkit, 2003). Generally, CAM users perceived complementary therapies as useful, although there is no evidence to suggest that these treatments are particularly effective. CAM is generally perceived as “safe,” despite evidence of harmful interactions between some herbal medicines and medical treatments and the evidence of associated risks (Ma et al., 2007). Specifically, recent studies have shown that herbal medicines can interact with ART in such a way as to contribute to treatment failure (Ma et al., 2007). Physicians around the world, however, do not routinely discuss CAM therapies with PLWH, despite knowing that CAM therapies are widely used (Ma et al., 2008; Hsiao et al., 2003).
Studies have examined PLWH attitudes toward ART and CAM in different countries (Littlewood & Vanable, 2008). One study described nurses in Uganda using a traditional, nurse-prepared ointment on PLWH as an alternative medication for skin problems because they “know it works” (Hardon et al., 2008). CAM has also been used to treat the psychological and physical effects of illness and the side effects of ART (Kaufman & Gregory, 2007). Studies show, however, that many PLWH do not report CAM use to their medical providers (Hsiao et al., 2003). To date, there has been little research on CAM use in the Chinese PLWH population.
This qualitative study explored issues related to positive and negative attitudes toward both ART and CAM in Chinese PLWH in Beijing, China. The study was part of a larger project examining behavioral interventions meant to enhance ART adherence in PLWH in China (Chen et al., 2007; Starks et al., 2008). Semi-structured, in-depth, interviews were used to explore PLWHA attitudes, experiences, and perceptions about ART and CAM.
doi:10.1016/j.jana.2008.12.004
PMCID: PMC2684986  PMID: 19427598
12.  Developing an efficient scheduling template of a chemotherapy treatment unit 
The Australasian Medical Journal  2011;4(10):575-588.
This study was undertaken to improve the performance of a Chemotherapy Treatment Unit by increasing the throughput and reducing the average patient’s waiting time. In order to achieve this objective, a scheduling template has been built. The scheduling template is a simple tool that can be used to schedule patients' arrival to the clinic. A simulation model of this system was built and several scenarios, that target match the arrival pattern of the patients and resources availability, were designed and evaluated. After performing detailed analysis, one scenario provide the best system’s performance. A scheduling template has been developed based on this scenario. After implementing the new scheduling template, 22.5% more patients can be served.
Introduction
CancerCare Manitoba is a provincially mandated cancer care agency. It is dedicated to provide quality care to those who have been diagnosed and are living with cancer. MacCharles Chemotherapy unit is specially built to provide chemotherapy treatment to the cancer patients of Winnipeg. In order to maintain an excellent service, it tries to ensure that patients get their treatment in a timely manner. It is challenging to maintain that goal because of the lack of a proper roster, the workload distribution and inefficient resource allotment. In order to maintain the satisfaction of the patients and the healthcare providers, by serving the maximum number of patients in a timely manner, it is necessary to develop an efficient scheduling template that matches the required demand with the availability of resources. This goal can be reached using simulation modelling. Simulation has proven to be an excellent modelling tool. It can be defined as building computer models that represent real world or hypothetical systems, and hence experimenting with these models to study system behaviour under different scenarios.1, 2
A study was undertaken at the Children's Hospital of Eastern Ontario to identify the issues behind the long waiting time of a emergency room.3 A 20-­‐day field observation revealed that the availability of the staff physician and interaction affects the patient wait time. Jyväskylä et al.4 used simulation to test different process scenarios, allocate resources and perform activity-­‐based cost analysis in the Emergency Department (ED) at the Central Hospital. The simulation also supported the study of a new operational method, named "triage-team" method without interrupting the main system. The proposed triage team method categorises the entire patient according to the urgency to see the doctor and allows the patient to complete the necessary test before being seen by the doctor for the first time. The simulation study showed that it will decrease the throughput time of the patient and reduce the utilisation of the specialist and enable the ordering all the tests the patient needs right after arrival, thus quickening the referral to treatment.
Santibáñez et al.5 developed a discrete event simulation model of British Columbia Cancer Agency"s ambulatory care unit which was used to study the impact of scenarios considering different operational factors (delay in starting clinic), appointment schedule (appointment order, appointment adjustment, add-­‐ons to the schedule) and resource allocation. It was found that the best outcomes were obtained when not one but multiple changes were implemented simultaneously. Sepúlveda et al.6 studied the M. D. Anderson Cancer Centre Orlando, which is a cancer treatment facility and built a simulation model to analyse and improve flow process and increase capacity in the main facility. Different scenarios were considered like, transferring laboratory and pharmacy areas, adding an extra blood draw room and applying different scheduling techniques of patients. The study shows that by increasing the number of short-­‐term (four hours or less) patients in the morning could increase chair utilisation.
Discrete event simulation also helps improve a service where staff are ignorant about the behaviour of the system as a whole; which can also be described as a real professional system. Niranjon et al.7 used simulation successfully where they had to face such constraints and lack of accessible data. Carlos et al. 8 used Total quality management and simulation – animation to improve the quality of the emergency room. Simulation was used to cover the key point of the emergency room and animation was used to indicate the areas of opportunity required. This study revealed that a long waiting time, overload personnel and increasing withdrawal rate of patients are caused by the lack of capacity in the emergency room.
Baesler et al.9 developed a methodology for a cancer treatment facility to find stochastically a global optimum point for the control variables. A simulation model generated the output using a goal programming framework for all the objectives involved in the analysis. Later a genetic algorithm was responsible for performing the search for an improved solution. The control variables that were considered in this research are number of treatment chairs, number of drawing blood nurses, laboratory personnel, and pharmacy personnel. Guo et al. 10 presented a simulation framework considering demand for appointment, patient flow logic, distribution of resources, scheduling rules followed by the scheduler. The objective of the study was to develop a scheduling rule which will ensure that 95% of all the appointment requests should be seen within one week after the request is made to increase the level of patient satisfaction and balance the schedule of each doctor to maintain a fine harmony between "busy clinic" and "quiet clinic".
Huschka et al.11 studied a healthcare system which was about to change their facility layout. In this case a simulation model study helped them to design a new healthcare practice by evaluating the change in layout before implementation. Historical data like the arrival rate of the patients, number of patients visited each day, patient flow logic, was used to build the current system model. Later, different scenarios were designed which measured the changes in the current layout and performance.
Wijewickrama et al.12 developed a simulation model to evaluate appointment schedule (AS) for second time consultations and patient appointment sequence (PSEQ) in a multi-­‐facility system. Five different appointment rule (ARULE) were considered: i) Baily; ii) 3Baily; iii) Individual (Ind); iv) two patients at a time (2AtaTime); v) Variable Interval and (V-­‐I) rule. PSEQ is based on type of patients: Appointment patients (APs) and new patients (NPs). The different PSEQ that were studied in this study were: i) first-­‐ come first-­‐serve; ii) appointment patient at the beginning of the clinic (APBEG); iii) new patient at the beginning of the clinic (NPBEG); iv) assigning appointed and new patients in an alternating manner (ALTER); v) assigning a new patient after every five-­‐appointment patients. Also patient no show (0% and 5%) and patient punctuality (PUNCT) (on-­‐time and 10 minutes early) were also considered. The study found that ALTER-­‐Ind. and ALTER5-­‐Ind. performed best on 0% NOSHOW, on-­‐time PUNCT and 5% NOSHOW, on-­‐time PUNCT situation to reduce WT and IT per patient. As NOSHOW created slack time for waiting patients, their WT tends to reduce while IT increases due to unexpected cancellation. Earliness increases congestion whichin turn increases waiting time.
Ramis et al.13 conducted a study of a Medical Imaging Center (MIC) to build a simulation model which was used to improve the patient journey through an imaging centre by reducing the wait time and making better use of the resources. The simulation model also used a Graphic User Interface (GUI) to provide the parameters of the centre, such as arrival rates, distances, processing times, resources and schedule. The simulation was used to measure the waiting time of the patients in different case scenarios. The study found that assigning a common function to the resource personnel could improve the waiting time of the patients.
The objective of this study is to develop an efficient scheduling template that maximises the number of served patients and minimises the average patient's waiting time at the given resources availability. To accomplish this objective, we will build a simulation model which mimics the working conditions of the clinic. Then we will suggest different scenarios of matching the arrival pattern of the patients with the availability of the resources. Full experiments will be performed to evaluate these scenarios. Hence, a simple and practical scheduling template will be built based on the indentified best scenario. The developed simulation model is described in section 2, which consists of a description of the treatment room, and a description of the types of patients and treatment durations. In section 3, different improvement scenarios are described and their analysis is presented in section 4. Section 5 illustrates a scheduling template based on one of the improvement scenarios. Finally, the conclusion and future direction of our work is exhibited in section 6.
Simulation Model
A simulation model represents the actual system and assists in visualising and evaluating the performance of the system under different scenarios without interrupting the actual system. Building a proper simulation model of a system consists of the following steps.
Observing the system to understand the flow of the entities, key players, availability of resources and overall generic framework.
Collecting the data on the number and type of entities, time consumed by the entities at each step of their journey, and availability of resources.
After building the simulation model it is necessary to confirm that the model is valid. This can be done by confirming that each entity flows as it is supposed to and the statistical data generated by the simulation model is similar to the collected data.
Figure 1 shows the patient flow process in the treatment room. On the patient's first appointment, the oncologist comes up with the treatment plan. The treatment time varies according to the patient’s condition, which may be 1 hour to 10 hours. Based on the type of the treatment, the physician or the clinical clerk books an available treatment chair for that time period.
On the day of the appointment, the patient will wait until the booked chair is free. When the chair is free a nurse from that station comes to the patient, verifies the name and date of birth and takes the patient to a treatment chair. Afterwards, the nurse flushes the chemotherapy drug line to the patient's body which takes about five minutes and sets up the treatment. Then the nurse leaves to serve another patient. Chemotherapy treatment lengths vary from less than an hour to 10 hour infusions. At the end of the treatment, the nurse returns, removes the line and notifies the patient about the next appointment date and time which also takes about five minutes. Most of the patients visit the clinic to take care of their PICC line (a peripherally inserted central catheter). A PICC is a line that is used to inject the patient with the chemical. This PICC line should be regularly cleaned, flushed to maintain patency and the insertion site checked for signs of infection. It takes approximately 10–15 minutes to take care of a PICC line by a nurse.
Cancer Care Manitoba provided access to the electronic scheduling system, also known as "ARIA" which is comprehensive information and image management system that aggregates patient data into a fully-­‐electronic medical chart, provided by VARIAN Medical System. This system was used to find out how many patients are booked in every clinic day. It also reveals which chair is used for how many hours. It was necessary to search a patient's history to find out how long the patient spends on which chair. Collecting the snapshot of each patient gives the complete picture of a one day clinic schedule.
The treatment room consists of the following two main limited resources:
Treatment Chairs: Chairs that are used to seat the patients during the treatment.
Nurses: Nurses are required to inject the treatment line into the patient and remove it at the end of the treatment. They also take care of the patients when they feel uncomfortable.
Mc Charles Chemotherapy unit consists of 11 nurses, and 5 stations with the following description:
Station 1: Station 1 has six chairs (numbered 1 to 6) and two nurses. The two nurses work from 8:00 to 16:00.
Station 2: Station 2 has six chairs (7 to 12) and three nurses. Two nurses work from 8:00 to 16:00 and one nurse works from 12:00 to 20:00.
Station 3: Station 4 has six chairs (13 to 18) and two nurses. The two nurses work from 8:00 to 16:00.
Station 4: Station 4 has six chairs (19 to 24) and three nurses. One nurse works from 8:00 to 16:00. Another nurse works from 10:00 to 18:00.
Solarium Station: Solarium Station has six chairs (Solarium Stretcher 1, Solarium Stretcher 2, Isolation, Isolation emergency, Fire Place 1, Fire Place 2). There is only one nurse assigned to this station that works from 12:00 to 20:00. The nurses from other stations can help when need arises.
There is one more nurse known as the "float nurse" who works from 11:00 to 19:00. This nurse can work at any station. Table 1 summarises the working hours of chairs and nurses. All treatment stations start at 8:00 and continue until the assigned nurse for that station completes her shift.
Currently, the clinic uses a scheduling template to assign the patients' appointments. But due to high demand of patient appointment it is not followed any more. We believe that this template can be improved based on the availability of nurses and chairs. Clinic workload was collected from 21 days of field observation. The current scheduling template has 10 types of appointment time slot: 15-­‐minute, 1-­‐hour, 1.5-­‐hour, 2-­‐hour, 3-­‐hour, 4-­‐hour, 5-­‐hour, 6-­‐hour, 8-­‐hour and 10-­‐hour and it is designed to serve 95 patients. But when the scheduling template was compared with the 21 days observations, it was found that the clinic is serving more patients than it is designed for. Therefore, the providers do not usually follow the scheduling template. Indeed they very often break the time slots to accommodate slots that do not exist in the template. Hence, we find that some of the stations are very busy (mostly station 2) and others are underused. If the scheduling template can be improved, it will be possible to bring more patients to the clinic and reduce their waiting time without adding more resources.
In order to build or develop a simulation model of the existing system, it is necessary to collect the following data:
Types of treatment durations.
Numbers of patients in each treatment type.
Arrival pattern of the patients.
Steps that the patients have to go through in their treatment journey and required time of each step.
Using the observations of 2,155 patients over 21 days of historical data, the types of treatment durations and the number of patients in each type were estimated. This data also assisted in determining the arrival rate and the frequency distribution of the patients. The patients were categorised into six types. The percentage of these types and their associated service times distributions are determined too.
ARENA Rockwell Simulation Software (v13) was used to build the simulation model. Entities of the model were tracked to verify that the patients move as intended. The model was run for 30 replications and statistical data was collected to validate the model. The total number of patients that go though the model was compared with the actual number of served patients during the 21 days of observations.
Improvement Scenarios
After verifying and validating the simulation model, different scenarios were designed and analysed to identify the best scenario that can handle more patients and reduces the average patient's waiting time. Based on the clinic observation and discussion with the healthcare providers, the following constraints have been stated:
The stations are filled up with treatment chairs. Therefore, it is literally impossible to fit any more chairs in the clinic. Moreover, the stakeholders are not interested in adding extra chairs.
The stakeholders and the caregivers are not interested in changing the layout of the treatment room.
Given these constraints the options that can be considered to design alternative scenarios are:
Changing the arrival pattern of the patients: that will fit over the nurses' availability.
Changing the nurses' schedule.
Adding one full time nurse at different starting times of the day.
Figure 2 compares the available number of nurses and the number of patients' arrival during different hours of a day. It can be noticed that there is a rapid growth in the arrival of patients (from 13 to 17) between 8:00 to 10:00 even though the clinic has the equal number of nurses during this time period. At 12:00 there is a sudden drop of patient arrival even though there are more available nurses. It is clear that there is an imbalance in the number of available nurses and the number of patient arrivals over different hours of the day. Consequently, balancing the demand (arrival rate of patients) and resources (available number of nurses) will reduce the patients' waiting time and increases the number of served patients. The alternative scenarios that satisfy the above three constraints are listed in Table 2. These scenarios respect the following rules:
Long treatments (between 4hr to 11hr) have to be scheduled early in the morning to avoid working overtime.
Patients of type 1 (15 minutes to 1hr treatment) are the most common. They can be fitted in at any time of the day because they take short treatment time. Hence, it is recommended to bring these patients in at the middle of the day when there are more nurses.
Nurses get tired at the end of the clinic day. Therefore, fewer patients should be scheduled at the late hours of the day.
In Scenario 1, the arrival pattern of the patient was changed so that it can fit with the nurse schedule. This arrival pattern is shown Table 3. Figure 3 shows the new patients' arrival pattern compared with the current arrival pattern. Similar patterns can be developed for the remaining scenarios too.
Analysis of Results
ARENA Rockwell Simulation software (v13) was used to develop the simulation model. There is no warm-­‐up period because the model simulates day-­‐to-­‐day scenarios. The patients of any day are supposed to be served in the same day. The model was run for 30 days (replications) and statistical data was collected to evaluate each scenario. Tables 4 and 5 show the detailed comparison of the system performance between the current scenario and Scenario 1. The results are quite interesting. The average throughput rate of the system has increased from 103 to 125 patients per day. The maximum throughput rate can reach 135 patients. Although the average waiting time has increased, the utilisation of the treatment station has increased by 15.6%. Similar analysis has been performed for the rest of the other scenarios. Due to the space limitation the detailed results are not given. However, Table 6 exhibits a summary of the results and comparison between the different scenarios. Scenario 1 was able to significantly increase the throughput of the system (by 21%) while it still results in an acceptable low average waiting time (13.4 minutes). In addition, it is worth noting that adding a nurse (Scenarios 3, 4, and 5) does not significantly reduce the average wait time or increase the system's throughput. The reason behind this is that when all the chairs are busy, the nurses have to wait until some patients finish the treatment. As a consequence, the other patients have to wait for the commencement of their treatment too. Therefore, hiring a nurse, without adding more chairs, will not reduce the waiting time or increase the throughput of the system. In this case, the only way to increase the throughput of the system is by adjusting the arrival pattern of patients over the nurses' schedule.
Developing a Scheduling Template based on Scenario 1
Scenario 1 provides the best performance. However a scheduling template is necessary for the care provider to book the patients. Therefore, a brief description is provided below on how scheduling the template is developed based on this scenario.
Table 3 gives the number of patients that arrive hourly, following Scenario 1. The distribution of each type of patient is shown in Table 7. This distribution is based on the percentage of each type of patient from the collected data. For example, in between 8:00-­‐9:00, 12 patients will come where 54.85% are of Type 1, 34.55% are of Type 2, 15.163% are of Type 3, 4.32% are of Type 4, 2.58% are of Type 5 and the rest are of Type 6. It is worth noting that, we assume that the patients of each type arrive as a group at the beginning of the hourly time slot. For example, all of the six patients of Type 1 from 8:00 to 9:00 time slot arrive at 8:00.
The numbers of patients from each type is distributed in such a way that it respects all the constraints described in Section 1.3. Most of the patients of the clinic are from type 1, 2 and 3 and they take less amount of treatment time compared with the patients of other types. Therefore, they are distributed all over the day. Patients of type 4, 5 and 6 take a longer treatment time. Hence, they are scheduled at the beginning of the day to avoid overtime. Because patients of type 4, 5 and 6 come at the beginning of the day, most of type 1 and 2 patients come at mid-­‐day (12:00 to 16:00). Another reason to make the treatment room more crowded in between 12:00 to 16:00 is because the clinic has the maximum number of nurses during this time period. Nurses become tired at the end of the clinic which is a reason not to schedule any patient after 19:00.
Based on the patient arrival schedule and nurse availability a scheduling template is built and shown in Figure 4. In order to build the template, if a nurse is available and there are patients waiting for service, a priority list of these patients will be developed. They are prioritised in a descending order based on their estimated slack time and secondarily based on the shortest service time. The secondary rule is used to break the tie if two patients have the same slack. The slack time is calculated using the following equation:
Slack time = Due time - (Arrival time + Treatment time)
Due time is the clinic closing time. To explain how the process works, assume at hour 8:00 (in between 8:00 to 8:15) two patients in station 1 (one 8-­‐hour and one 15-­‐ minute patient), two patients in station 2 (two 12-­‐hour patients), two patients in station 3 (one 2-­‐hour and one 15-­‐ minute patient) and one patient in station 4 (one 3-­‐hour patient) in total seven patients are scheduled. According to Figure 2, there are seven nurses who are available at 8:00 and it takes 15 minutes to set-­‐up a patient. Therefore, it is not possible to schedule more than seven patients in between 8:00 to 8:15 and the current scheduling is also serving seven patients by this time. The rest of the template can be justified similarly.
doi:10.4066/AMJ.2011.837
PMCID: PMC3562880  PMID: 23386870
13.  Considerations for practice-based research: a cross-sectional survey of chiropractic, acupuncture and massage practices 
Background
Complementary and alternative medicine (CAM) use has steadily increased globally over the past two decades and is increasingly playing a role in the healthcare system in the United States. CAM practice-based effectiveness research requires an understanding of the settings in which CAM practitioners provide services. This paper describes and quantifies practice environment characteristics for a cross-sectional sample of doctors of chiropractic (DCs), licensed acupuncturists (LAcs), and licensed massage therapists (LMTs) in the United States.
Methods
Using a cross-sectional telephone survey of DCs (n = 32), LAcs (n = 70), and LMTs (n = 184) in the Tucson, AZ metropolitan area, we collected data about each location where practitioners work, as well as measures on practitioner and practice characteristics including: patient volume, number of locations where practitioners worked, CAM practitioner types working at each location, and business models of practice.
Results
The majority of practitioners reported having one practice location (93.8% of DCs, 80% of LAcs and 59.8% of LMTs) where they treat patients. Patient volume/week was related to practitioner type; DCs saw 83.13 (SD = 49.29) patients/week, LAcs saw 22.29 (SD = 16.88) patients/week, and LMTs saw 14.21 (SD =10.25) patients per week. Practitioners completed surveys for N = 388 practice locations. Many CAM practices were found to be multidisciplinary and/or have more than one practitioner: 9/35 (25.7%) chiropractic practices, 24/87 (27.6%) acupuncture practices, and 141/266 (53.0%) massage practices. Practice business models across CAM practitioner types were heterogeneous, e.g. sole proprietor, employee, partner, and independent contractor.
Conclusions
CAM practices vary across and within disciplines in ways that can significantly impact design and implementation of practice-based research. CAM research and intervention programs need to be mindful of the heterogeneity of CAM practices in order to create appropriate interventions, study designs, and implementation plans.
doi:10.1186/s12906-015-0659-7
PMCID: PMC4429345  PMID: 25933801
Complementary and alternative medicine; Practitioners; Chiropractors; Acupuncturists; Massage therapists; Practice-based research; Practice patterns; Cross-sectional survey
14.  Use and Acceptance of Complementary and Alternative Medicine Among the General Population and Medical Personnel: A Systematic Review 
The Ochsner Journal  2012;12(1):45-56.
Background
The interest in complementary and alternative medicine (CAM) has increased during the past decade and the attitude of the general public is mainly positive, but the debate about the clinical effectiveness of these therapies remains controversial among many medical professionals.
Methods
We conducted a systematic search of the existing literature utilizing different databases, including PubMed/Medline, PSYNDEX, and PsycLit, to research the use and acceptance of CAM among the general population and medical personnel. A special focus on CAM-referring literature was set by limiting the PubMed search to “Complementary Medicine” and adding two other search engines: CAMbase (www.cambase.de) and CAMRESEARCH (www.camresearch.net). These engines were used to reveal publications that at the time of the review were not indexed in PubMed.
Results
A total of 16 papers met the scope criteria. Prevalence rates of CAM in each of the included studies were between 5% and 74.8%. We found a higher utilization of homeopathy and acupuncture in German-speaking countries. Excluding any form of spiritual prayer, the data demonstrate that chiropractic manipulation, herbal medicine, massage, and homeopathy were the therapies most commonly used by the general population. We identified sex, age, and education as predictors of CAM utilization: More users were women, middle aged, and more educated. The ailments most often associated with CAM utilization included back pain or pathology, depression, insomnia, severe headache or migraine, and stomach or intestinal illnesses. Medical students were the most critical toward CAM. Compared to students of other professions (ie, nursing students: 44.7%, pharmacy students: 18.2%), medical students reported the least consultation with a CAM practitioner (10%).
Conclusions
The present data demonstrate an increase of CAM usage from 1990 through 2006 in all countries investigated. We found geographical differences, as well as differences between the general population and medical personnel.
PMCID: PMC3307506  PMID: 22438782
Alternative medicine; complementary medicine
15.  Online Tobacco Cessation Training and Competency Assessment for Complementary and Alternative Medicine (CAM) Practitioners: Protocol for the CAM Reach Web Study 
JMIR Research Protocols  2016;5(1):e2.
Background
Complementary and alternative medicine (CAM) practitioners, such as chiropractors, acupuncturists, and massage therapists, are a growing presence in the US health care landscape and already provide health and wellness care to significant numbers of patients who use tobacco. For decades, conventional biomedical practitioners have received training to provide evidence-based tobacco cessation brief interventions (BIs) and referrals to cessation services as part of routine clinical care, whereas CAM practitioners have been largely overlooked for BI training. Web-based training has clear potential to meet large-scale training dissemination needs. However, despite the exploding use of Web-based training for health professionals, Web-based evaluation of clinical skills competency remains underdeveloped.
Objective
In pursuit of a long-term goal of helping CAM practitioners integrate evidence-based practices from US Public Health Service Tobacco Dependence Treatment Guideline into routine clinical care, this pilot protocol aims to develop and test a Web-based tobacco cessation training program tailored for CAM practitioners.
Methods
In preparation for a larger trial to examine the effect of training on CAM practitioner clinical practice behaviors around tobacco cessation, this developmental study will (1) adapt an existing in-person tobacco cessation BI training program that is specifically tailored for CAM therapists for delivery via the Internet; (2) develop a novel, Web-based tool to assess CAM practitioner competence in tobacco cessation BI skills, and conduct a pilot validation study comparing the competency assessment tool to live video role plays with a standardized patient; (3) pilot test the Web-based training with 120 CAM practitioners (40 acupuncturists, 40 chiropractors, 40 massage therapists) for usability, accessibility, acceptability, and effects on practitioner knowledge, self-efficacy, and competency with tobacco cessation; and (4) conduct qualitative and quantitative formative research on factors influencing practitioner tobacco cessation clinical behaviors (eg, practice environment, peer social influence, and insurance reimbursement).
Results
Web-training and competency assessment tool development and study enrollment and training activities are complete (N=203 practitioners enrolled). Training completion rates were lower than expected (36.9%, 75/203), necessitating over enrollment to ensure a sufficient number of training completers. Follow-up data collection is in progress. Data analysis will begin immediately after data collection is complete.
Conclusions
To realize CAM practitioners’ potential to promote tobacco cessation and use of evidence-based treatments, there is a need to know more about the facilitative and inhibitory factors influencing CAM practitioner tobacco intervention behaviors (eg, social influence and insurance reimbursement). Given marked differences between conventional and CAM practitioners, extant knowledge about factors influencing conventional practitioner adoption of tobacco cessation behaviors cannot be confidently extrapolated to CAM practitioners. The potential impact of this study is to expand tobacco cessation and health promotion infrastructure in a new group of health practitioners who can help combat the continuing epidemic of tobacco use.
doi:10.2196/resprot.5061
PMCID: PMC4720835  PMID: 26740468
tobacco cessation; brief intervention; online training; communication; acupuncture; chiropractic; massage therapy
16.  Physicians' Attitudes Toward Complementary and Alternative Medicine and Their Knowledge of Specific Therapies: A Survey at an Academic Medical Center 
The purpose of this study was to evaluate the attitudes of physicians at an academic medical center toward complementary and alternative medicine (CAM) therapies and the physicians' knowledge base regarding common CAM therapies. A link to a Web-based survey was e-mailed to 660 internists at Mayo Clinic in Rochester, MN, USA. Physicians were asked about their attitudes toward CAM in general and their knowledge regarding specific CAM therapies. The level of evidence a physician would require before incorporating such therapies into clinical care was also assessed. Of the 233 physicians responding to the survey, 76% had never referred a patient to a CAM practitioner. However, 44% stated that they would refer a patient if a CAM practitioner were available at their institution. Fifty-seven percent of physicians thought that incorporating CAM therapies would have a positive effect on patient satisfaction, and 48% believed that offering CAM would attract more patients. Most physicians agreed that some CAM therapies hold promise for the treatment of symptoms or diseases, but most of them were not comfortable in counseling their patients about most CAM treatments. Prospective, randomized controlled trials were considered the level of evidence required for most physicians to consider incorporating a CAM therapy into their practice. The results of this survey provide insight into the attitudes of physicians toward CAM at an academic medical center. This study highlights the need for educational interventions and the importance of providing physicians ready access to evidence-based information regarding CAM.
doi:10.1093/ecam/nel036
PMCID: PMC1697740  PMID: 17173114
integrative medicine; physician attitudes; physician education
17.  Complementary and Alternative Medicine for the Management of Cervical Radiculopathy: An Overview of Systematic Reviews 
Background. Complementary and alternative medicine (CAM) is widely applied in the clinical practice of neck pain owing to cervical radiculopathy (CR). While many systematic reviews exist in CAM to improve CR, research is distributed across population, intervention, comparison, and setting. Objective. This overview aims to summarize the characteristics and evaluate critically the evidence from systematic reviews. Methods. A comprehensive literature search was performed in the six databases without language restrictions on February 24, 2015. We had identified relevant systematic reviews that examined the subjects with neck pain due to cervical radiculopathy undergoing CAM. Two authors independently appraised the methodological quality using the revised assessment of multiple systematic reviews instrument. Results. We had included eight systematic reviews. The effectiveness and safety of acupotomy, acupuncture, Jingfukang granule, manual therapies, and cervical spine manipulation were investigated. Based on available evidence, the systematic reviews supported various forms of CAM for CR. Nevertheless, the methodological quality for most of systematic reviews was low or moderate. In addition, adverse reactions of primary studies were infrequent. Conclusions. Current systematic reviews showed potential advantages to CAM for CR. Due to the frequently poor methodological quality of primary studies, the conclusions should be treated with caution for clinical practice.
doi:10.1155/2015/793649
PMCID: PMC4541004  PMID: 26345336
18.  Understanding clinical reasoning in osteopathy: a qualitative research approach 
Background
Clinical reasoning has been described as a process that draws heavily on the knowledge, skills and attributes that are particular to each health profession. However, the clinical reasoning processes of practitioners of different disciplines demonstrate many similarities, including hypothesis generation and reflective practice. The aim of this study was to understand clinical reasoning in osteopathy from the perspective of osteopathic clinical educators and the extent to which it was similar or different from clinical reasoning in other health professions.
Methods
This study was informed by constructivist grounded theory. Participants were clinical educators in osteopathic teaching institutions in Australia, New Zealand and the UK. Focus groups and written critical reflections provided a rich data set. Data were analysed using constant comparison to develop inductive categories.
Results
According to participants, clinical reasoning in osteopathy is different from clinical reasoning in other health professions. Osteopaths use a two-phase approach: an initial biomedical screen for serious pathology, followed by use of osteopathic reasoning models that are based on the relationship between structure and function in the human body. Clinical reasoning in osteopathy was also described as occurring in a number of contexts (e.g. patient, practitioner and community) and drawing on a range of metaskills (e.g. hypothesis generation and reflexivity) that have been described in other health professions.
Conclusions
The use of diagnostic reasoning models that are based on the relationship between structure and function in the human body differentiated clinical reasoning in osteopathy. These models were not used to name a medical condition but rather to guide the selection of treatment approaches. If confirmed by further research that clinical reasoning in osteopathy is distinct from clinical reasoning in other health professions, then osteopaths may have a unique perspective to bring to multidisciplinary decision-making and potentially enhance the quality of patient care.
Where commonalities exist in the clinical reasoning processes of osteopathy and other health professions, shared learning opportunities may be available, including the exchange of scaffolded clinical reasoning exercises and assessment practices among health disciplines.
doi:10.1186/s12998-016-0087-x
PMCID: PMC4782380  PMID: 26958339
19.  Complementary and Alternative Medicine Treatment Options for Otitis Media 
Medicine  2016;95(6):e2695.
Abstract
Otitis media (OM) has numerous presentations in children. Together with conventional medical therapies aimed to prevent and/or treat OM, a rising number of complementary and alternative medicine (CAM) treatment options can be offered. Since OM is common in children, parents may ask healthcare professionals about possible CAM therapies. Many physicians feel that their knowledge is limited regarding these therapies, and that they desire some information. Therefore, we conducted a literature review of CAM therapies for OM, taking into account that many of these treatments, their validity and efficacy and have not been scientifically demonstrated.
We performed a search in MEDLINE (accessed via PubMed) using the following terms: “CAM” in conjunction with “OM” and “children. Retrieved publications regarding treatment of OM in children which included these terms included randomized controlled trials, prospective/retrospective studies, and case studies.
The following CAM options for OM treatment in children were considered: acupuncture, homeopathy, herbal medicine/phytotherapy, osteopathy, chiropractic, xylitol, ear candling, vitamin D supplement, and systemic and topical probiotics. We reviewed each treatment and described the level of scientific evidence of the relevant publications.
The therapeutic approaches commonly associated with CAM are usually conservative, and do not include drugs or surgery. Currently, CAM is not considered by physicians a potential treatment of OM, as there is limited supporting evidence. Further studies are warranted in order to evaluate the potential value of CAM therapies for OM.
doi:10.1097/MD.0000000000002695
PMCID: PMC4753897  PMID: 26871802
20.  The Impact of an Evidence-Based Medicine Educational Intervention on Primary Care Physicians: A Qualitative Study 
Background
Attitudes and barriers to implementing EBM have been examined extensively, but scant evidence exists regarding the impact of EBM teaching on primary care physicians’ point of care behavior.
Objective
Gaining insight into behavioral and attitudinal changes of facilitators and participants during a multifaceted EBM educational intervention.
Design, setting, and participants
A qualitative study on primary care physicians and facilitators from a large HMO selected from the intervention arm of a parallel controlled trial using purposeful sampling. We conducted focus groups with 13 facilitators and 17 physicians and semi-structured interviews with 10 facilitators and 11 physicians.
Results
Both facilitators and participants believed EBM enhanced the quality of their practice. The intervention affected attitudes and knowledge, but had little impact on physicians’ ability to utilize pre-appraised resources at the point of care. Using EBM resources during consultation was perceived to be a complex task and impractical in a busy setting. Conversely, a positive impact on using medication databases was noted. Medication databases were perceived as easy to use during consultations in which the benefits outweighed the barriers. The intervention prompted physicians to write down clinical questions more frequently and to search for answers at home.
Conclusions
This study underlines the need not only to enhance EBM skills, but also to improve the ease of use of EBM resources at the point of care. Tasks should be simplified by tailoring evidence-based information retrieval systems to the busy clinical schedule. Participants’ recommendations to establish an HMO decision support service should be considered.
doi:10.1007/s11606-006-0055-6
PMCID: PMC1824748  PMID: 17356963
evidence-based medicine; primary care; medical education
21.  The Impact of an Evidence-Based Medicine Educational Intervention on Primary Care Physicians: A Qualitative Study 
Background
Attitudes and barriers to implementing EBM have been examined extensively, but scant evidence exists regarding the impact of EBM teaching on primary care physicians’ point of care behavior.
Objective
Gaining insight into behavioral and attitudinal changes of facilitators and participants during a multifaceted EBM educational intervention.
Design, setting, and participants
A qualitative study on primary care physicians and facilitators from a large HMO selected from the intervention arm of a parallel controlled trial using purposeful sampling. We conducted focus groups with 13 facilitators and 17 physicians and semi-structured interviews with 10 facilitators and 11 physicians.
Results
Both facilitators and participants believed EBM enhanced the quality of their practice. The intervention affected attitudes and knowledge, but had little impact on physicians’ ability to utilize pre-appraised resources at the point of care. Using EBM resources during consultation was perceived to be a complex task and impractical in a busy setting. Conversely, a positive impact on using medication databases was noted. Medication databases were perceived as easy to use during consultations in which the benefits outweighed the barriers. The intervention prompted physicians to write down clinical questions more frequently and to search for answers at home.
Conclusions
This study underlines the need not only to enhance EBM skills, but also to improve the ease of use of EBM resources at the point of care. Tasks should be simplified by tailoring evidence-based information retrieval systems to the busy clinical schedule. Participants’ recommendations to establish an HMO decision support service should be considered.
doi:10.1007/s11606-006-0055-6
PMCID: PMC1824748  PMID: 17356963
evidence-based medicine; primary care; medical education
22.  DISCLOSURE TO PHYSICIANS OF CAM USE BY BREAST CANCER PATIENTS: FINDINGS FROM THE WOMEN’S HEALTHY EATING AND LIVING STUDY 
Integrative cancer therapies  2008;7(3):122-129.
Background
Physician awareness of their patients’ use of complementary and alternative medicine (CAM) is crucial, particularly in the setting of a potentially life-threatening disease such as cancer. The potential for harmful treatment interactions may be greatest when a patient sees a CAM practitioner – perceived as a physician-like authority figure – but does not disclose this to their physician. We therefore investigated the extent of nondisclosure in a large cohort of cancer patients.
Methods
We investigated CAM use in participants of the UCSD Women’s Healthy Eating and Living (WHEL) Study, a multicenter study of the effect of diet and lifestyle on disease-free and overall survival in women ages 18–70 who had completed treatment for invasive breast cancer between 1995 and 2000. Data regarding CAM use and disclosure was collected via a telephone-administered questionnaire in 2003–2004. This questionnaire asked about different CAM modalities including those requiring a “skilled CAM practitioner” (acupuncturist, chiropractor, homeopath, or naturopath) for administration. Demographic data was obtained at the WHEL baseline clinic interview. Modality-specific disclosure rates were determined and a comparison of demographic variables of disclosers versus nondisclosers was conducted using Chi-squared tests for categorical variables, and t-tests for continuous variables.
Results
Of 3088 total WHEL participants, 2527 completed the CAM questionnaire. Of these, 2017 reported using some form of CAM. Of these, 300 received treatment from an acupuncturist, chiropractor, homeopath, or naturopath and also provided information on whether or not they disclosed this care to their conventional physician. The highest disclosure rate was for naturopathy (85%), followed by homeopathy (74%), acupuncture (71%), and chiropractic (47%). Among demographic characteristics, only education (p = 0.047) and study site (p=0.039) were associated with disclosure. College graduates and postgraduates, in particular, were more likely to disclose CAM use to their physicians than those with lesser education.
Conclusion
Overall, we observed moderately high rates of physician disclosure of CAM use for all modalities except chiropractic. Education and study site associations suggest that disclosure may be greater when CAM use is more prevalent and possibly more socially accepted. These findings underscore the importance of open, destigmatized patient-physician communication regarding CAM use.
PMCID: PMC2763208  PMID: 18956493
Breast cancer; CAM; complementary and alternative medicine; acupuncture; naturopathy; chiropractic; health communication; disclosure
23.  Health Beliefs, Treatment Preferences and Complementary and Alternative Medicine for Asthma, Smoking and Lung Cancer Self-Management in Diverse Black Communities 
Patient education and counseling  2012;89(3):489-500.
Objectives
The purpose of this literature review is to characterize unconventional health beliefs and complementary and alternative medicine (CAM) for asthma, smoking and lung cancer as those that are likely safe and those that likely increase risk in diverse Black communities. These findings should provide the impetus for enhanced patient-provider communication that elicits patients’ beliefs and self-management preferences so that they may be accommodated, or when necessary, reconciled through discussion and partnership.
Methods
Original research articles relevant to this topic were obtained by conducting a literature search of the PubMed Plus, PsychINFO and SCOPUS databases using combinations of the following search terms: asthma, lung cancer, emphysema, chronic obstructive pulmonary disease (COPD), smoking, beliefs, complementary medicine, alternative medicine, complementary and alternative medicine (CAM), explanatory models, African American, and Black.
Results
Using predetermined inclusion and exclusion criteria, 51 original research papers were retained. Taken together, they provide evidence that patients hold unconventional beliefs about the origins of asthma and lung cancer and the health risks of smoking, have negative opinions of standard medical and surgical treatments, and have favorable attitudes about using CAM. All but a small number of CAM and health behaviors were considered safe.
Conclusions
When patients’ unconventional beliefs and preferences are not identified and discussed, there is an increased risk that standard approaches to self-management of lung disease will be sub-optimal, that potentially dangerous CAM practices might be used and that timely medical interventions may be delayed.
Practice implications
Providers need effective communication skills as the medical dialogue forms the basis of patients’ understanding of disease and self-management options. The preferred endpoint of such discussions should be agreement around an integrated treatment plan that is effective, safe and acceptable to both.
doi:10.1016/j.pec.2012.05.003
PMCID: PMC3463761  PMID: 22683293
24.  Teaching Evidence-Based Medicine at Complementary and Alternative Medicine Institutions: Strategies, Competencies, and Evaluation 
Abstract
Background: As evidence-based medicine (EBM) becomes a standard in health care, it is essential that practitioners of complementary and alternative medicine (CAM) become experts in searching and evaluating the research literature. In support of this goal, the National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine (NCCAM) provided R25 funding to nine CAM colleges to develop individual programs focused on teaching EBM. An overarching goal of these research education grants has been to provide CAM faculty and students with the skills they need to apply a rigorous evidence-based perspective to their training and practice.
Methods/Results: This paper reviews the competencies and teaching strategies developed and implemented to enhance research literacy at all nine R25-funded institutions. While each institution designed approaches suitable for its research culture, the guiding principles were similar: to develop evidence-informed skills and knowledge, thereby helping students and faculty to critically appraise evidence and then use that evidence to guide their clinical practice. Curriculum development and assessment included faculty-driven learning activities and longitudinal curricular initiatives to encourage skill reinforcement and evaluate progress.
Conclusion: As the field of integrative medicine matures, the NIH-NCCAM research education grants provide essential training for future clinicians and clinician-researchers. Building this workforce will facilitate multidisciplinary collaborations that address the unique needs for research that informs integrative clinical practice.
doi:10.1089/acm.2014.0087
PMCID: PMC4270143  PMID: 25380144
25.  Complementary therapies for acne vulgaris 
Background
Acne is a chronic skin disease characterised by inflamed spots and blackheads on the face, neck, back, and chest. Cysts and scarring can also occur, especially in more severe disease. People with acne often turn to complementary and alternative medicine (CAM), such as herbal medicine, acupuncture, and dietary modifications, because of their concerns about the adverse effects of conventional medicines. However, evidence for CAM therapies has not been systematically assessed.
Objectives
To assess the effects and safety of any complementary therapies in people with acne vulgaris.
Search methods
We searched the following databases from inception up to 22 January 2014: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 1), MEDLINE (from 1946), Embase (from 1974), PsycINFO (from 1806), AMED (from 1985), CINAHL (from 1981), Scopus (from 1966), and a number of other databases listed in the Methods section of the review. The Cochrane CAM Field Specialised Register was searched up to May 2014. We also searched five trials registers and checked the reference lists of articles for further references to relevant trials.
Selection criteria
We included parallel-group randomised controlled trials (or the first phase data of randomised cross-over trials) of any kind of CAM, compared with no treatment, placebo, or other active therapies, in people with a diagnosis of acne vulgaris.
Data collection and analysis
Three authors collected data from each included trial and evaluated the methodological quality independently. They resolved disagreements by discussion and, as needed, arbitration by another author.
Main results
We included 35 studies, with a total of 3227 participants. We evaluated the majority as having unclear risk of selection, attrition, reporting, detection, and other biases. Because of the clinical heterogeneity between trials and the incomplete data reporting, we could only include four trials in two meta-analyses, with two trials in each meta-analysis. The categories of CAM included herbal medicine, acupuncture, cupping therapy, diet, purified bee venom (PBV), and tea tree oil. A pharmaceutical company funded one trial; the other trials did not report their funding sources.
Our main primary outcome was ’Improvement of clinical signs assessed through skin lesion counts’, which we have reported as ’Change in inflammatory and non-inflammatory lesion counts’, ’Change of total skin lesion counts’, ’Skin lesion scores’, and ’Change of acne severity score’. For ’Change in inflammatory and non-inflammatory lesion counts’, we combined 2 studies that compared a low- with a high-glycaemic-load diet (LGLD, HGLD) at 12 weeks and found no clear evidence of a difference between the groups in change in non-inflammatory lesion counts (mean difference (MD) −3.89, 95% confidence interval (CI) −10.07 to 2.29, P = 0.10, 75 participants, 2 trials, low quality of evidence). However, although data from 1 of these 2 trials showed benefit of LGLD for reducing inflammatory lesions (MD −7.60, 95% CI −13.52 to −1.68, 43 participants, 1 trial) and total skin lesion counts (MD −8.10, 95% CI −14.89 to −1.31, 43 participants, 1 trial) for people with acne vulgaris, data regarding inflammatory and total lesion counts from the other study were incomplete and unusable in synthesis.
Data from a single trial showed potential benefit of tea tree oil compared with placebo in improving total skin lesion counts (MD −7.53, 95% CI −10.40 to −4.66, 60 participants, 1 trial, low quality of evidence) and acne severity scores (MD −5.75, 95% CI −9.51 to −1.99, 60 participants, 1 trial). Another trial showed pollen bee venom to be better than control in reducing numbers of skin lesions (MD −1.17, 95% CI −2.06 to −0.28, 12 participants, 1 trial).
Results from the other 31 trials showed inconsistent effects in terms of whether acupuncture, herbal medicine, or wet-cupping therapy were superior to controls in increasing remission or reducing skin lesions.
Twenty-six of the 35 included studies reported adverse effects; they did not report any severe adverse events, but specific included trials reported mild adverse effects from herbal medicines, wet-cupping therapy, and tea tree oil gel.
Thirty trials measured two of our secondary outcomes, which we combined and expressed as ’Number of participants with remission’. We were able to combine 2 studies (low quality of evidence), which compared Ziyin Qinggan Xiaocuo Granule and the antibiotic, minocycline (100 mg daily) (worst case = risk ratio (RR) 0.49, 95% CI 0.09 to 2.53, 2 trials, 206 participants at 4 weeks; best case = RR 2.82, 95% CI 0.82 to 9.06, 2 trials, 206 participants at 4 weeks), but there was no clear evidence of a difference between the groups.
None of the included studies assessed ’Psychosocial function’.
Two studies assessed ’Quality of life’, and significant differences in favour of the complementary therapy were found in both of them on ’feelings of self-worth’ (MD 1.51, 95% CI 0.88 to 2.14, P < 0.00001, 1 trial, 70 participants; MD 1.26, 95% CI 0.20 to 2.32, 1 trial, 46 participants) and emotional functionality (MD 2.20, 95% CI 1.75 to 2.65, P < 0.00001, 1 trial, 70 participants; MD 0.93, 95% CI 0.17 to 1.69, 1 trial, 46 participants).
Because of limitations and concerns about the quality of the included studies, we could not draw a robust conclusion for consistency, size, and direction of outcome effects in this review.
Authors’ conclusions
There is some low-quality evidence from single trials that LGLD, tea tree oil, and bee venom may reduce total skin lesions in acne vulgaris, but there is a lack of evidence from the current review to support the use of other CAMs, such as herbal medicine, acupuncture, or wet-cupping therapy, for the treatment of this condition. There is a potential for adverse effects from herbal medicines; however, future studies need to assess the safety of all of these CAM therapies. Methodological and reporting quality limitations in the included studies weakened any evidence. Future studies should be designed to ensure low risk of bias and meet current reporting standards for clinical trials.
doi:10.1002/14651858.CD009436.pub2
PMCID: PMC4486007  PMID: 25597924

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