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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 
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).
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.
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%).
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.
PMCID: PMC3932037  PMID: 24529279
Drug information; Complementary and alternative medicine; Decision support
2.  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.
PMCID: PMC3137728  PMID: 19468052
3.  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
4.  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
5.  Real-time EBM: From Bed Board to Keyboard and Back 
Journal of General Internal Medicine  2007;22(12):1656-1660.
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.
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.
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.
Second- and 3rd-year IM residents.
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.
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.
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.
PMCID: PMC2219829  PMID: 17922170
evidence-based medicine; medical education; internship and residency; searching
6.  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.
PMCID: PMC1853104  PMID: 17407592
7.  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.
PMCID: PMC2684986  PMID: 19427598
8.  CAM practitioners in the Australian health workforce: an underutilized resource 
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.
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.
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.
PMCID: PMC3528465  PMID: 23116374
9.  The Impact of an Evidence-Based Medicine Educational Intervention on Primary Care Physicians: A Qualitative Study 
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.
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.
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.
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.
PMCID: PMC1824748  PMID: 17356963
evidence-based medicine; primary care; medical education
10.  The Impact of an Evidence-Based Medicine Educational Intervention on Primary Care Physicians: A Qualitative Study 
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.
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.
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.
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.
PMCID: PMC1824748  PMID: 17356963
evidence-based medicine; primary care; medical education
11.  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.
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.
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.
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.
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.
PMCID: PMC3463761  PMID: 22683293
12.  Utilization of the PICO framework to improve searching PubMed for clinical questions 
Supporting 21st century health care and the practice of evidence-based medicine (EBM) requires ubiquitous access to clinical information and to knowledge-based resources to answer clinical questions. Many questions go unanswered, however, due to lack of skills in formulating questions, crafting effective search strategies, and accessing databases to identify best levels of evidence.
This randomized trial was designed as a pilot study to measure the relevancy of search results using three different interfaces for the PubMed search system. Two of the search interfaces utilized a specific framework called PICO, which was designed to focus clinical questions and to prompt for publication type or type of question asked. The third interface was the standard PubMed interface readily available on the Web. Study subjects were recruited from interns and residents on an inpatient general medicine rotation at an academic medical center in the US. Thirty-one subjects were randomized to one of the three interfaces, given 3 clinical questions, and asked to search PubMed for a set of relevant articles that would provide an answer for each question. The success of the search results was determined by a precision score, which compared the number of relevant or gold standard articles retrieved in a result set to the total number of articles retrieved in that set.
Participants using the PICO templates (Protocol A or Protocol B) had higher precision scores for each question than the participants who used Protocol C, the standard PubMed Web interface. (Question 1: A = 35%, B = 28%, C = 20%; Question 2: A = 5%, B = 6%, C = 4%; Question 3: A = 1%, B = 0%, C = 0%) 95% confidence intervals were calculated for the precision for each question using a lower boundary of zero. However, the 95% confidence limits were overlapping, suggesting no statistical difference between the groups.
Due to the small number of searches for each arm, this pilot study could not demonstrate a statistically significant difference between the search protocols. However there was a trend towards higher precision that needs to be investigated in a larger study to determine if PICO can improve the relevancy of search results.
PMCID: PMC1904193  PMID: 17573961
13.  Searching biomedical databases on complementary medicine: the use of controlled vocabulary among authors, indexers and investigators 
The optimal retrieval of a literature search in biomedicine depends on the appropriate use of Medical Subject Headings (MeSH), descriptors and keywords among authors and indexers. We hypothesized that authors, investigators and indexers in four biomedical databases are not consistent in their use of terminology in Complementary and Alternative Medicine (CAM).
Based on a research question addressing the validity of spinal palpation for the diagnosis of neuromuscular dysfunction, we developed four search concepts with their respective controlled vocabulary and key terms. We calculated the frequency of MeSH, descriptors, and keywords used by authors in titles and abstracts in comparison to standard practices in semantic and analytic indexing in MEDLINE, MANTIS, CINAHL, and Web of Science.
Multiple searches resulted in the final selection of 38 relevant studies that were indexed at least in one of the four selected databases. Of the four search concepts, validity showed the greatest inconsistency in terminology among authors, indexers and investigators. The use of spinal terms showed the greatest consistency. Of the 22 neuromuscular dysfunction terms provided by the investigators, 11 were not contained in the controlled vocabulary and six were never used by authors or indexers. Most authors did not seem familiar with the controlled vocabulary for validity in the area of neuromuscular dysfunction. Recently, standard glossaries have been developed to assist in the research development of manual medicine.
Searching biomedical databases for CAM is challenging due to inconsistent use of controlled vocabulary and indexing procedures in different databases. A standard terminology should be used by investigators in conducting their search strategies and authors when writing titles, abstracts and submitting keywords for publications.
PMCID: PMC166167  PMID: 12846931
14.  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.
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.
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
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
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:
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
PMCID: PMC3022523  PMID: 21267058
15.  The application of foraging theory to the information searching behaviour of general practitioners 
BMC Family Practice  2011;12:90.
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.
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.
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%.
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.
PMCID: PMC3175159  PMID: 21861880
Information Foraging; General Practitioners; Evidence - based medicine; Information Seeking Behavior; Questionnaires.
16.  A survey of Canadian regulated complementary and alternative medicine schools about research, evidence-based health care and interprofessional training, as well as continuing education 
While some effort has been made to integrate complementary and alternative medicine (CAM) information in conventional biomedical training, it is unclear whether regulated Canadian CAM schools’ students are exposed to research activities and continuing education, or whether topics such as evidence-based health care and interprofessional collaboration (IPC) are covered during their training. Since these areas are valued by the biomedical training field, this may help to bridge the attitudinal and communication gaps between these different practices. The aim of this study was to describe the training offered in these areas and gather the perceptions of curriculum/program directors in regulated Canadian CAM schools.
A two-phase study consisting of an electronic survey and subsequent semi-structured telephone interviews was conducted with curriculum/program (C/P) directors in regulated Canadian CAM schools. Questions assessed the extent of the research, evidence-based health care, IPC training and continuing education, as well as the C/P directors’ perceptions about the training. Descriptive statistics were used to describe the schools’, curriculum’s and the C/P directors’ characteristics. Content analysis was conducted on the interview material.
Twenty-eight C/P directors replied to the electronic survey and 11 participated in the interviews, representing chiropractic, naturopathy, acupuncture and massage therapy schools. Canadian regulated CAM schools offered research and evidence-based health care training as well as opportunities for collaboration with biomedical peers and continuing education to a various extent (58% to 91%). Although directors were generally satisfied with the training offered at their school, they expressed a desire for improvements. They felt future CAM providers should understand research findings and be able to rely on high quality research and to communicate with conventional care providers as well as to engage in continuing education. Limited length of the curriculum was one of the barriers to such improvements.
These findings seem to reinforce the directors’ interest and the importance of integrating these topics in order to ensure best CAM practices and improve communication between CAM and conventional providers.
PMCID: PMC3877872  PMID: 24373181
Complementary and alternative medicine; Continuing education; Curriculum development; Evidence-based health care training; Interprofessional training; Research training
17.  Finding toxicological information: An approach for occupational health professionals 
It can be difficult for occupational health professionals to assess which toxicological databases available on the Internet are the most useful for answering their questions. Therefore we evaluated toxicological databases for their ability to answer practical questions about exposure and prevention. We also propose recommended practices for searching for toxicological properties of chemicals.
We used a systematic search to find databases available on the Internet. Our criteria for the databases were the following: has a search engine, includes factual information on toxic and hazardous chemicals harmful for human health, and is free of charge. We developed both a qualitative and a quantitative rating method, which was used by four independent assessors to determine appropriateness, the quality of content, and ease of use of the database. Final ratings were based on a consensus of at least two evaluators.
Out of 822 results we found 21 databases that met our inclusion criteria. Out of these 21 databases 14 are administered in the US, five in Europe, one in Australia, and one in Canada. Nine are administered by a governmental organization. No database achieved the maximum score of 27. The databases GESTIS, ESIS, Hazardous Substances Data Bank, TOXNET and NIOSH Pocket Guide to Chemical Hazards all scored more than 20 points. The following approach was developed for occupational health professionals searching for the toxicological properties of chemicals: start with the identity of the chemical; then search for health hazards, exposure route and measurement; next the limit values; and finally look for the preventive measures.
A rating system of toxicological databases to assess their value for occupational health professionals discriminated well between databases in terms of their appropriateness, quality of information, and ease of use. Several American and European databases yielded high scores and provide a valuable source for occupational health professionals.
PMCID: PMC2551601  PMID: 18700959
18.  Efficacy of Quality Criteria to Identify Potentially Harmful Information: A Cross-sectional Survey of Complementary and Alternative Medicine Web Sites 
Many users search the Internet for answers to health questions. Complementary and alternative medicine (CAM) is a particularly common search topic. Because many CAM therapies do not require a clinician's prescription, false or misleading CAM information may be more dangerous than information about traditional therapies. Many quality criteria have been suggested to filter out potentially harmful online health information. However, assessing the accuracy of CAM information is uniquely challenging since CAM is generally not supported by conventional literature.
The purpose of this study is to determine whether domain-independent technical quality criteria can identify potentially harmful online CAM content.
We analyzed 150 Web sites retrieved from a search for the three most popular herbs: ginseng, ginkgo and St. John's wort and their purported uses on the ten most commonly used search engines. The presence of technical quality criteria as well as potentially harmful statements (commissions) and vital information that should have been mentioned (omissions) was recorded.
Thirty-eight sites (25%) contained statements that could lead to direct physical harm if acted upon. One hundred forty five sites (97%) had omitted information. We found no relationship between technical quality criteria and potentially harmful information.
Current technical quality criteria do not identify potentially harmful CAM information online. Consumers should be warned to use other means of validation or to trust only known sites. Quality criteria that consider the uniqueness of CAM must be developed and validated.
PMCID: PMC1550600  PMID: 15249270
Quality; harm; Internet; medical information; World Wide Web; complementary and alternative medicine
19.  Comparative survey of Complementary and Alternative Medicine (CAM) attitudes, use, and information-seeking behaviour among medical students, residents & faculty 
There is significant and growing national interest for introducing Complementary and Alternative Medicine (CAM) instruction into allopathic medical education. We measured CAM attitudes, use, and information-seeking behaviors as a baseline to evaluate future planned CAM instruction.
Cross-sectional and longitudinal survey data on CAM attitudes, modality use, and common information resources was collected for (a) medical students (n = 355), (b) interns entering residencies in medical and surgical disciplines (n = 258), and (c) faculty from diverse health professions attending workshops on evidence-based CAM (n = 54). One student cohort was tracked longitudinally in their first, second and third years of training.
Compared to medical students and interns, faculty who teach or intend to integrate CAM into their instruction had significantly (p < .0005) more positive attitudes and used CAM modalities significantly (p < .0005) more often. Medical students followed longitudinally showed no change in their already positive attitudes. The 3 survey groups did not differ on the total number of CAM information resources they used. Each group surveyed used about two out of the five common information sources listed, with the Internet and journals most frequently cited.
Students, interns and a selected faculty group demonstrate positive attitudes toward CAM and frequently use various CAM modalities. CAM instruction should therefore be focused on acquiring knowledge of available CAM modalities and skills to appraise evidence to appropriately advise patients on best approaches to CAM use. Trainees may benefit from exposure to a wider array of CAM information resources.
PMCID: PMC1702344  PMID: 17156463
20.  Chiropractic treatment of lumbar spinal stenosis: a review of the literature☆ 
The objective of this article was to review the literature on the use of chiropractic for the treatment of lumbar spinal stenosis.
A literature search was conducted on 4 electronic databases (Medline, Index to Chiropractic Literature, Cumulative Index to Nursing and Allied Health Literature, and Allied and Complementary Medicine Database) for clinical research pertaining to chiropractic treatment of lumbar spinal stenosis. Retrieved articles were hand searched for relevant references. Inclusion criteria consisted of any clinical study design (including case reports) using chiropractic care on patients with lumbar spinal stenosis published in English in the past 25 years.
Six articles on a total of 70 patients met the inclusion criteria for the review. These articles included 4 case studies, a case series, and an observational cohort study. Treatments included spinal manipulation and, most often, flexion-distraction manipulation. Numerous other interventions including exercise, activity of daily living modifications, and various passive care modalities were selectively used in the included studies.
There is a paucity of evidence available with respect to chiropractic treatment of spinal stenosis. The limited evidence that is available points toward chiropractic care being potentially beneficial in the treatment of patients with lumbar spinal stenosis, but further clinical investigations are necessary.
PMCID: PMC2780929  PMID: 19646390
Spinal stenosis; Chiropractic; Manipulation, Spinal; Review literature
21.  The use of CAM and conventional treatments among primary care consulters with chronic musculoskeletal pain 
BMC Family Practice  2007;8:26.
Chronic musculoskeletal pain is the single most cited reason for use of complementary and alternative medicine (CAM). Primary care is the most frequent conventional medical service used by patients with pain in the UK. We are unaware, however, of a direct evidence of the extent of CAM use by primary care patients, and how successful they perceive it to be.
Aims and objectives
To determine CAM use among patients with chronic musculoskeletal pain who have consulted about their pain in primary care.
Study design
Face-to-face interview-based survey.
Three general practices in North Staffordshire.
Respondents to a population pain survey who had reported having musculoskeletal pain in the survey and who had consulted about their pain in primary care in the previous 12 months as well as consenting to further research and agreeing to an interview. Information was gathered about their pain and the use of all treatments for pain, including CAM, in the previous year.
138 interviews were completed. 116 participants (84%) had used at least one CAM treatment for pain in the previous year. 65% were current users of CAM. The ratio of over-the-counter CAM use to care from a CAM provider was 3:2. 111 participants (80%) had used conventional treatment. 95 (69%) were using a combination of CAM and conventional treatment. Glucosamine and fish oil were the most commonly used CAM treatments (38%, 35% respectively). Most CAM treatments were scored on average as being helpful, and users indicated that they intended to use again 87% of the CAM treatments they had already used.
We provide direct evidence that most primary care consulters with chronic musculoskeletal pain have used CAM in the previous year, usually in combination with conventional treatments. The high prevalence and wide range of users experiences of benefit and harm from CAM strengthen the argument for more research into this type of medicine to quantify benefit and assess safety. The observation that most users of conventional medicine also used CAM suggests a continuing need for more investigation of effective pain management in primary care.
PMCID: PMC1878478  PMID: 17480212
22.  Evaluating the prevalence, content and readability of complementary and alternative medicine (CAM) web pages on the internet. 
Complementary and alternative medicine (CAM) use is growing rapidly. As CAM is relatively unregulated, it is important to evaluate the type and availability of CAM information. The goal of this study is to deter-mine the prevalence, content and readability of online CAM information based on searches for arthritis, diabetes and fibromyalgia using four common search engines. Fifty-eight of 599 web pages retrieved by a "condition search" (9.6%) were CAM-oriented. Of 216 CAM pages found by the "condition" and "condition + herbs" searches, 78% were authored by commercial organizations, whose pur-pose involved commerce 69% of the time and 52.3% had no references. Although 98% of the CAM information was intended for consumers, the mean read-ability was at grade level 11. We conclude that consumers searching the web for health information are likely to encounter consumer-oriented CAM advertising, which is difficult to read and is not supported by the conventional literature.
PMCID: PMC2244422  PMID: 12463909
23.  Complementary and Alternative Medicines Use during Pregnancy: A Systematic Review of Pregnant Women and Healthcare Professional Views and Experiences 
Aims. To undertake a systematic review of the recent (2008–2013) primary literature, describing views and experiences of CAM use during pregnancy by women and healthcare professionals. Method. Medline, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Review Library and Allied, and Complementary Medicine Database were searched. Studies reporting systemic CAM products (homeopathic preparations, herbal medicines, Vitamins and minerals, homeopathy, and special diets) alone or in combination with other nonsystemic CAM modalities (e.g., acupuncture) were included. Results. Database searches retrieved 2,549 citations. Removal of duplicates followed by review of titles and abstracts yielded 32 relevant studies. Twenty-two reported the perspectives of women and their CAM use during pregnancy, while 10 focused on healthcare professionals. The majority of studies had significant flaws in study design and reporting, including a lack of appropriate definitions of CAM and associated modalities, absence of detailed checklists provided to participants, the use of convenience sampling, and a general lack of scientific robustness in terms of data validity and reliability. Conclusion. To permit generalisability of study findings, there is an urgent need to expand the evidence base assessing CAMs use during pregnancy using appropriately designed studies.
PMCID: PMC3806151  PMID: 24194778
24.  Decision-making about complementary and alternative medicine by cancer patients: integrative literature review 
Open Medicine  2014;8(2):e54-e66.
Patients with cancer consistently report conflict and anxiety when making decisions about complementary and alternative medicine (CAM) treatment. To design evidence-informed decision-support strategies, a better understanding is needed of how the decision-making process unfolds for these patients during their experience with cancer. We undertook this study to review the research literature regarding CAM-related decisionmaking by patients with cancer within the context of treatment, survivorship, and palliation. We also aimed to summarize emergent concepts within a preliminary conceptual framework.
We conducted an integrative literature review, searching 12 electronic databases for articles published in English that described studies of the process, context, or outcomes of CAM-related decision-making. We summarized descriptive data using frequencies and used a descriptive constant comparative method to analyze statements about original qualitative results, with the goal of identifying distinct concepts pertaining to CAM-related decision-making by patients with cancer and the relationships among these concepts.
Of 425 articles initially identified, 35 met our inclusion criteria. Seven unique concepts related to CAM and cancer decision-making emerged: decision-making phases, information-seeking and evaluation, decision-making roles, beliefs, contextual factors, decision-making outcomes, and the relationship between CAM and conventional medical decision-making. CAM decision-making begins with the diagnosis of cancer and encompasses 3 distinct phases (early, mid, and late), each marked by unique aims for CAM treatment and distinct patterns of informationseeking and evaluation. Phase transitions correspond to changes in health status or other milestones within the cancer trajectory. An emergent conceptual framework illustrating relationships among the 7 central concepts is presented.
CAM-related decision-making by patients with cancer occurs as a nonlinear, complex, dynamic process. The conceptual framework presented here identifies influential factors within that process, as well as patients' unique needs during different phases. The framework can guide the development and evaluation of theorybased decision-support programs that are responsive to patients' beliefs and preferences.
PMCID: PMC4085086  PMID: 25009685
25.  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.
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.
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 ( and CAMRESEARCH ( These engines were used to reveal publications that at the time of the review were not indexed in PubMed.
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%).
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

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