CAM practices in practice

National efforts emphasize more integrative approach to medicine

In September, Neal Halfon, MD, MPH, of the University of California, Los Angeles, and colleagues published data from a survey indicating that one in three well-child visits lasts no more than 10 minutes.

The data on about 1,600 parents, which were taken from the 2000 National Survey of Early Childhood Health, showed that about one-third of parents reported spending no more than 10 minutes on a well-child visit, 47.1% spent 11 to 20 minutes, and 20.3% spent more than 20 minutes.

Lawrence D. Rosen, MD, who is the Chair of the AAP Section on Complementary and Integrative Medicine, told Infectious Diseases in Children that he recently read this study and was struck with one thought: “We can do better. When we are talking about 10 minutes being spent on well-child care, I think that shows we have lost a lot of what makes us special as pediatricians. Where we excel, what we are best at is supposed to be health care promotion, but it is impossible to do that in 10 minutes.”

Rosen said there are a number of issues that are expected to be covered in the well-child visit, from assessing developmental milestones to promoting healthy behaviors, such as emphasizing the importance of a well-balanced diet and vitamin supplementation where appropriate. Rosen also said he understands the problems pediatricians face in addressing these issues. Many are challenged with ever-growing client bases and rapidly dwindling profit lines due to low reimbursement rates for immunizations and other services. However, a federal program that emphasizes altering practices into “patient-centered medical homes,” which emphasize a proactive approach to health maintenance, may offer some solutions to those challenges.

Although some pediatricians may find it too time-consuming to change their practices to take more of an integrative approach, or even dismiss some of these approaches as “pseudoscientific,” a panel of complementary and alternative medicine (CAM) experts at the AAP National Conference and Exhibition said integrating these CAM techniques may be less difficult than clinicians think, and there are sound, evidence-based reasons to do so.

Getting started

“In integrative medicine, a lot of what we focus on as clinicians is nutrition, fitness, sleep or relaxation,” Rosen said. “The challenge is: Are we working within a system that emphasizes true well care, and if not, how do we go about changing that or working within that system?”

Designating a practice as a patient-centered medical home may be a good start, he said. Using this model, which is being championed at the federal level as a part of the Affordable Care Act, more practices are emphasizing an integrative approach to wellness as part of their regular visits.

The program also emphasizes “compassionate, culturally effective care,” Rosen said, which is particularly appropriate for pediatricians who work with a wide range of cultures and generations of families.

According to Rosen, the key components of this medical home model include: 1) care is available through scheduling; 2) the office offers several options for communication; and 3) there is at least one primary person focused on this type of care in the office. The value, Rosen said, in going through the application process to be designated a patient-centered medical home is that reimbursement rates may actually go up in these practices.

Gregg C. Lund, DO, MS, who is with the department of osteopathic manipulative medicine at Touro University in Vallejo, Calif., said before considering incorporating more integrative options into a practice, it is important to first consider overarching goals.

“You must know your goals. Are they philosophy, profit, competition, or are you just hoping for a change in specialty or lifestyle?” Lund asked the audience at the AAP meeting. “Identifying the goal will affect how you develop your plan to integrate these modalities.” Regardless of the goals, having a good plan for integration based on principles just as they would use in any other part of their practice is important.

Next, Lund said, it is important to consider how clinicians would incorporate these methods into their own practice.

“Will you train a current practice member to do CAM therapies, or will you hire a new member who is familiar with these techniques? Will you share space with a practitioner, or will you just refer?” he said.

“To make the most of these referrals, talk to the clinician you are referring, ask questions about their practice and keep track of the patients who are referred to different clinicians. Also, these referrals can offer insight about modalities you may be evaluating for greater integration in your practice,” Lund said.

He said startup costs, potential profits, and liabilities are all factors that may influence a clinician’s decision to integrate CAM into his practice. It is also important to consider how the CAM modalities will be paid. Options to discuss include cash, insurance or a blend of the two. Additionally, the practice or institution may support the activities if the goals are primarily for philosophy or competition, where financial losses are offset.

Also, there is the issue to consider about whether a practice would sell CAM products. This is a difficult decision, Lund said, because similar to vaccines, there may be liabilities and costs that surround stocking these type of products that could affect a product’s bottom line. Plus, there is the added concern about whether “you are going to be seen as a vitamin store if you sell something out of your office.”

CAM fits with pediatrics

Ali Carine, DO, who is in private practice in Columbus, Ohio, views selling CAM products out of her office much the same way that she views writing antibiotic prescriptions. “I wouldn’t just tell my patient: ‘Go to the pharmacy and pick any antibiotic off the shelf and use it.’ And I don’t want to do that with my probiotics either,” she said.

Carine, who is in her 10th year of practice, said she views integrative medicine as a natural fit for pediatric practices because “children need to see medicine and their health from a preventive, holistic approach.”

She adopted the medical home care model and delivers primary care, osteopathic treatments, as well as autism care, and is able to successfully juggle all these roles by carefully planning her day, incorporating her office staff where possible and appropriate. She said there are several advantages of integrating CAM modalities into a private office: “Ownership provides a potential for more income, but it comes with more work. You have far more flexibility to make adjustments as they are needed, and no one tells you how to see patients or forces particular treatment algorithms on you.”

However, the disadvantage, Carine said, is that reimbursement rates are not the same as in hospital-managed practices, mainly due to lack of bargaining power.

Timothy Culbert, MD, who is the medical director of integrative pediatrics programs at Ridgeview Medical Center in Chaska, Minn., said that it is difficult to break-even doing only inpatient integrative pediatrics work, “but it is a great patient satisfier and also offers market differentiation. Studies also support that health care consumers want complementary options along with conventional medicine for their kids, even kids with serious illness,” he said.

In planning for these types of programs, Culbert said it is key to identify the stakeholders, including oncology, neurology, nursing and other hospital units, and also clarify overall values of the program.

According to Culbert, there are three strong arguments for incorporating an integrative medicine program into a hospital. The first argument is the business case, which means that consumers want it, and it adds value by creating alternative revenue streams and provides a good marketing tool for the hospital. He cited survey data that included 1,003 parents, many of whom had children with serious illnesses, and two-thirds wanted access to integrative medicine modalities.

“They wanted to go to a hospital that offered CAM and traditional medicine, and they wanted them combined. Yet, many hospitals don’t offer it,” Culbert said.

The second argument is the medical case. There are good data demonstrating certain supplements and other modalities are effective for patients. He said one study demonstrated that patients who had access to CAM-based pain management had a significant reduction of pain scores, about 1.9 on a scale of 1 to 10.

The third argument in favor of such programs, Culbert said, is the ethical one.

“We are charged with taking care of all types of people, and there are certain demographics, like Native Americans, Latinos and other groups, who very much appreciate non-drug approaches to treatment,” he said. “As stewards of health care, we should consider all cost-effective alternatives for our patients.”

Interpretation of data

Culbert said another study showed that many children — between 4% and 30% — were using at least one type of CAM, and 75% of parents believed they had no potential adverse events or interactions with prescription medication. This should serve as a reminder to pediatricians to ask about CAM use during every visit, he added.

“One problem identified was that doctors don’t bring up the topic of CAM often at visits. At the same time, studies suggest that over 50% of people stated they don’t bring up use of CAM with their doctor (or their child’s doctor) for fear of being criticized,” Culbert told Infectious Diseases in Children.

Cora Collette Breuner, MD, MPH, who is professor of pediatrics and adolescent medicine at Seattle Children’s Hospital, said asking about CAM can be done on the patient form that is completed while the patient is in the waiting room. However, it is important to ask again during the visit because parents of patients will sometimes forget or may even be embarrassed to admit they are using a certain CAM modality.

“You want to ask your patients and their parents if they are taking supplements or seeing alternative practitioners. This should be done in the same manner as asking whether they are up-to-date on vaccines,” Breuner said.

Communication is important

She also advises pediatricians to communicate with other health care providers in the community who may be seeing their patients because it will provide some additional insights on treating the patient. Plus, there is the added benefit of picking up additional patients.

Breuner also said she makes an effort to work with osteopathic and naturopathic students. “We have to shift this culture from mistrust to collaboration.”

Pediatricians should consider providing as much data as possible on these modalities for their patients. She said this is particularly important because respiratory infection season is beginning in the United States.

Often, parents will ask about echinacea for prevention or intervention for the common cold, Breuner said, but there are no data to support this. Results of a 2003 study from researchers at the University of Washington noted that echinacea does not make a difference in the length or severity of febrile URI in children.

However, for patients with complaints of irritable bowel syndrome, studies have shown success for other CAM treatments. Kline and colleagues compared enteric peppermint capsules with placebo in children with irritable bowel syndrome and noted a 75% improvement in symptom scores. Breuner said, however, that it is important to remember infantile apnea may present when peppermint is applied under or in the nose, and heartburn and mild rectal burning may be an adverse effect.

Breuner also cited a study that showed in four of six randomized controlled trials, ginger was superior over placebo in reducing pregnancy-related nausea and vomiting.

Editorials and meta-analysis published in Pediatrics on probiotics showed that in a review of 11 randomized controlled trials of 2,176 infants less than 34 weeks’ gestation, oral probiotics reduced all-cause mortality and necrotizing enterocolitis by more than half.

Other studies have also shown success with probiotics and antibiotic-associated diarrhea.

Where to apply

Rosen told pediatricians that it is one thing to incorporate and discuss these modalities in the office, but it is another to be designated a patient-centered medical home. He said those clinicians who are interested in this process can find more information through the National Committee for Quality Assurance (NCQA).

According to materials from the NCQA’s website, patient-centered medical homes organize care around patients and work in teams to coordinate, track and improve care. That means:

• Patients have long-term partnerships with clinicians, not a series of sporadic, hurried visits.
• Clinician-led teams coordinate care, especially prevention and chronic conditions.
• Medical homes coordinate other clinicians’ care and community supports, as needed.
• Medical homes offer enhanced access through expanded hours and online communication.
• The medical team promotes shared decisions, so patients make informed choices and get better results.

Rosen said the key to being a patient-centered medical home is recognition.

“It is nice to call yourself a medical home, but to be accredited is where the third-party payers recognize you,” he said.

Many will offer financial incentives for this designation because there is demonstrated cost-savings with a patient-centered home model. Rosen cited several studies out of Geisinger Health System in Pennsylvania that demonstrated savings of about $200 per patient when a hospital adopted integrative modalities into their programs.

The process is labor-intensive because there are several markers that must be demonstrated, and startup costs can be high. The NCQA’s website, at www.ncqa.org/tabid/1432/Default.aspx, is a good place for find additional information, he said.

Rosen closed the AAP presentation with one comment: “While we may adopt these models and integrate these into our practice, we have to start asking ourselves whether people in this country really want a health care system that emphasizes wellness and prevention, because there are compromises that must be made. If people in this country are not willing to make the sacrifices necessary to improve their own health, that’s going to be a continuing challenge for all of us.” – by Colleen Zacharyczuk

For more information:

• Barrett B. Ann Intern Med. 2010;153:769-777.
• Breuner C. #S1132. Presented at: AAP National Conference and Exhibition; Oct. 15-18, 2011; Boston.
• Carine A. #H1070. Presented at: AAP National Conference and Exhibition; Oct. 15-18, 2011; Boston.
• Deshpande G. Pediatrics. 2010;125:921-930.
• Halfon N. Pediatrics. 2011;128:657-664.
• Kline RM. J Pediatr. 2001;138:125-128.
• Taylor JA. JAMA. 2003. 290:2824-30.
• Turner RB. N Engl J Med. 2005;353:341-348.

Disclosure: The researchers report no relevant financial disclosures.

What do you feel is the overall societal impact of broad-based legalized medical marijuana?

It is important to advocate for scientific studies on the role of cannabinoids in medical treatment.

Medical marijuana is not a new drug; it has been available since ancient times in China, Egypt and Greece, and was commonly used throughout the 19th century as a pain reliever before the discovery of aspirin. There are several FDA-approved uses for prescription synthetic cannabinoids, such as dronabinol, which has been used in pediatric settings to alleviate nausea and vomiting from cancer chemotherapy. Cannabinoids have also been studied for use in conditions such as glaucoma, multiple sclerosis and neuropathic pain.

Cannabinoids have not been shown to be safe or effective when delivered in smoked form. Preparations are not standardized, contaminants and adulterants may be present, and there is no reason to believe that marijuana smoke is any less toxic than tobacco smoke.

Medical marijuana is not held to the same high standards of safety and efficacy applied to other prescription drugs and, in fact, remains largely unregulated. In 2004, the AAP issued a statement that backed “rigorous scientific research regarding the use of cannabinoids for the relief of symptoms not currently ameliorated by existing legal drug formulations.”

Furthermore, marijuana use has been shown to have adverse effects on adolescent brain development and to contribute to morbidity and mortality from traffic crashes and other risk behaviors.

It is also important to consider the overall impact that legalizing medical marijuana has on our adolescent patients. There are now 16 states that allow prescription of medical marijuana, leading to the teen’s view that it’s a legitimate, safe and effective drug. Data from the past 35 years clearly demonstrate that as the teenager’s perception of risk decreases, marijuana use increases.

As pediatricians, I think it is important for each of us to learn the current legal status for both medical and recreational use of marijuana in our home state, to advocate for rigorous scientific study of the role of cannabinoids in medical treatment and to share evidence-based anticipatory guidance with our young patients and their parents.

John Kulig, MD, MPH, is a pediatrician and director of adolescent medicine at the Floating Hospital for Children at Tufts Medical Center in Boston. He was the speaker at the AAP’s National Conference and Exhibition in 2011 at a presentation titled, ”Is Marijuana Really Medicine and a Harmless Drug?” Disclosure: Dr. Kulig reports no relevant financial disclosures.

I have my concerns that we are allocating our resources in the wrong places.

There are no questions about marijuana’s detrimental effects on young children and adolescents. However, when you consider what happened during Prohibition, and the fact that crime went up tremendously during that era, it is not entirely out of the possibility to consider that gang-related violence that we see over drugs are somewhat parallel to that seen during Prohibition.

Although I agree that there are much better medications with less harmful effects for treating conditions such as glaucoma and nausea, I have my concerns that we are allocating our resources in the wrong places. This war on drugs doesn’t seem to be working, and so many people land in jail for minor marijuana infractions, that it seems we may want to place our efforts elsewhere. We need more intensive studies of medicinal uses of marijuana and better educational efforts to prevent drug abuse.

Heike Rolle-Daya, MD, is a pediatrician in private practice in Stoneham, Mass. Disclosure: Dr. Rolle-Daya reports no relevant financial disclosures.

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