Military Medicine 2011 (Jun); 176 (6): 685–688 ~ FULL TEXT
MAJ Susan George , MC USA ; COL Jeffrey L. Jackson , MC USA (Ret.); Mark Passamonti , MD
Department of Medicine,
Walter Reed Army Medical Center,
6900 Georgia Avenue NW,
Washington, DC 20307, USA.
Previous studies have found that complementary and alternative medication (CAM) use is common. We enrolled 500 adults presenting to a primary care military clinic. Subjects completed surveys before the visit, immediately afterwards, at 2 weeks, 3 months, and 5 years. Over 5 years, 25% used CAM for their presenting symptom. Most (72%) reported that CAM helped their symptom. Independent predictors of CAM use included female sex (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1-3.7), college educated (OR, 3.4; 95% CI, 1.8-6.3), more severe symptoms (OR, 1.14; 95% CI, 1.01-1.28), and persistence of symptom beyond 3 months (OR, 3.9; 95% CI, 2.0-7.5). We concluded that a quarter of military primary care patients use CAM over 5 years of follow-up and most find it helpful. CAM users tend to be female and better educated. Patients with more severe symptoms or symptoms that persist beyond 3 months are also more likely to turn to CAM.
From the FULL TEXT Article:
Complementary and alternative medicine (CAM) has been
defi ned as a group of diverse medical and health care systems,
therapies, and products that are not currently considered
to be part of allopathic medicine. The National Center for
Complementary and Alternative Medicine, a component of
the National Institutes of Health, recognizes 4 major domains
of CAM: mind–body medicine, body-based/manipulative
therapies, biologically based practices, and energy therapy,
in addition to whole medical systems that cut across several
domains.  The use of CAM has been increasing among the
general population. In a population-based survey, Eisenberg 
found that 34% of respondents used some form of CAM in
1991 increasing to 42.1% by 1997.  Another general population
survey in 2002 found that 62% of respondents used some
form of CAM. 
Most studies of CAM took 2 forms. They either ask questions
about CAM use in general over a specified period of
time or study CAM use for specific symptoms, such as tension 
and migraine headaches,  inflammatory bowel disease, 
arthritis,  back pain, 
HIV,  and cancer. 
Few studies focus on
internal medicine patients but none on military medicine beneficiaries.
A 2004 ambulatory internal medicine study found
that 48.2% of patients had used vitamins, herbal remedies, or
folk remedies in the past year  for any reason. The purpose of
our study was to evaluate the prevalence of CAM for a specific
presenting symptom in patients in a general internal medicine
clinic, assess the patient’s perspective on the efficacy of CAM
for their symptom, and determine clinical predictors of CAM
use in this cohort.
Consecutive adults (18 years or older) presenting to the primary
care walk-in clinic at Walter Reed Army Medical Center with
a chief complaint of a physical symptom were eligible to participate.
Of 528 patients approached, 500 agreed to participate.
Informed consent was obtained from all participating patients
and our Institution’s Review Board approved this study.
Immediately before their clinic visit, subjects completed surveys
that verified about their symptom characteristics (type,
duration, and severity), whether they were worried the problem
could be serious, whether they have been under stress in the
past week, and a 6-item functional status assessment from the
Medical Outcomes Study Short Form (MOS SF-6).  Patients
were also screened for mental disorders using the Primary
Care Evaluation of Mental Disorders (PRIME-MD) screening
questionnaire for depressive symptoms.  Somatization was
assessed using the Patient Health Questionnaire (PHQ), which
asks how much the patient has been bothered during the past
month by 15 common physical symptoms.  Clinicians completed
surveys assessing how difficult the patient was to work
with during the index visit using the Difficult Doctor Patient
Relationship Questionnaire. 
Immediately after the visit, satisfaction with the clinician in 5
domains (overall, technical competence, bedside manner, time
spent with the patient, and explanation of what was done) was
assessed with the clinician focused questions in the Medical
Outcomes Short Form instrument.  Patients were also asked
whether they were still worried that the symptoms could be
due to a serious medical problem and whether they had post-visit
unmet expectations from a check list (diagnosis, prognostic
information, prescription, diagnostic test, referral, or
other). Patients completed a mailed follow-up questionnaire
2 weeks, 3 months, and 5 years after the visit that assessed
symptom outcome, whether they had experienced stress in the
past week, whether they were worried the symptoms could
represent a serious illness, functional status (MOS SF6), satisfaction,
and unmet expectations (explanation of symptom
cause or prognosis, prescription, diagnostic test, referral, or
other). At 5 years, patients additionally completed the PHQ,
as well as symptom-related outcomes, including symptom frequency,
how disabling the symptom was, and whether they
had received an explanation for their symptoms.
To minimize recall bias, our follow-up questionnaires
specified the date of the index appointment, the name of the
clinician they saw, and the chief complaint for which they presented
using the same words the patient wrote on the initial
survey. Finally, subjects were asked at 5 years whether they
had used any complementary or alternative therapies for the
specific complaint for which they had originally presented. If
so, patients were asked to specify any used from a list including
chiropractic care, herbal remedies, copper, vinegar, dietary
supplements, electricity, salves, special diets, minerals, homeopathy,
acupuncture, spiritual healing/prayer, or other. If the
patients mentioned others, they were asked to specify what
specific therapy was used. If patients reported using CAM, they
were asked to rate the effectiveness of CAM on a 5-point Likert
scale (helped a lot, helped a little, neither helped nor harmed,
made symptom a little worse, or made symptom a lot worse).
The primary analysis was the use of CAM, and univariate
relationships were explored using the Student t test or the
Kruskall–Wallis signed rank test for continuous variables and
χ2 test for categorical variables (STATA; version 9.0, College
Station, Texas). Logistic regression models of predictors of
CAM use were built with initial variable selection on the
basis of earlier literature and univariate screening, and candidate
variables were selected based on p values less than
0.25. Regression model diagnostics, including goodness of fit,
assessment for confounding, colinearity, and linearity, were
based on the methods of Homser and Lemeshow. 
Among 500 participating patients, the average age at the index
visit was 54.5 years. Fifty-two percent of the patients was
female (Table 1), with similar proportions white and African
American patients (48% white and 45% African American).
One-third reported some college education. Mental disorders
were common, with 26% meeting criteria for major depression
(8%), anxiety (3%), or multi-somatoform disorder (7.8%)
at the time of index visit. Seventy-three participants (14.6%)
were active duty military subjects.
Patient chief complaints were collapsed into 14 categories,
with musculoskeletal symptoms reported most commonly
(Table I). Twenty-one percent had experienced their presenting
symptom less than 3 days, 55% less than 2 weeks, and
68% less than a month. Sixty-four percent were worried that
their symptom could represent a serious illness. We attained
92% follow-up at 2 weeks, 81% follow-up at 3 months, and
73% follow-up at 5 years. During the 5 years of follow-up,
there were 42 deaths (8.4%). By 2 weeks, 18% reported that
their symptom had resolved, increasing to 35% at 3 months
and 46% at 5 years. Active duty subjects were more likely to
experience resolution of their symptom at each time point.
At 5 years, 26% (83/326) of patients reported using CAM for
their presenting symptom. No specific symptom was more
likely to be treated with CAM than others.
The most commonly utilized CAM was
dietary supplements (27%), followed by
chiropractic care (21%),
minerals (21%), and
spiritual healing (16%).
There were a number of correlates with CAM use
(Table I), including being female, having at least some college
education, having a greater number of “other bothersome”
symptoms. In addition, patients who ranked their symptom
as more severe at the time of index visit, 2-week and 5-year
follow-up were more likely to use CAM. Patients who failed
to experience symptom resolution at 2 weeks, 3 months, or
5 years were more likely to try CAM for their specific symptom
Patients with worse functioning and lower satisfaction
were more likely to use CAM as were those with longer symptom duration at the index visit. Patients turning
to CAM were more likely to have been rated as “difficult” by
their clinician at the index visit. Active duty subjects were less
likely to use CAM (27% vs. 22%, p = 0.03). On multi-variable
modeling, independent predictors of CAM use included being
female (odds ratio [OR], 2.0; 95% confidence interval [CI],
1.1–3.7), college educated (OR, 3.4; 95% CI, 1.8–6.3), more
severe symptoms (OR, 1.14; 95% CI, 1.01–1.28), and symptom
persistence or recurrence beyond 3 months (OR, 3.9; 95%
CI, 2.0–7.5). When adjusted for higher rates of symptom resolution,
there was no difference in the use of CAM for active
duty vs. nonactive duty subjects.
Among CAM users, 78% felt it was somewhat or very
helpful for their physical symptom (Figure 2). Twenty-one
percent felt that CAM neither harmed nor helped and 6%
felt that CAM made their problem somewhat worse. No one
reported that CAM made their symptom “much worse.”
In our study, one-quarter of the patients presenting to general
medicine clinic used some form of CAM for their specific
presenting physical symptom. This is lower than other studies
that asked questions about CAM use in general, rather than for
a specific symptom. [3–5, 9–11]
This is also lower than that found in
a general use questionnaire administered to active duty Navy
and Marine personnel  but similar to rates found in the military
millennium cohort.  Our findings are consistent with the
San Diego Unified Research in Family Medicine Network
(SURF*NET) study that found that 21% of family practice
patients had used CAM in the past year for their primary
health problem leading to their clinic visit, 
Our cohort is
also consistent with previous studies that have found a higher
prevalence of CAM use among women and those with better
education. Although CAM use was associated with a number
of variables, including longer symptom duration and severity,
greater numbers of symptoms, lower functional status,
and lower satisfaction, on multivariable analysis, independent
predictors of CAM use included female sex, college education,
more severe symptoms, and persistence of the symptom
beyond 3 months.
Our data have a number of important limitations. First,
although we had a good representation from whites and
African Americans, there were very few Hispanics or Asians
in our study population. These populations need further evaluation
in regard to their CAM use because previous studies
have shown that use of CAM is related to cultural and
health beliefs. [22, 23] In addition, our findings could be susceptible
to recall bias because we asked about CAM at 5 years
and not at the earlier intervals.
Also, our measure of effectiveness
of CAM for the specific symptom was a general
question about the patient’s perception of CAM effectiveness.
Controlled clinical trails of CAM effectiveness are still
lacking for most modalities and symptoms and need to be conducted.
Fourth, we did not narrow our symptoms to a specific
spectrum, resulting in few patients with some symptom categories.
Although this more clearly mirrors the patient population
seen in primary care, it limits our results. Finally, there
were too few subjects with any specific CAM modality to analyze
whether satisfaction or use of CAM varied by specific
type of CAM used or the type of symptom for which CAM
There are several strengths of our study. First, the large
size of the cohort and high follow-up rates at 5 years allow
for strong statistical correlations. Second, this study adds to
our understanding of CAM use in ambulatory medicine. Our
findings suggest that large proportions of general internal
medicine patients are using CAM for their presenting symptom,
emphasizing the need for internists to ask about CAM
use with every visit. Clinicians often do not ask about CAM
and patients frequently are not forthcoming, with nondisclosure
rates up to 72%. Patients often report lack of reporting
simply because their clinicians did not ask, amongst other
reasons like not feeling it was important for their doctor to
know.  In addition, our data show that certain subgroups have
higher rates of CAM use. Patients with more severe symptoms
and those with symptom persistence beyond 3 months
should particularly be questioned about CAM use by their
Alternative Medicine: Expanding Medical Horizons.
National Institute of Health.
Washington, DC , U.S. Government Printing Offi ce , 1992
Eisenberg DM, Kessler RC, Foster C, Morlock FE, Calkins DR, Delbanco TL.
Unconventional Medicine in the United States: Prevalence, Costs, and Patterns of Use
New England Journal of Medicine 1993 (Jan 28); 328 (4): 246–252
Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC.
Trends in Alternative Medicine Use in the United States, 1990 to 1997:
Results of a Follow-up National Survey
JAMA 1998 (Nov 11); 280 (18): 1569–1575
Barnes PM , Powell-Grinner E , McFann K , Nahin RL:
Complimentary and alternative medicine use among adults: United States, 2002.
Adv Data 2004 ; 343: 1–19.
Rossi P , Di Lorenzo G , Faroni J , Malpezzi MG , Cesarino F , Nappi G:
Use of complementary and alternative medicine by patients with chronic tension-type headache:
results of a headache clinic survey.
Headache 2006 ; 46 (4): 622–31.
Rossi P , Di Lorenzo G , Malpezzi MG , et al:
Prevalence, pattern and predictors of use of complementary and alternative medicine(CAM) in migraine
patients attending headache clinic in Italy.
Cephalgia 2005 ; 25 (7): 493–506.
Burgmann T , Rawsthorne P , Bernstein CN:
Predictors of alternative and complementary medicine use in inflammatory bowel disease:
do measures of conventional health care utilization relate to use?
Am J Gastroenterol 2004 ; 99 (5): 889–93.
Herman CJ , Allen P , Hunt WC , Prasad A , Brady TJ:
Use of complementary therapies among primary care clinic patients with arthritis.
Prev Chronic Dis 2004 ; 1 (4): A12.
Lind BK , Lafferty WE , Tyree PT , Sherman KJ , Deyo RA , Cherkin DC:
The role of alternative medical providers for the outpatient treatment of insured patients with back pain.
Spine 2005 ; 30 (12): 1454–9.
Fairfield KM , Eisenberg DM , Davis RB , Libman H , Phillips RS:
Patterns of Use, Expenditures, and Perceived Efficacy of Complementary and Alternative
Therapies in HIV-Infected Patients
Archives of Internal Medicine 1998 (Nov 9); 158 (20): 2257–2264
Shumay DM , Maskarinec G , Gotay CC , Heiby EM , Kakai H:
Determinants of the degree of complementary and alternative medicine use among patients with cancer.
J Altern Complement Med 2002; 8 (5): 661– 71.
Rhee SM , Vinod KG , Hershey CO:
Use of complementary and alternative medicines in ambulatory patients.
Arch Intern Med 2004 ; 164: 1004–9.
Ware JE , Nelson EC , Sherbourne CD , Stewart AL:
Preliminary tests of a 6-item general health survey: a patient application.
In: Measuring Functioning and Well Being: The Medical Outcomes Study Approach , pp 199–308.
Edited by Stewart AL , Ware JE.
Durham, Duke University Press , 1997.
Spitzer RL , Kroenke K , Williams JB:
Validation and utility of a self report version of the PRIME-MD: the PHQ primary care study.
Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire.
JAMA 1999 ; 282 (18): 1737–44.
Kroenke K , Spitzer RL , Williams JB:
The PHQ 15: validity of a new measure for evaluating the severity of somatic symptoms.
Psychosom Med 2002 ; 64 (2): 258–66.
Jackson JL , Kroenke K:
Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes.
Arch Intern Med 1999 ; 159 (10): 1069–75.
Rubin HR , Gandek B , Rogers WH , Kosinski M , McHorney CA , Ware
Patients’ ratings of outpatient visits in different practice settings. Results from the Medical Outcomes Study.
JAMA 1993 ; 270: 1449–53.
Hosmer DW , Lemeshow S:
Applied logistic regression. Ed 2.
Wiley Series in Probability and Statistics.
New York, NY , John Wiley and Sons , 2000.
Smith TC, Ryan MA, Smith B, et al.
Complementary and Alternative Medicine Use Among US Navy and Marine Corps Personnel
BMC Complement Altern Med. 2007 (May 16); 7: 16
Jacobson IG , White MR , Smith TC , et al:
Self-reported health symptoms and conditions among complementary and alternative medicine users
in a large military cohort.
Ann Epidemiol 2009 ; 19 (9): 613–22.
Palinkas LA , Kabongo ML:
The use of complementary and alternative medicine by primary care patients. A SURF*NET study.
J Fam Pract 2000 ; 49: 1121–30.
Lee GB , Charn TC , Chew ZH , Ng TP:
Complementary and alternative medicine use in patients with chronic diseases in primary care is associated
with perceived quality of care and cultural beliefs.
Fam Pract 2004 ; 21: 654–60.
Hsiao AF , et al:
Variation in complementary and alternative medicine (CAM) use across racial/ethnic groups and the
development of ethnic specific measures of CAM use.
J Altern Complement Med 2006 ; 12 (3):
Eisenberg DM, Kessler RC, Van Rompay MI, Kaptchuk TJ, Wilkey SA, Appel S.
Perceptions About Complementary Therapies Relative To Conventional Therapies Among Adults
Who Use Both: Results From A National Survey
Annals of Internal Medicine 2001 (Sep 4); 135 (5): 344–351
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