WASHINGTON – Complementary and alternative therapies should be held to the same standards as conventional treatments, according to a new report from the Institute of Medicine.
“Complementary and alternative medicine [CAM] use is widespread and here to stay,” Stuart Bondurant, M.D., said at a press briefing sponsored by the institute. “The same rules should apply for testing of effectiveness and safety regardless of the origin, whether CAM or conventional medicine.”
Already, the use of CAM therapies in the United States is widespread and amounts to $27 billion a year in out-of-pocket costs by consumers, a figure that is comparable with the projected out-of-pocket expenditures for all U.S. physician services, the report said. In 1997, the total number of visits to CAM providers (629 million) outpaced the total number of visits to all primary care physicians (386 million), according to a survey from that year.
But despite the increases in the use of CAM services, few patients are disclosing their use of CAM therapies to their physicians. Less than 40% of CAM users told their physicians about their use of alternative therapies, according to surveys conducted in 1990 and 1997.
The IOM committee defined CAM broadly as encompassing “health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the dominant health system of a particular society or culture in a given historical period.” The committee's definition also states that CAM includes resources that patients perceive as being associated with positive health outcomes.
While the same principles should be used in evaluating both conventional and alternative treatments, some new testing methods may have to be devised for CAM therapies, said Dr. Bondurant, interim executive vice president and executive dean of Georgetown University Medical Center in Washington.
For example, randomized controlled trials might not be appropriate for all CAM treatments. However, other innovative designs include preference trials that include randomized and nonrandomized arms, observational and cohort studies, case-control studies, studies of bundles of therapies, studies that specifically account for placebo or expectation effects, and attribute-treatment interaction analyses.
The committee also recommended that physicians and other health care providers should be educated about CAM therapies. Medical schools should incorporate information about CAM treatment in their curricula and it should continue to be addressed in CME courses.
Training programs can incorporate CAM information in a way similar to how they have addressed areas such as geriatrics and HIV/AIDS over the last decade, said committee member Florence Comite, M.D., of Yale University, New Haven.
Licensing boards and accrediting and certifying organizations should set competency standards for the appropriate use of both conventional medicine and CAM, the committee said.
CAM practitioners also have a role to play by being trained as researchers. This approach would help to ensure that the research reflects the actual ways in which CAM therapies are used, the report said. CAM practitioners should also work to develop practice guidelines for CAM therapies, the committee recommended.
“The intent of the report is not to medicalize or co-opt CAM but to sustain the existing forms of validated CAM therapies whether integrated into conventional practices or continuing as freestanding approaches,” Dr. Bondurant said. “The committee urged that great care be taken to test CAM therapies in the ways that they are actually used.”
The report also addresses the area of dietary supplements by calling on Congress and other federal agencies to amend the Dietary Supplement Health and Education Act of 1994. The law should be changed to strengthen quality control, accuracy and comprehensiveness in labeling, enforcement actions for misleading claims, and consumer protection, the committee said.
The National Institutes of Health and the Agency for Healthcare Research and Quality requested the report.
The IOM report is available online at http://national-academies.org