Room for improvement: complementary therapy users and the Australian health system

Integrating Traditional and Complementary Medicine Recommendations into Clinical Practice Guidelines for People with Diabetes in Need of Palliative and End-of-Life Care: A Scoping Review

Objectives: This study was conducted before an evidence review on Traditional and Complementary Medicine (TCM) to update the clinical practice guidelines (CPGs): "Deciding palliative and end-of-life (P/EoL) care for people with diabetes." The aim was to frame the PICO (population/problems, interventions/comparisons, and outcomes), ascertain their importance, and identify other modifying factors for grading recommendations. Design: A systematic scoping review mapped information about diabetes P/EoL problems and outcomes, TCM use, provision, benefits and risks, and stakeholder preferences and values. Thirteen electronic databases were searched in 2017/18 until no new information was identified. Relevant data were extracted, rated for quality, directness, and relevance, and synthesized using triangulation methods. Excluded was diabetes prevention or treatment, as this is not an important P/EoL problem. Results: Of the 228 included articles, except for diabetes P/EoL problems, insufficient direct evidence led to data being extrapolated from either adults with diabetes or any P/EoL diagnosis. The findings affirmed that caring for people with diabetes in need of P/EoL care is complex due to multiple fluctuating needs that are influenced by the P/EoL trajectories (stable, unstable, deteriorating, terminal, or bereaved), multimorbidity, and difficult-to-manage chronic and acute problems. The only problem specific to diabetes P/EoL care, was unstable glycemia. Over 50 TCM interventions commonly used by patients and/or provided by services were identified, of which, many might simultaneously address multiple problems and 18 had been appraised in systematic reviews. Physical and psychologic symptom reliefs were most often evaluated; however, these were only one aspect of a "good death." Other important outcomes were the quality and location of care, personal agency, relationships, preparations for the dying process, spirituality, and affirmation of the whole person. Other important modifying factors included opportunity costs, affordability, availability, preferences, cultural appropriateness, and alignment with beliefs about the meaning of illness and death. Conclusions: There is a role for TCM in the multidisciplinary holistic P/EoL care of people with diabetes. Due to the paucity of evidence specific to this population, the generalizability of some of these results is broader and the updated CPG will also need to consider indirect evidence from other patient groups. Along with recommendations about indications for TCM use, the CGP should provide guidance on ceasing unnecessary interventions, reducing polypharmacy and managing unstable glycemia is required. Before ceasing a TCM, a broader risk-benefit analysis is recommended, as unlike many conventional therapies, there may be multiple benefits warranting its continuation.

Interface, interaction and integration: how people with chronic disease in Australia manage CAM and conventional medical services

OBJECTIVES

To understand the extent to which conventional and complementary health care are integrated for CAM users with chronic conditions.

METHODS

In-depth interviews and a self-administered questionnaire were used to collect data on care-seeking, self-management and CAM use among people with type 2 diabetes and/or cardiovascular disease living in Victoria, Australia.

RESULTS

Many participants reported regular, frequent and long-term use of CAM therapies to maintain their health or assist in the management of their chronic condition. They generally managed the interface between convention and complementary health care on their own, as the perceived or expressed negative attitudes of some doctors, or the belief that the doctor did not need to know, were barriers to the disclosure of CAM use. For a smaller group, there was interaction between conventional and CAM providers, which limited the extent of uncertainty and conflicting information being (mis)interpreted by consumers.

CONCLUSIONS

Greater interaction between CAM and medical providers would be beneficial to consumers. Structural barriers, related to financing and service organization, need to be addressed. Attitudinal shifts of some health-care practitioners also need to be addressed, in the context of workforce development.

Perceptions of benefit of complementary therapy use among people with diabetes and cardiovascular disease

BACKGROUND

Little is known about why and how people with type 2 diabetes and cardiovascular disease (CVD) use CAM, or of the perceived benefits of CAM use. The CAMELOT study explored care-seeking, self-management, costs, barriers and benefits of CAM use among this population. We report here on CAM used for treatment of diabetes and CVD, and non-clinical outcomes of CAM use.

METHODS

Data were collected in 2009-2010 via in-depth interviews (n = 69) and a self-report questionnaire (n = 2,915) among people with diabetes and/or CVD, throughout an Australian state. Analysis included contingency tables, chi-square analysis and thematic coding of interview and long answer survey data.

RESULTS

CAM use was generally part of a multi-component approach to chronic condition management. Choice of CAM practitioners and products varied and included CAM not usually associated with diabetes or CVD treatment, such as massage or manipulative therapies (44%). Most survey respondents perceived that CAM consultations resulted in symptom relief, improved general health and increased knowledge, understanding and confidence in condition management. Few people reported that they experienced any side effects from CAM. Economic barriers were significant in limiting access to CAM.

CONCLUSION

More research is required to understand how the appropriate use and perceived benefits of CAM can be reinforced by stronger interaction or integration with mainstream health service delivery for chronic condition management and illness prevention.

Serious decisions: chronic conditions and choice of provider

People with chronic health conditions combine conventional medical care with different complementary and alternative medicine (CAM) therapies for varying reasons. The data on which we drew to elucidate this derive from a large mixed-methods study utilizing participant observation, in-depth interviews with 69 people with type 2 diabetes mellitus and/or cardiovascular disease (CVD), and interviews with 20 health care providers. Although integrative practices are increasingly common, people make clear choices about and trade-offs between conventional medical care and CAM, often using CAM and prescribed pharmaceuticals in tandem for different conditions and distinct purposes and outcomes. As we illustrate, some people perceived type 2 diabetes and CVD as "too serious" for CAM treatment, but concurrently, many turned to CAM providers in appreciation of the serious attention these providers paid to their health-related concerns.