When a whole practice model is the intervention: developing fidelity evaluation components using program theory-driven science for an integrative medicine primary care clinic

Protocol for a scoping review of traditional medicine research methods, methodologies, frameworks and strategies

Background

The World Health Organization (WHO) has called for the evidence-informed integration of traditional medicine (TM) into health systems. Research rigor requires a good "fit" between research designs and what is being studied. The expectation that TM research fully adheres to biomedical evidentiary norms potentially creates tensions, as TM paradigms have their own distinct features. A scoping review will be conducted to describe and characterize the research approaches used in TM and their paradigmatic alignment with the TM being studied.

Methods

This scoping review protocol was informed by Joanna Briggs Institute (JBI) methods. This protocol outlines an a priori conceptual framework, provisionally termed "paradigmatic alignment." The review will include all populations, TM types, research approaches (i.e., methods, methodologies, frameworks, strategies), cultural contexts, and health care settings. Up to 38 English and non-English language databases will be searched sequentially for both published and gray literature until reaching data saturation across relevant concepts and contexts. Analysis will begin deductively, using a pre-piloted data extraction template to describe the TM research approaches. A basic qualitative content analysis of a sample of evidence sources will explore how research approaches are applied or modified to align with the TM therapeutic paradigm, and the manner in which they co-exist, contrast, complement or align with established biomedical research approaches. The findings will be narrated and summarized in charting tables and figures. The review will be reported according to the PRISMA scoping review extension. Consultative engagement with knowledge users across all review stages is planned.

Discussion

Aligned with the principle of Two-Eyed Seeing (Etuaptmumk), wherein Indigenous/traditional and biomedical knowledges may equitably co-exist, this review promises to advance scholarly insights of critical value in an increasingly pluralistic, globalized world.Clinical trial registration: https://clinicaltrials.gov/, identifier INPLASY2023110071.

Real-World Evidence from the Integrative Medicine Primary Care Trial (IMPACT): Assessing Patient-Reported Outcomes at Baseline and 12-Month Follow-Up

Purpose

The University of Arizona Integrative Health Center (UAIHC) was an innovative membership-supported integrative medicine (IM) adult primary care clinic in Phoenix, Arizona. UAIHC delivered healthcare using an integrative medicine model that combined conventional and complementary medical treatments, including nutrition, mind-body medicine, acupuncture, manual medicine, health coaching, educational classes, and groups. Results from pre-post evaluation of patient-reported outcomes on several standardized measures are presented here.

Methods

UAIHC patients completed surveys at baseline and after 12 months of continuous integrative primary care. Patients reported on perceived changes in health outcomes as measured by Short-Form Health Survey (SF-12 general, mental, and physical health), Perceived Stress Scale (PSS4), Work Productivity and Activity Impairment Questionnaire (WPAI), World Health Organization Well-Being Index (WHO-5), Pain Visual Analog Scale (VAS), Fatigue Severity Scale (VAS; FSS), Generalized Anxiety Disorder Scale (GAD2), Patient Health Questionnaire for depression (PHQ2), Pittsburgh Sleep Quality Index (PSQI) global rating of sleep quality, and the Behavioral Risk Factor Surveillance System (BRFSS; nutrition, exercise, and physical activity). Overall differences between time points were assessed for statistical significance. Patient demographics are also described.

Results

177 patients completed baseline and follow-up outcome measures. Patients were predominantly white, female, college-educated, and employed. Baseline to one-year follow-up results indicate statistically significant improvements (p <.05) on all but perceived stress (PSS-4) and work absenteeism (WPAI). Clinical impact and/or practical effects are reported as percent change or standardized effect sizes whenever possible. Other demographic and descriptive information is summarized.

Conclusions

Following one year of IM primary care at UAIHC, patient-reported outcomes indicated positive impacts in several areas of patients' lives: mental, physical, and overall health; work productivity; sleep quality; pain; fatigue; overall well-being; and physical activity.

Lessons from Outside and Within: Exploring Advancements in Methodology for Naturopathic Medicine Clinical Research

INTRODUCTION

Naturopathy is a mixture of both traditional and complementary medicine. It incorporates a broad set of health care practices that may or may not be traditional to that country or conventional medicine and are not fully integrated into the dominant health care system. Research required to evaluate or substantiate naturopathic medicine may not fall under the testing of randomized clinical trials, which opens up discussions on what is the best practice for research in naturopathic medicine.

DISCUSSION

Not only do advances in health research methodology offer important opportunities to progress naturopathic research, there are also areas where the unique characteristics of naturopathic philosophy and practice can impact other areas of health research. Some of the new advances in health research methodology involve whole-system research, pragmatic trials, template for intervention description and replication protocols for complex interventions, patient-centered care models, and the pragmatic-explanatory continuum indicator summary tool for designing pragmatic trials. Discussion and critique of these health-related methodologies shows that these research methods are more suited for the philosophy and treatment options that naturopathy is based on.

CONCLUSIONS

Successful implementation of naturopathic research methodologies, and translation and dissemination of research will require a substantial paradigm shift in which naturopathic practitioners adopt a greater level of responsibility for developing an evidence base for naturopathic medicine.

Integrative medicine primary care: assessing the practice model through patients' experiences

BACKGROUND

The University of Arizona Integrative Health Center (UAIHC) was an innovative integrative medicine (IM) adult primary care clinic in Phoenix, Arizona. UAIHC used a hybrid payment model to deliver comprehensive healthcare that includes conventional and complementary medical treatments.

METHODS

Fidelity measures were collected to evaluate how well the IM care delivery process matched ideals for IM. Patient experiences are presented here. Patients visiting UAIHC on 1 of 10 randomly selected days between September 2013 and February 2015 were surveyed. Patients were asked about their experience with: holistic care; promotion of health, self-care, and well-being; relationship and communication with practitioners; and overall satisfaction.

RESULTS

Eighty-three patients completed surveys. Based on patient-reported experiences, UAIHC delivered IM care as defined by the practice model.

CONCLUSIONS

Patients received holistic care, established positive caring relationships with providers who promoted their self-care and well-being, and reported high overall satisfaction with UAIHC.

Whole Medical Systems versus the System of Conventional Biomedicine: A Critical, Narrative Review of Similarities, Differences, and Factors That Promote the Integration Process

BACKGROUND

There is an increasing need for a worldwide professional integration of conventional medicine and traditional/complementary whole medical systems (WMSs). However, the integration is perceived by conventional medicine as problematic or unacceptable, because of a supposed lack of evidence for specific effects of WMSs therapies and supposed prescientific or unscientific paradigms of WMSs.

OBJECTIVES

To review the literature on the features of WMSs, similarities and differences between conventional medicine and WMSs, and scientific and clinical practice issues that should be dealt with in order to promote the integration process.

METHODS

A critical, narrative review of the literature on six WMSs.

RESULTS AND CONCLUSIONS

Key factors for the integration of WMSs and conventional medicine are as follows: legal frameworks, quality standards, high-quality research on safety and efficacy of WMS interventions, infrastructure, and financial resources. For scientific assessment of WMSs, there are unresolved ontological, epistemological, and methodological issues and issues of diagnostics, therapy delivery, and outcome assessment in clinical practice. Future research not only should be directed at quality assurance and generating the necessary data on safety and efficacy/effectiveness but also should address more fundamental (ontological, epistemological, and methodological) issues, in order to overcome the differences between WMSs and conventional medicine.

Process of care in outpatient Integrative healthcare facilities: a systematic review of clinical trials

BACKGROUND

Patients currently integrate complementary medicine (CM) and allopathic, choosing a combination of therapies rather than a single therapy in isolation. Understanding integrative healthcare (IHC) extends beyond evaluation of specific therapies to encompass evaluations of multidisciplinary complex interventions. IHC is defined as a therapeutic strategy integrating conventional and complementary medical practices and practitioners in a shared care setting to administer an individualized treatment plan. We sought to review the outcomes of recent clinical trials, explore the design of the interventions and to discuss the methodological approaches and issues that arise when investigating a complex mix of interventions in order to guide future research.

METHOD

Five databases were searched from inception to 30 March 2013. We included randomized and quasi-experimental clinical trials of IHC. Data elements covering process of care (initial assessment, treatment planning and review, means for integration) were extracted.

RESULTS

Six thousand two hundred fifty six papers were screened, 5772 were excluded and 484 full text articles retrieved. Five studies met the inclusion criteria. There are few experimental studies of IHC. Of the five studies conducted, four were in people with lower back pain. The positive findings of these studies indicate that it is feasible to conduct a rigorous clinical trial of an integrative intervention involving allopathic and CM treatment. Further, such interventions may improve patient outcomes.

CONCLUSIONS

The trials in our review provide a small yet critical base from which to refine and develop larger studies. Future studies need to be adequately powered to address efficacy, safety and include data on cost effectiveness.

Health Care Consumption during Pregnancy in relation to Maternal Body Mass Index: A Swedish Population Based Observational Study

OBJECTIVE

To assess whether antenatal health care consumption is associated with maternal body mass index (BMI).

DESIGN

A register based observational study.

METHODS

The Swedish Medical Birth Register, the Maternal Health Care Register, and the Inpatient Register were used to determine antenatal health care consumption according to BMI categories for primiparous women with singleton pregnancies, from 2006 to 2008, n = 71,638. Pairwise comparisons among BMI groups are obtained post hoc by Tukey HSD test.

RESULT

Obese women were more often admitted for in-patient care (p < 0.001), had longer antenatal hospital stays (p < 0.001), and were more often sick-listed by an obstetrician (p < 0.001) during their pregnancy, compared to women with normal weight women. Preeclampsia was more than four times as common, hypertension five times as common, and gestational diabetes 11 times as common when comparing in-patient care, obese to normal weight women (p < 0.001 for all comparisons). Underweight mothers had longer stay in hospitals (p < 0.05) and hydronephrosis and hyperemesis gravidarum were more than twice as common (both p < 0.001).

CONCLUSION

Obese and underweight mothers consumed significantly more health care resources and obese women were significantly more often sick-listed during their pregnancy when compared to pregnant women of normal weight.

IMPACT--Integrative Medicine PrimAry Care Trial: protocol for a comparative effectiveness study of the clinical and cost outcomes of an integrative primary care clinic model

BACKGROUND

Integrative medicine (IM) is a patient-centered, healing-oriented clinical paradigm that explicitly includes all appropriate therapeutic approaches whether they originate in conventional or complementary medicine (CM). While there is some evidence for the clinical and cost-effectiveness of IM practice models, the existing evidence base for IM depends largely on studies of individual CM therapies. This may in part be due to the methodological challenges inherent in evaluating a complex intervention (i.e., many interacting components applied flexibly and with tailoring) such as IM.

METHODS/DESIGN

This study will use a combination of observational quantitative and qualitative methods to rigorously measure the health and healthcare utilization outcomes of the University of Arizona Integrative Health Center (UAIHC), an IM adult primary care clinic in Phoenix, Arizona. There are four groups of study participants. The primary group consists of clinic patients for whom clinical and cost outcomes will be tracked indicating the impact of the UAIHC clinic (n = 500). In addition to comparing outcomes pre/post clinic enrollment, where possible, these outcomes will be compared to those of two matched control groups, and for some self-report measures, to regional and national data. The second and third study groups consist of clinic patients (n = 180) and clinic personnel (n = 15-20) from whom fidelity data (i.e., data indicating the extent to which the IM practice model was implemented as planned) will be collected. These data will be analyzed to determine the exact nature of the intervention as implemented and to provide covariates to the outcomes analyses as the clinic evolves. The fourth group is made up of patients (n = 8) whose path through the clinic will be studied in detail using qualitative (periodic semi-structured interviews) methods. These data will be used to develop hypotheses regarding how the clinic works.

DISCUSSION

The US health care system needs new models of care that are more patient-centered and empower patients to make positive lifestyle changes. These models have the potential to reduce the burden of chronic disease, lower the cost of healthcare, and offer a sustainable financial paradigm for our nation. This protocol has been designed to test whether the UAIHC can achieve this potential.

TRIAL REGISTRATION

Clinical Trials.gov NCT01785485.