Evaluating CAM Therapies: Tools for Better Care
BOSTON – Learning how to evaluate complementary and alternative medical (CAM) therapies can empower healthcare providers to deliver better integrative care and increase patient satisfaction with the U.S. healthcare system, according to several speakers at the 2014 National Association of Pediatric Nurse Practitioners Annual Conference.
“When it comes to CAM and natural health products, most healthcare providers have a don't ask don't tell relationship with their patients,” Emily Guttierrez, MSN, RN, C-PNP, and DNP candidate at Johns Hopkins School of Nursing in Baltimore, said at the meeting. “Patients fear judgment and assume that healthcare providers don't have knowledge of these products, so they go to friends, family and the internet, and come to us least for information.”
Approximately 12% of children and 38% of adults have used some form of CAM in the past year, data from the 2007 National Health Interview Survey (NHIS) indicate, and as many as 31% of children have used a natural health product, findings from the 2013 National Health and Nutrition Examination Survey show.
Natural health products consist of vitamins, minerals, homeopathic medicines, herbal medicines, probiotics, amino acids and essential fatty acids and make up about 75% of all CAM use, Guttierrez explained.
It is not uncommon for children and their caregivers to turn to these options to help treat conditions ranging from allergies to lactation disorders.
Identifying which patients are most likely to use CAM and familiarizing yourself with validated resources to evaluate alternative therapies are good starting points to open up the discussion, Kimberly Erlich, RN, MPH, CPNP, MPHS, of Sutter Health Mills-Peninsula Health Services in San Mateo, Calif., suggested.
In pediatrics, CAM use is greater among white adolescents aged 12–17 years vs. younger children of black or Hispanic ethnicity, according to NHIS data. Children whose parents have a greater than high-school education level and whose parents use CAM are also more likely to use alternative therapies, as are children with six or more health conditions and those who delayed conventional care because of cost.
In terms of evaluating CAM, Erhlich recommended the German Commission E Monographs, which includes information on use, side effects and known drug interactions for more than 200 herbs as the “gold standard.”
Other reputable sources include the U.S. National Center for Alternative and Complimentary Medicine (NCCAM), an arm of the National Institutes of Health formed in 1999 to rigorously evaluate the safety and efficacy of CAM therapies. NCCAM's Herbs at a Glance website and Clinical Practice Guidelines, a collection of practice guidelines and literature reviews from third party organizations, are particularly useful.
“I don't recommend any CAM to any patients unless it's been evaluated by someone other than the manufacturer,” Erhlich said.
Clinicians should also be aware of weaknesses in CAM research, including lack of a unified definition of what constitutes CAM, lack of randomized trials and small patient population due to sparse economic incentives to develop treatments that are not FDA-regulated or patent eligible.
When researching CAM, Erhlich recommends taking five factors into consideration -- ask is the information authentic, true and correct, up-to-date, comprehensive and impartial. She also emphasized looking for studies that compare a defined dose of a single herb to a defined dose of a standard drug and placebo controlled studies.
Additionally, having conversations with patients about herbal health products and CAM may help uncover health issues a patient may have failed to mention during routine examination.
“If a patient is using an herbal health product to boost the immune system, ask them, ‘What about your immune health am I not aware about?',” Guttierrez said. “This becomes an opportunity to collaborate with families and really provide integrative care.”
- Erhlich K, Guttierrez E, Willis MW. #306. “Clinical Round-Up: Demystifying Complementary and Alternative Therapies.” Presented at: 2014 National Association of Pediatric Nurse Practitioners Annual Conference. March 11-14, 2014; Boston.