The Growth of Chiropractic and CAM

Two recent studies published in the Annals of Internal Medicine^1,2 go a long way in defining the current role of "complementary and alternative medical (CAM) therapies" in the United States. Each provides a look at CAM from a different perspective: that of the industry and that of the patient consumer.

History of Alternative Care

The first study reads like a history of alternative care. The study, conducted by the Harvard Medical School and Beth Israel Deaconess Medical Center, examines the growth of CAM from the 1930s through the 1990s.¹ The results are extremely encouraging.

First Time Users of a Particular CAM Therapy by Decade as Expressed in % Person Years This graph shows the changes in the first time users by decade for each form of alternative care. These changes are expressed in "% person years," a measurement that incorporates not only the number of new CAM users, but also the number of years in that decade that CAM use continued. Readers are encouraged to note the trends expressed by this data, rather than focus on the specific "% person years" for a particular form of care, as this value does not directly correlate to a particular percentage of the U.S. adult population.

The objective of the study was to focus on the trends for CAM use over the last 50 years. The authors also divided the respondents by age to determine if there was a difference between who was using alternative forms of care.

The authors used a telephone survey to interview a representative sample of 2,055 people. In addition to learning about their usage of alternative forms of care, the authors also gained information about the patients' gender, ethnicity, education and geographic location in the United States.

Age is an Issue

The respondents were divided into three groups:

• pre-baby-boomers - 54 years of age or older

   

• baby boomers - 34 to 53 years old

   

• post-baby-boomers - 18 to 33 years old

The results show that the younger you are, the more likely you are to use some form of alternative care, and that you will begin using it at a younger age. Using the age of 33 as the measuring point, the results showed that:

• 30% of pre-baby-boomers have used at least one form of CAM;

   

• 50% of baby boomers have used some form of CAM; and

   

• 70% of post-baby-boomers have used some form of CAM.

Once Tried, Do They Keep Using It?

An additional finding of the study had to do with the continued use of some type of CAM once a person had tried it. The results dispelled the myth that patients who try CAM tend not to continue its use:

Years Since First Use	Current Use (%) Among Users
1 - 4 years	60.2%
5 - 10 years	47.0%
11 - 20 years	48.8%
21 years or more	45.7%

First Use by Decade

Perhaps the most important findings relate to the "first use" of chiropractic and other alternatives forms of care. The investigators compiled a table that demonstrated the number of people who used a particular form of care for the first time in terms of percentage-person years for each decade. This data (see graph below) shows how different forms of care enjoyed greater or lesser popularity during particular decades.

It is important to note that there were "no statistically significant (0.05 level in two-sided tests) differences in trends were found for sex, race/ethnicity, education level, region of the country, or urbanicity."

Quotable Comments

The authors provide the following statements that you may find useful to remember and refer to:

"Subsequent analysis of lifetime use and age to onset showed that 67.7% of respondents had used at least one CAM therapy in their lifetime."

"Of respondents that ever used CAM therapy, nearly half continued to use many years later."

"These consistent and pervasive results should dispel any suggestion that use has increased for only singular complementary or alternative modalities, or that the use of CAM therapies is a passing fad associated with one particular generation or fringe segment of the population."

"This finding is consistent with the finding of a previous report that most CAM therapies are used, at least in part, to prevent future illness or to maintain health and vitality as part of lifestyle choices linked to the perceived value of disease prevention and health promotion."

"The trend of increased CAM therapy use across all cohorts since 1950, coupled with the strong persistence of use, suggests a continuing increased demand for CAM therapies that will affect all facets of health care delivery over the next 25 years."

Consumer Perceptions

The second study² looks at how the public uses and thinks about CAM vs. conventional medicine. The participants were 831 U.S. adults who saw both a medical doctor and a CAM therapist in 1997. This study was conducted by many of the same researchers that conducted the former study, using very similar methodology. These results are generalizable only to this point. They should not be interpreted to include consumers who only see an alternative care provider on a regular basis.

Using Both Is Better

When asked to compare and contrast alternative vs. conventional medicine, the results were definitely mixed:

• Only 29% agreed that "(a)lterna-tive therapies are superior to conventional therapies."

   

• 79% agreed that "(u)sing both conventional and alternative therapies is better than using either one alone [for your problems]."

   

• 49% agreed (vs. 47% who disagreed) that their alternative provider "spends more time with you than does your conventional medical doctor."

   

• 41% agreed (vs. 52% who disagreed) that their alternative provider "offers a more understandable and useful explanation of your medical problems than your conventional medical doctor."

   

• 42% agreed (vs. 56% who disagreed) that their alternative provider "is a better listener than your conventional medical doctor."

Half Visit MD First

Of those that saw both providers in 1997, 51.2% saw a medical doctor first, 18.5% saw both at the same time, and 15.4% saw their alternative care provider first. It would be interesting to test this again in 2002 (five years later) to see if there would be a trend toward more alternative care first visits.

Equal Confidence

When asked how much confidence consumers had in their conventional and alternative care providers, the responses were essentially even. As noted by the authors:

"Perceived confidence in CAM providers was not substantially different from confidence in medical doctors."

More Effective on the Top 10

When comparing the effectiveness of alternative forms of care on the 10 most commonly reported ailments, alternative care providers came out on top more often. (Please see the graph above) For those ailments with large enough responses, "CAM therapy" was considered better for back conditions, arthritis, headaches and neck conditions. Conventional medical care was considered superior for only hypertension.

Don't Ask, Don't Tell

Consumers are still not telling their medical doctors about their use of alternative care. Of those surveyed, 63% "did not disclose the use of at least one of their CAM therapies." The reasons why patients didn't disclose their use of alternative care was different than the reasons reported by some studies in the past:

• "It wasn't important for your (medical) doctor to know" - 60%

   

• "Your doctor never asked" - 60%

   

• "It was none of your doctor's business" - 31%

   

• "The doctor would not understand" - 20% - 34%, depending on the therapy

   

• "Your doctor would disapprove" - 14%

   

• "Your doctor would discourage you" - 14%

   

• "Your doctor might not continue as your provider" - 2%

Important Statements

Among many important comments made by the authors, these are the most notable:

"Regarding CAM therapies for specific medical conditions, we found that CAM therapies were perceived to be more helpful than conventional medical care for chronic, debilitating conditions such as headaches and neck and back conditions."

"Moreover, when patients choose not to tell their physicians that they use CAM therapies, they appear to be less concerned about their physician's disapproval than their physician's perceived inability to understand and incorporate CAM therapies into their overall medical management."

"Wolpe suggested that as a society, adults are not abdicating the role of modern biomedicine, but rather, are redefining biomedicine's responsibility within the larger model of health care delivery."³

"Collectively, these data suggest that many patients, in their capacity as consumers of care, view medical doctors as members of a larger, patient-selected health care team. Increasingly, medical doctors are being viewed as one of several professionals whom the average adult seeks for advice or treatment of health-related matters."

Strong Signals

These studies identify trends and consumer perceptions that send some strong signals:

• Consumers are increasingly using alternative care to address current ailments and improve overall health;

   

• Consumers are spending their own money for chiropractic and other forms of alternative care, and are becoming more responsible for choosing which care is most appropriate for them;

   

• This trend is taking place in all parts of our society and is growing;

   

• Younger people are driving this trend and are expected to do so well into the future; and

   

• Medical doctors are no longer the dictators of health; they are just another team member.

References

1. Kessler RC, Davis RB, Foster DF, Van Rompay MI, Walters EE, Wilkey SA, Kaptchuk TJ, Eisenberg DM. Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med 2001;135:262-268.
2. Eisenberg DM, Kessler RC, Van Rompay MI, Kaptchuk TJ, Wilkey SA, Appel S, Davis RB. Perceptions about complementary therapies relative to conventional therapies among adults who use both: Results form a national survey. Ann Intern Med 2001;135:344-351.
3. Wolpe PR. Alternative medicine in the social and historical context. Presented at Retreat on the Role of Alternative Medicine in the Academic Medical Center, 24 March 1999, Philadelphia, Pennsylvania.