Associate Professor Torkel FalkenbergLeader – R esearch Unit for Studies of Integrative Health Care,

Department of Neurobiology, Care Sciences and Societ y, Divisionof Nursing, Karolinska Institutet

Head of Research – The Vidar Institute Foundation

Integration of unconventionaltreatments in Health Services

MEDICINA INTEGRATA per la qualità di vita delle donne

”Our research aim is to contribute to integrativehealth care development based on a broadand multidisciplinary 'evidence house' whereresearch methods are triangulated to generateresults relevant for health sector reform andbest practice development…”

TM/CAM is widely and increasinglyused in all regions of the world

Populations usingtraditional medicinefor primary healthcare

Ethiopia

Benin

India

Rwanda

Tanzania

Uganda

Populations indev eloped countrieswho hav e usedcomplementary andalternative medicineat least once

Canada

Australia

France

USA

Belgium

Sources:Eisenberg DM etal.1998;Fisher P&Ward A, 1994;Health Canada,2001;World Health Organization,1998;and government reports submitted to WHO.

The herbal medicines market

0

1 000

2 000

3 000

4 000

5 000

6 000

1990 1991 1994 1996 1997 1998 1999 2000 2002

2 400

1 000

JapanJapan

92 184UK

5 400

860

USAUSA

Million USD

WHO, 2002

POST-MODERN MEDICINEsocial concerns and trends

for many patients, the process of care is as importantas the outcome;

the process of care can influence the outcomes ofcare, not only with respect to patient satisfaction butalso in terms of the patient’s state of health andeffectiveness of treatment;

modern medicine and complementary medicine canbe used together in what has been called’’integrative medicineintegrative medicine’;

that patients are more concerned about the risks ofmodern medicine than the medical establishmentwhich, until now, has emphasized the benefits.

JA Muir Gray. Evidence-based Healthcare. How to make health policy and management

decisions. Churchil l Liv ingstone. 2001.

Integrative Medicine (IM)

• An evidence-based approach integrating conventionalcare with complementary therapies

• Reinforces patient-provider partnership in health• Focuses on health and healing as well as disease and

symptomatic treatment

Trends:

- IM in conventional care settings and county councils- IM in medical education and university hospitals- IM in health care organisations and insurance plans

NCCAM/NIH 2010; Carlsson & Falkenberg 2007; Vohra et al 2005; Sipkoff 2005; Eisenberg et al2002; Wolsko et al 2002; Rees & Weil 2001; Landstingsförbundet 2001

United States> 400 programs for integrative medicine

Memorial Sloan-Kettering Cancer Center(Total Employees 7,953)

The Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center was established in 1999 tocomplement mainstream medical care and addressthe emotional, social, and spiritual needs of patientsand families

Research perspective

20 years ago: no academic infrastructure & scarce funding

Today: NCCAM >100 million USD/year

EU funded project: “CAMbrella”

6 professor CAM chairs in Germany

Osher Center Europe Karolinska Institutet

Raising campaign against CAM

Exploring Integrative Medicinefor Back and Neck Pain

On the integration of manual and complementarytherapies in Swedish primary care

Tobias SundbergPT, DO, MMedSc

Feb 12, 2010

Torkel FalkenbergAssociate professorMain supervisor

Per WändellAssociate professorSupervisor

Health Technology Assessment &Evidence Based Decision Making

Rawlins M. The Harveian oration of 2008. London: Royal College of Physicians

“Hierarchies of evidence should bereplaced by accepting - indeedembracing - a diversity of approaches.”

Sir Henry Rawlins, president NICE, UK

Sundberg et al 2007-2010

Health ServicesResearch

RandomisedClinical Trial

Focus GroupDiscussions

Cost-UtilityAnalysis

Triangulation of researchmethods

Towards a model for integrativemedicine in Swedish primary care

Sundberg et al 2007

Sundberg T, Halpin J, Warenmark A, Falkenberg TBMC Health Services Research 2007, 7:107

“Developing the IM model – what is an appropriateIM model for Swedish primary care?”

Study 1

Exploring Integrative Medicine forBack and Neck Pain – a pragmatic

randomised clinial pilot trial

Sundberg et al 2009

Sundberg T, Petzold M, Wandell P, Rydén A, Falkenberg TBMC Complementary and Alternative Medicine 2009, 9:33

“Implementing and testing the model.”

Study 2

Patients’ experiences and perceptionsof integrative medicine for

back and neck painAndersson S, Sundberg T, Johansson E, Falkenberg TSubmitted

“Patients’ perspectives – generating hypothesisof integrative care characteristics.”

Study 3

Andersson & Sundberg et al 2010

Integrative medicine for back and neck pain– exploring cost-effectiveness alongside a

randomised clinical pilot trial

Sundberg et al 2010

Sundberg T, Hagberg L, Wandell P, Falkenberg TSubmitted

Study 4

“Health economic evaluation.”

Sundberg et al 2007

Qualitative group basedaction research

Immersion/crystallization& research group consensus

Meeting notes, ongoingworking documents

Group reflection, refinementof strategi es and actions

Further data collection

Research group meetings,FGDs, seminars (CC, CT, RES)

- Processes- Structures- Outcomes

- Facilitators- Barriers- Strategies

Sundberg et al 2007

SFunding

IMproviders

IM clinicat PC unit

IM clinicdecentralized

Clin

ical

meeting

s

Ethical

clea

rance

Patient

group

Diagn

oses

Educatio

nal

semin

ars

Snowbal

lingfor

provid

ers

Logisti cs

Docu

men

tatio

n

Refer

rals

CTs

Referralnetwork

P

Results:Processes (P) and Structures (S)

Conventionalcare

MassageManip ther

ShiatsuAcupQigong

CTintegration(≤12 wks)

Plan

PrimaryCare Unit

?

Results:IM Model Outcome

Sundberg et al 2007

AdviceAnalgesics

Sick-leavePhysio

From To Percentunits

Percentunits

Integrative care

diff P, OR(95% CI)

Outcome From To

Conventionalcare

Sundberg et al 2009

Comparative effectiveness after 4 months:Change in use of analgesics and health care

Theme Integrative care combines valuable conv entional medicaldiagnosis with empowering self -help strategies

Categories Managementcharacteristics

Carestrenghts

Careweaknesses

Sub-categories

Specialist andreductionist

management(Conventi onal)

Health insuranceparadox

(Conventi onal)

Whole-personmanagement

(Complementary)

Valuable diagnosticsupport (Conventional)

Increased treatmentresponse and reduced

need f or analgesics(Complementary)

Indiv idual support,empowerment andself -help strategies

(Complementary)

Lack ofaccessibility time

and guidance(Conventi onal)

Financial andcollaborativ echallenges

(Complementary)

Andersson & Sundberg et al 2010

Sundberg et al 2010

Costs, gained QALYs, cost/QALY and likelihood of cost-effectiveness (%) for the IM model vs conventional care

Summary of results

Sundberg et al 2010

The IM model

The clinicalpilot trial

Patients’perspectives

Cost-effectiveness

Implications for research

Sundberg et al 2010

Challenges

Care vs Cure

If it works? (pRCT) vs How it works? (RCT)

Models of integration – assimilation or true

integration?

Evidence Based Medicine (EBM) definition

Breaking of the dominance of the pharmacological

model

Health Services Research

Multiple avenues to evidence

Reduce sick-leave?

Reduce drug utilisation?

Increase care giver andpatient satisfaction?

Increase patient safety?

Re

se

arc

hq

ues

tio

ns

Opportunities

Thank you for theattention!

torkel.falkenberg@ki.se