Integration of Complementary and Alternative Care in Primary Health Care S. Joos International Congress for Integrative Health & Medicine June 2016 - Stuttgart

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Institute for General Practice and Interprofessional Care University Hospital Tuebingen Österbergstraße 9, 72074 Tuebingen Medical Director: Prof. Dr. med. Stefanie Joos

Agenda

• What is „primary health care“?

• CAM in primary health care - status quo in Germany

• Study findings

• Future challenges

University Hospital Tuebingen Institute for General Practice and Interprofessional Care S. Joos

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Helen, 38, presents with neck pain, mild headache for the past 3-4 months, works a lot with computers, much stress with her 2 children, no time for sports in the moment Since you are her GP for some years, you know that she is keen to explore 'natural' management of her symptoms. The further anamnesis and examination leads you to the diagnosis: Chronic neck pain with tension headache What treatment can you advise? Evidence-based recommendations: • pain killers (NSAR) • physical activity/exercise • manual medicine • acupuncture • Peppermint oil (headache) • relaxation techniques (headache)

What is Primary Health Care ?

University Hospital Tuebingen Institute for General Practice and Interprofessional Care S. Joos

Primary Health Care… … is based on practical, scientifically sound

and socially acceptable methods universally accessible to individuals and families […]

provided by a suitably trained workforce […] maximises individual self-reliance […] and involves collaboration with other sectors.

(Declaration of Alma-Ata, 1978)

General practitioners

www.woncaeurope.org

• Primary care management • Community orientation • Specific problem solving skills • Person-centred care • Comprehensive approach (health promotion and disease prevention)

• Holistic modelling (bio-psycho-social model)

→ General practitioners are key provider in PHC

Core competencies of general practice: defined by the European Academy of Teachers in General Practice

CAM work force

Professional groups in primary care providing CAM in Germany

• Physicians (additional qualifications in acupuncture, naturopathy, homeopathy, manual medicine)

• Heilpraktiker (= state licensed non-physician naturopaths without standardized educational curricula and competencies)

• Dentists • Nurses • Physiotherapists • Midwives • Dieticians usw.

→ multiprofessional field → lack of transparence → lack of cooperation

[Quelle: Gesundheitsberichterstattung des Bundes: www.gbe-bund.de]

Development of physicians with CAM qualification and „Heilpraktiker“

Reimbursement of CAM services in ambulatory care in Germany (statutory health insurance):

• Phytotherapeutics (limited to misteltoe, ginkgo, St. John's wort, flea seeds)

• Acupuncture (low back pain, knee pain)

• Manual medicine (limited over time)

• Physiotherapeutic interventions (limited over time)

• Homeopathy, osteopathy (limited to special contracts)

→ all other services/phytotherapeutics have to be paid out-of-pocket or by additional private insurances → not in accordance with scientific evidence and guidelines → much more physicians provide CAM in their practices

CAM reimbursement

GP Survey

Postal survey among 3.000 GPs in Germany (response rate: 50%) Questions: • Do you use CAM in your daily practice? • Which CAM methods do you use in practice? • What do you think about CAM?

Results • 60% of GPs use CAM

• 49% have a positive CAM attitude • 12% have a negative CAM attitude

Joos S, Musselmann B, Szecsenyi J. Integration of complementary and alternative medicine into family practices in Germany: results of a national survey. Evid Based Complement Alternat Med 2009; Mar 17

0% 20% 40% 60% 80% 100%

autohaemotherapy

homeopathy

manual medicine

acupuncture

phytotherapy

neural therapy

(very) frequent sometimes rare/never

Which CAM methods do you use in practice?

Joos S, Musselmann B, Szecsenyi J. Integration of complementary and alternative medicine into family practices in Germany: results of a national survey. Evid Based Complement Alternat Med 2009; Mar 17

GP Survey - results I

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358

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51 42 26 24

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50

100

150

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muscu

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pain

cold sy

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mental

illne

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gastr

oint. d

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malign

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sleep

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Indications for CAM use number of mentions/free text; max. 3 possible

*Joos S, Musselmann B, Szecsenyi J. Integration of complementary and alternative medicine into family practices in Germany: results of a national survey. Evid Based Complement Alternat Med 2009; Mar 17

GP Survey - results II

Are there differences between GPs using CAM vs. not using CAM?

Personal characteristics • younger, female, non-smoking, own use of CAM

Practice characteristics

• more privately insured patients

work load • less working hours/week, higher job satisfaction (only those with „positive attitude“)

Joos S et al. Use of Complementary and Alternative Medicine (CAM) in Germany – comparing characteristics and job

satisfaction of general practitioners BMC Complement Altern Med. 2011 Dec 19;11:131

GP Survey - results III

Question: • Which patients are seen by Heilpraktiker?

Methods: • cross-sectional study with patients of randomly selected GPs with and without CAM provision (CAM-GP vs. nCAM-GP) and Heilpraktiker (HPs) • questionnaire asking patients in the waiting rooms for health status, current symptoms (MYMOP-D) and more • 567 patients from 11 HPs, 15 CAM-GPs, 19 nCAM-GPs included

Results: Comparison of patients from HP vs. CAM-GPs vs. non-CAM GPs • HP patients higher educated and more often female

Krug K, Kraus K, Hermann K, Joos S. Complementary and alternative medicine (CAM) as part of primary health care in Germany – comparison of patients consulting general practitioners and CAM practitioners: a cross-sectional study (submitted)

Heilpraktiker vs. GP setting

0 5 10 15 20 25 30 35

General and Unspecified

Blood, Immune system

Digestive

Eye

Ear

Cardiovascular

Musculoskeletal

Neurological

Psychological

Respiratory

Skin

Endocrine/Metabolic/Nutritional

Urological

Female Genital

Social Problems

% of patients

HP CAM-GP nCAM-GP

n=567 patients

Reasons for consultation*

*patient reported reasons for consultation posthoc classified with the Internat. Classific. f.Primary Care (ICPC)

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0-4 weeks 4-12 weeks 3 months - 1 year 1-5 years > 5 years

% o

f pat

ient

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nCAM-GP CAM-GP HP

n=567 patients

Duration of symptoms

n=567 patients

Summary

• CAM well integrated in primary health care

• multiprofessional field with heterogeneous education/trainings

• strongly increasing numbers of qualificated CAM providers in the last 15 ys

• lack of reimbursement for evidence-based CAM

• 60% of GPs use CAM; only 12 % negative attitude

• Heilpraktiker see more patients with long-term symptoms and psychological problems compared to GPs

Future Challenges

• further rigorous research in primary care setting (incl. cost- effectiveness studies) to increase CAM evidence is needed

• for GPs: integrating CAM in postgraduate training

• for Heilpraktiker: starting to define competencies and developing standardized curricula

• promoting reimbursement of evidence-based therapies (implementation research in cooperation with insurances)

• improving interprofessional cooperation

• need of quality control (for health care and education)

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Thank you for listening! Contact:

stefanie.joos@med.uni-tuebingen.de

Institute for General Practice and Interprofessional Care University Hospital Tuebingen

Österbergstraße 9, 72074 Tuebingen