Volume 7, Issue 1, February 2015, Pages 76–84
A Special Issue: Traditional and Integrative Approaches for Global Health
Review article
Defining integrative medicine in narrative and systematic reviews: A suggested checklist for reporting ☆
Abstract
Introduction
The
use of the term integrative medicine (IM) is evolving over time but its
exact definition remains imprecise. In this paper we use IM to mean
complementary and alternative medicine (CAM) provided holistically and
in conjunction with conventional medicine. Drawing from the experience
of experts in different geographical areas (USA, UK, Australia, and
China), this review aimed to identify key elements which could be used
to define IM in order to develop a potential guide for reporting IM in
clinical research.
Method
A
total of 54 sources were searched (including websites of governments,
key authorities, representative clinical sites, academic journals,
relevant textbooks) to identify definitions of IM from the four
countries from 1990 to 2014. Key elements characterizing IM were
extracted and categorized using a thematic approach in order to identify
the key items to consider when reporting IM in research studies.
Results
Seventeen
definitions were identified and extracted from 17 sources. The
remaining 37 sources did not provide a definition of IM. The most common
key elements which defined IM were: using aspects of both CAM and
conventional medicine; goals of health and healing; holistic approach;
optimum treatment; and the body's innate healing response. Integration
was also defined at three levels: theoretical, diagnostic and
therapeutic. A potential checklist of items is proposed for reporting IM
in clinical studies.
Conclusion
This
paper identifies the key elements which define IM and provides a
potential reporting guide for IM clinical trials and which could be used
in narrative/systematic reviews. Further debate, discussion and input
is now needed from the research and clinical IM communities to further
advance this agenda.
This article belongs to the Special Issue: Traditional and Integrative Approaches for Global Health.
Keywords
- Integrative medicine;
- Definition;
- Cross-cultural;
- Reporting guidelines;
- Checklist;
- Systematic review
Introduction
The
term integrative medicine (IM, also called integrative/integrated
healthcare) is frequently used in different healthcare sectors/systems,
education, research, and clinical practice. There is no standard
definition. The terminology has evolved over the last 20 years from
“unconventional medicine” to “holistic”, to “complementary and
alternative medicine (CAM)”, reflecting the dynamic state of this field.
The term IM, is often used for example in palliative care. For this
paper, IM was considered as a holistic approach that involves CAM.
In
western countries, various IM practices are emerging, with current
literature focusing on IM models and strategies for integration within
health care settings and systems [3], [4] and [5].
In the West, the clinical evidence for IM consists largely of studies
of individual CAM practices. However, the research evidence on the
effectiveness of IM provided as a package of care is limited due to its
complex nature and definition, lack of standardization and challenges in
methodological design [6], [7], [8], [9] and [10].
IM in the west has generally been an ad hoc development, which has been
gradually emerging and is available in different forms and in different
settings.
In the UK,
healthcare is provided by the National Health Service (NHS). Integration
within the NHS is unusual although many patients choose to use CAM
privately alongside their conventional NHS care [11] and [12].
For example, in the primary care setting there are three forms of IM:
referral between the primary health care team and local CAM
practitioners; CAM practitioners working directly within the same
setting as the primary health care team; or a primary health care team
member with training in CAM, such as acupuncture [13] and [14].
In the secondary care setting, there may be statutory registered health
professionals who have undertaken additional training in a CAM
modality, such as in the clinical delivery at the Royal London Hospital
for Integrated Medicine [15], where autogenic training is provided [16].
In
the US, the National Institutes of Health (NIH)’s started an Office of
Research on Unconventional Medical Practices which subsequently became
the Office of Alternative Medicine (OAM) in 1992. It changed to the
National Center for Complementary and Alternative Medicine (NCCAM) in
1998; as of 2014, its new name is – the National Center for Research on
Complementary and Integrative Health (NCRCI) [17]).
Initially, the OAM focused on practices not typically taught or
provided in conventional medical settings, and not covered by most
insurance. Over time, as CAM therapies were integrated into curricula,
care, and insurance plans, this definition has proved problematic. For
example, by 2005, acupuncture was offered in over 1/3 of academic
pediatric pain programs in North America [18]. Professional organizations have developed interest groups or committees focusing on CAM since 1990s [19], [20] and [21].
In primary care and in various specialty settings, a combination of
biomedical and mental health care is regarded as IM. There are many
similar examples which focus on using treatments in parallel or in
combination. Such approaches consider patients’ needs and require
careful coordination, such as: nutrition (e.g. prenatal vitamins are
universally recommended; folate supplements being advised for use by
pregnant women; older adults are advised to take vitamin D), and
therapies routinely provided in a rehabilitation setting such as
acupuncture and physiotherapy, etc. Insurance coverage and licensure for
chiropractic is universal in all US states. Professional licensing has
also grown; acupuncture is licensed in over 85% of US states, and
naturopathic physicians are licensed in 19 states, districts and
territories in the US. In 1999 NCCAM funded 14 training programs at
medical schools and teaching hospitals [22].
By 2013, over 20 family medicine residency programs offered tracks in
IM and, in 2014, five pediatric residencies began offering similar IM
training programs. Meanwhile the formation of the Consortium of Academic
Health Centers for Integrative Medicine was founded at the most recent
turn of the century with 8 centers, and has grown to include over 54
North American programs and centers [23].
In
Australia, the integration of some CAM within conventional medical and
healthcare settings remains largely ad hoc and informal [24], despite interest in CAM amongst some GPs, midwives and other health professionals [25]. Recent research suggests referral networks and communications between doctors and CAM practitioners are still often poor [26].
However some health professionals, midwives and nurses in particular,
do appear to be engaging in direct integrative practice whereby they are
trained and practicing another therapy [27].
IM
in China always refers to the integration of Traditional Chinese
Medicine (TCM) and Western medicine. The Chinese integrative health care
system was purposively created and promoted by Mao Zedong in 1956, “to
integrate the knowledge of Chinese medicine and materia medica with the
knowledge of western medicine and pharmacology, to create our unique
new medicine and new pharmacology” [28].
Subsequently, integration developed within education, licensing,
clinical practice, research and policy. It is embedded in Chinese
culture as it is a part of a long-term policy in China and is
extensively used throughout China. Both TCM and Western medicine are
regulated and supported by the Chinese government and national funding
executive agencies. They coexist and share methods of diagnosis and
treatment based on both TCM and Western medicine theories [28].
Due to its political stance, IM in China has been a planned
development, rather than growing organically as in the west. In China,
IM is actively practiced in the Chinese medicine departments in western
medicine hospitals, all departments of Chinese medicine hospitals, as
well as all departments of integrative medicine hospitals for various
conditions [29]. China is the only country with medical licensing in IM, allowing clinicians to practice both conventional and TCM [28].
In most cases, the same clinician can provide both an IM diagnosis and
treatment using the knowledge from both disciplines. They also have
opportunities to cross refer to multidisciplinary collaborative teams as
a result of the unifying paradigm which is shared jointly with other
clinicians.
Problems emerge when trying to identify and synthesize studies on IM [6] and [10].
A wide range of search terms are necessary to identify all potential IM
studies due to the absence of standardized terminology or a recognized
definition of IM. The lack of a shared conceptual framework and taxonomy
for IM models is also problematic. There are further challenges due to
differences between countries and manuscripts published in different
languages, often extensive work is required in order to identify search
terms and synthesize findings [10].
Difficulties include the fact that many studies are not labeled as IM
so may not be captured in searches using IM keywords or MeSH terms; and
many studies purport to be ‘IM’ but this may not be the case [6] and [10].
These
problems have been previously identified for complex interventions,
suggesting it is not useful or problematic to conduct systematic reviews
for such interventions [6]. A realistic review, explaining rather than judging and using qualitatively narrative synthesis, may be more appropriate [6].
This paper reports results from such a qualitative narrative review of
IM definitions in literature from the US, UK, Australia, and China and
aims to identify the key elements of defining IM. Rather than attempting
to review all examples of IM worldwide it provides a starting point to
begin to explore the issues faced when synthesizing IM research and
practice for research purposes.
Various
checklists for researchers and reviewers have been developed to enhance
the quality of reporting in clinical studies, e.g. Consolidated
Standards of Reporting Trials (CONSORT) [30] and the Consolidated criteria for reporting qualitative research (COREQ) [31].
However, many of these checklists may not be suited to complex
interventions such as IM. Some extensions have already been developed to
adapt these checklists for alternative interventions, such as Standards
for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA)
[32] and the complex interventions extension for CONSORT [33].
The second purpose of this paper was to begin to develop a guide for
reporting IM (along the lines of CONSORT), which could be further
developed for research purposes.
