Medical Acupuncture
A Journal For Physicians By Physicians

Volume 14 / Number 1
"Aurum Nostrum Non Est Aurum Vulgi"

Medical Acupuncture At A Complementary
Medicine Clinic: A 2-Year Retrospective Study
Michael Fredericson, MD
Stephanie Pun
Lorene Nelson, PhD
David Speigel, MD

ABSTRACT
Background Complementary and alternative medicine (CAM) use has been increasing in the United States. Use of acupuncture in CAM settings is not well defined.
Objectives To evaluate the characteristics of patients in and referral patterns to an academic complementary medicine acupuncture clinic, and to delineate patient referral patterns.
Design, Setting, and Subjects Retrospective chart review of 181 consecutive patients seen for acupuncture treatment at the Stanford University Complementary Medicine Clinic from May 1998-June 2000.
Main Outcome Measures Demographics, usage, and referral patterns for acupuncture.
Results Patients were predominantly middle-aged (mean, 50 years), well-educated (35.3% with post-graduate degrees, 30.9% with college degrees), married (50.8%), white (69.1%), women (71.8%). A majority of patients were referred to the clinic through a specialty physician (49.2%); others were referred by a primary care physician (26.0%) or were self-referred (21.5%). Acupuncture treatments were covered by insurance for most patients (79.6%); self-referred patients were somewhat less likely to have insurance coverage for acupuncture (74.4%) than were physician-referred patients (80.9%). Referrals were most likely from physiatrists/ orthopedists (51.6%) and pain management specialists (23.6%). Chronic pain such as myofascial back pain, degenerative disk disease, and fibromyalgia were the most common complaints of patients who sought acupuncture treatment (79.0%). The majority of referrals for acute pain (58.3%) and chronic pain (51.4%) were received from specialty physicians, whereas those with medical conditions were more commonly self-referred (54.2%) or from a primary care physician (37.5%).
Conclusion Our findings suggested that a majority of patients seeking acupuncture in this CAM setting were middle-aged, educated, white women. Further research is warranted on its use in other settings.
KEY WORDS
Acupuncture, Academic Medical Centers, Pain, Referral Patterns, Complementary and Alternative Medicine

INTRODUCTION
The use of complementary and alternative medicine (CAM) increased in the last decade and will likely be more prevalent in coming years. A 1997 national survey found that 42.2% of US adults had used at least one form of CAM that year, up from 33.8% in 1990, and that 1 in 3 individuals seeking care from a physician also used an alternative therapy.1

Further evidence of the widespread use of CAM is revealed in physician attitudes and patient referral rates. A survey of adult primary care physicians found that two-thirds expressed moderate interest in using alternative therapies and nearly one-fourth reported using alternative techniques in their practices.2 Another study reported that 77% of surveyed physicians had referred patients to alternative health care providers at least once during the previous year.3 Common reasons physicians cite as prompting referrals to CAM providers are (1) patient’s lack of response to conventional treatment, (2) patient’s request or preference, (3) belief that a holistic (mind-body) approach to treatment may yield better results than conventional treatment approaches, and (4) belief that patients have a “non-organic” or “psychological” disease.2-4

Although insurance coverage of CAM therapies is still limited, insurers have been motivated by consumer demand to offer more extensive coverage. Some insurers have developed major medical plans that specifically include CAM coverage.5 CAM use would likely increase significantly with added insurance coverage.1

Existing research has shown that CAM users are generally younger or middle-aged, they are more educated and have higher incomes than non-users, and they tend to live in the West.1,2,4,6,7,9,11 CAM users are more likely to be women and less likely to be African-American than any other ethnicity.5,8,9,11 The most popular therapies are massage, chiropractic, hypnosis, biofeedback, herbal medicine, and acupuncture.2,6,10 The most common reasons for visiting a CAM provider are pain, back problems, anxiety, headaches, cancer, eating disorders, psychological disorders, other musculoskeletal disorders, and chronic illnesses.2,4,6,10,11
The studies cited above do not distinguish between modalities but rather treat CAM as a single entity. They do not identify the various demographic and usage patterns associated with each type of alternative therapy. Given the popularity of acupuncture among both patients and physicians, it is important to specifically examine the characteristics and medical complaints of acupuncture patients. Furthermore, although a number of medical centers have collaborated with CAM facilities or have clinics that provide CAM services within the hospital, few have been in operation long enough to assess the outcomes of their programs.5 We sought to provide information on usage patterns of acupuncture in an effort to inform other major medical centers that are considering establishing complementary medicine clinics.

METHODS
This study examined the demographic and usage patterns of acupuncture patients at the Complementary Medicine Clinic at Stanford University Medical Center over a 2-year period. Stanford University Medical Center is a tertiary care medical center that receives referrals primarily from the San FranciscoBay Area and throughout Cali-
fornia. The clinic is in a unique position among CAM facilities because it has provided acupuncture services alongside a major medical center for more than 2 years.
A retrospective chart review was conducted by 1 investigator (S.P.) for all 181 patients seen for acupuncture treatment at the Complementary Medicine Clinic between May 1998 and June 2000. During this period, there were 4 acupuncturists treating patients part-time: 1 physiatrist, 2 anesthesiologists, and 1 non-physician licensed acupuncturist. Intake sheets completed by patients on their 1st clinic visit provided information on date of birth, sex, education, marital status, type of referral, and specialty of referral (if applicable). Race/ethnicity information was gathered from the university registration database that lists all patients who are in the main hospital computer system. (Patients were not individually questioned regarding race/ethnicity.) The clinic’s insurance coordinator provided information about patients’ insurance coverage status.

RESULTS
The majority of patients were middle-aged, well-educated, married, white women (Table 1). Patients ranged in age from 17-94 years (mean, 50 years). A majority of patients were referred to the clinic through a specialty physician (49.2%); a substantial minority were referred by a primary care physician in internal medicine, family practice, or pediatrics or were self-referred. Acupuncture treatments were covered by insurance for most patients (79.6%). Self-referred patients were somewhat less likely to have insurance coverage for acupuncture (74.4%) than were physician-referred patients (80.9%) (Table 2).

Physiatry/orthopedics (51.6%) and pain management specialists (23.6%) most frequently referred for acupuncture. The other leading referral sources were from specialists in rheumatology (5.6%) and psychiatry (3.4%), with no other specialty providing more than 2.2% of the referrals to the clinic (Table 3).

Chronic pain such as myofascial back pain, degenerative disk disease, and fibromyalgia were the most common complaints of patients who sought acupuncture treatment (79.0%). Medical conditions such as hyperhydrosis and adverse effects from cancer therapies were also common reasons for treatment (11.6%). Treatment for acute pain such as muscle strains and back and neck pain was less frequent (7.7%). Psychiatric conditions such as depression and insomnia were the least common complaints treated (1.7%).

Men and women equally sought acupuncture treatment for similar conditions: 5.4% of women and 7.8% of men had acute pain; 76.2% of women and 80.4% of men had chronic pain; 21.5% of women and 15.7% of men had medical conditions; and 2.3% of women and 7.8% of men had psychiatric conditions. None of these differences was statistically significant.

The majority of referrals for acute pain (58.3%) and chronic pain (51.4%) were received from specialty physicians, whereas those with medical conditions were more commonly self-referred (54.2%) or from a primary care physician (37.5%) (Table 4).

DISCUSSION
Medical acupuncture is part of a wide range of services offered at this clinic including biofeedback, chi gung, hypnosis, mindfulness meditation, therapeutic cancer support groups, and therapeutic massage.

The demographic and usage pattern findings from this study support previously reported CAM data. Acupuncture patients seen at this clinic tend to be middle-aged white women with chronic pain, mirroring the demographics and usage patterns of CAM patients in general. The racial/ethnic distribution of patients, mostly whites with a significant proportion of Asians, is probably influenced by geography; the population of patients seen at this clinic reflects the racial/ethnic composition of the area.
Physicians from physiatry and orthopedic specialties referred the most patients, which likely contributed to the large numbers of patients with chronic pain due to musculoskeletal disorders. (One of the clinic’s acupuncturists also works in the Division of Physical Medicine & Rehabilitation at Stanford; 16.6% of the patients were direct referrals from his practice.)

A high percentage of patients had insurance coverage for acupuncture treatment. Insurance coverage for acupuncture was slightly lower among self-referred than physician-referred patients. During the same 2-year period, 48 patients contacted the clinic for acupuncture but declined treatment when their insurance carrier did not provide coverage. Thus, the data in this study did not accurately reflect the number of patients who would choose to receive medical acupuncture treatment; more extensive insurance coverage would likely increase the number of patients seeking such treatment.

CONCLUSION
This study was a limited retrospective chart review having a goal to provide descriptive information on patient demographics and referral patterns for medical acupuncture use within a major academic medical center. Further research is needed to examine these trends in other settings. In addition, further research is necessary to determine which diagnoses are best treated with medical acupuncture, either alone or in combination.

Acknowledgement
We thank RoseAnn Kushner and Kim Pryle for their assistance with data collection.

REFERENCES

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AUTHORS’ INFORMATION
Dr Michael Fredericson is Assistant Professor of Physical Medicine, Department of Orthopedics, Stanford University School of Medicine, and Attending Acupuncturist, Stanford Center for Integrative Medicine in Stanford, California.
Michael Fredericson, MD*
Stanford University Medical Center
Physical Medicine/Edwards Bldg, R-107B
Stanford, CA 94305
Phone: 650-498-4649 • Fax: 650-498-7546
E-mail: mfred2@leland.stanford.edu

Stephanie Pun is an undergraduate student in Biological Sciences at Stanford University in Stanford, California.
Stephanie Pun
P O Box 16425
Stanford, CA 94309
E-mail: sypun@stanford.edu

Dr Lorene Nelson is Associate Professor and Chief of the Epidemiology Division, Department of Health Research and Policy, at Stanford University School of Medicine in Stanford, California. Dr Nelson is an Epidemiologist and Statistician whose research focus is neurologic disorders.
Lorene Nelson, PhD
Associate Professor, Chief, Division of Epidemiology
Dept of Health Research and Policy
HRP Redwood Bldg, Room T216
Stanford University School of Medicine
Stanford, CA 94305-5405
Phone: 650-723-6854 • Fax: 650-725-6951
E-mail: lnelson@stanford.edu

Dr David Spiegel is a Psychiatrist and Associate Chair of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in Stanford, California.
David Spiegel, MD
Dept of Psychiatry and Behavorial Sciences
Stanford University School of Medicine
401 Quarry Rd, Office 2325
Stanford, CA 94305-5718
Phone: 650-723-6421 • Fax: 650-725-3762
E-mail: dspiegel@stanford.edu
*Send all correspondence and reprint requests regarding this article to Michael Fredericson, MD, at the address listed above.

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