MEDICAL OUTCOME RESEARCH AND ACUPUNCTURE

JAMES ROTCHFORD, M.D., M.P.H.

ABSTRACT -- This paper reviews the results of a pilot study surveying the outcomes obtained by physicians using acupuncture as adjunctive therapy in their practices.

INTRODUCTION
     Most physicians who practice acupuncture in the United States do so for pragmatic reasons: they have found it to be a therapeutic intervention that works well and with few side effects in those patients for whom Western orthodox treatments are either ineffective or otherwise unacceptable to the patient. These physicians know, however, that the mechanisms of action of acupuncture need to be unraveled and agreed upon, and that the need for serious and systematic investigation to accomplish this goal, is evident (1, 2, 3, 4, 5, 6, 7).
     The purpose of this study was to assess how acupuncture is associated with health outcomes. No other study in the English literature has determined "medical outcomes" associated with medical acupuncture. Support for looking at outcomes as a means of evaluating differences in systems of care, clinician specialty and clinician's technical and interpersonal styles, is provided by the Medical Outcome Study(MOS) (8, 9).
     In the MOS, the emphasis is placed on patient assessment of functioning and well being, allowing for a uniform approach when evaluating the outcomes of several medical conditions. This supports, in part, the long-held principle in clinical medicine of the importance of treating the patient and not the disease (10). In addition, measures of function and well being have been shown to predict health care expenditures and death (11, 12).
     In terms of the applicability of using the MOS to study the intervention of acupuncture, functional measures are widely used in evaluating therapy for painful conditions, and most acupuncture in this country is delivered for the treatment of pain. Therefore, it would seem an appropriate evaluative method to measure treatment response for conditions which are difficult to evaluate using a disease-specific model (13).

OBJECTIVES AND HYPOTHESIS
     The primary objective of the study was to evaluate the outcomes of medical acupuncture as an adjunct to medical therapy. The null hypothesis postulated that there was no statistically significant difference between the health of patients prior to receiving medical acupuncture and the health of those patients more than four weeks after therapy. No conclusions were drawn about the effectiveness of acupuncture as an adjunct therapeutic intervention, or about individual physician's success rates, given that case-mix control was absent, internal validity questionable without randomization, and further extrapolation of data was limited by the absence of strict diagnostic criteria.
     However, no other study has examined the medical outcomes of acupuncture using current health status assessment instruments, which are both valid and reliable such as the MOS short form health survey and the Wisconsin Brief Pain Inventory Questionnaire (WBPIQ) (14, 16).

METHODOLOGY
     Eight physicians, recruited from the membership of the American Academy of Medical Acupuncture, participated in the study: two from the state of Washington and one each from British Columbia, Illinois, New York, Oregon, Pennsylvania and Texas. Patients recruited from these physicians practices were enrolled in the study between April and July, 1990. Patients were selected among those having conditions for which they were intending to receive medical acupuncture, for which there was a known ICD-9-CM code, and for which acupuncture was being offered by the treating physician as an appropriate therapeutic modality. The condition for which they were seeking medical care had to be one never treated with acupuncture or at least not within the preceding three months.
     A total of 69 patients were enrolled in the study. A baseline questionnaire was administered to all patients, and a separate baseline questionnaire was administered to the physicians whose patients were enrolled in the study. A follow-up questionnaire was administered to physicians and patients four weeks following the initial treatment. Physicians were blinded to the patients responses. Another requirement was that patients had to be seen at least once during the four week period following the initial treatment. The number of acupuncture treatments and/or adjunctive therapies between the initial and the follow-up visit was left to the discretion of the treating physician. Eighty percent (80%) of the enrolled patients completed the four week follow-up visit and questionnaire. Eleven percent (11%) responded after receiving a follow-up letter or telephone call. The attrition rate was nine percent (9%).

MEASURES
     Health outcomes were measured using the MOS Short Form Health Survey and parts of the WBPIQ. The MOS form is a general health survey, which is comprehensive and psychometrically sound, yet short enough to be practical for use in large scale studies of individuals in an outpatient setting. The MOS has 20 questions in 6 different areas of health outcomes: physical function, role function, social function. mental health, health perception, and pain perception. Each area is given a score from 0 to 100, a higher score indicating better health. Patients with pain conditions were also assessed by the WBPIQ, which is a recognized valid and reliable measurement of pain. In the patients follow-up questionnaires there were eight additional questions to measure patient satisfaction, side effects and smoking habits.

OUTCOMES
     The median age of the patient population was 47, with a mean of 51. Fifty five percent (55%) were female. Seventy two percent (72%) of patients had a painful condition, and in twelve percent (12%) of the patients the condition was job-related. Fifty eight percent (58%) of the patients had their primary condition for more than six months. The mean number of patient visits during the study was 3.87, with a minimum of 1 visit and a maximum of 14 visits. The median number of days between the initial visit and the follow-up visit was 42 days.
     Physicians rated seventy two percent (72%) of the patients as improving markedly, while patients rated their primary condition as better or resolved in eighty three percent (83%) of the cases. Patients also rated acupuncture as very helpful in sixty eight percent (68%) of the cases. These findings were supported by significant differences between the baseline and follow-up health measures scores.

DISCUSSION
     As mentioned earlier, the design of the study does not allow for any final conclusion about the effectiveness of medical acupuncture. It does confirm, however, the clinical impression of a growing number of physicians that medical acupuncture works. In this small study, about eighty three percent (83%) of the patients rated their primary condition as better or resolved after an average of 3 visits to a physician acupuncturist. This reported improvement contrasts with an expected pIacebo effect in the usual 30-35 % range (15). The additional reported improvement falls close to the 50-80% improvement following acupuncture, reported in many studies (7, 17, 18, 19), reinforcing the conclusion of different investigators that acupuncture has at least beneficial effects on pain conditions.
     The results of this pilot study provide sufficient support for a larger study with a greater sample size. In addition, randomization and the introduction of a control group is highly desirable. It should be kept in mind that some difficulties may be encountered when randomizing office-based medical practices, since patients who seek private acupuncture treatments may not be agreeable to randomization. The solution may be to conduct studies at larger medical institutions interested in investigating safer, cheaper, and possibly more effective modes of therapy for a variety of common conditions presenting in clinical practice.
     Note: This paper is an abstract of an unpublished thesis by the author, completed during his tenure as a graduate student in the Department of Health Services at the University of Washington's School of Public Health, in Seattle.

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