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• NCCAM
  Guy A Chapman
  Published on: 23 November 2015
• Does CAM training for GPs really reduce healthcare costs?
  Christopher J. Sampson
  Published on: 23 November 2015

• Published on: 23 November 2015

  NCCAM

  • Guy A Chapman, Engineer

  CAM includes both complementary and alternative practices. Alternative practices, by definition, either have not been proven to work, or have been proven not to work. Complementary practices have always been mainstream and many are evidence-based. There is no sound scientific or medical justification for analysing the two together. Alternative practitioners may prefer them to be considered together, as this may provide...

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  CAM includes both complementary and alternative practices. Alternative practices, by definition, either have not been proven to work, or have been proven not to work. Complementary practices have always been mainstream and many are evidence-based. There is no sound scientific or medical justification for analysing the two together. Alternative practitioners may prefer them to be considered together, as this may provide a halo effect of legitimacy from being considered alongside obviously valid concepts such as diet and exercise, but in analysing the cost-effectiveness of these interventions it seems to me rather important to unpick the two.

  For example, any judgment of the validity of medical training in nutrition cannot possibly shed light on the validity of training in a refuted dogma such as homeopathy or reiki.

  It is plausible that autohypnosis may be able to materially benefit patients with anxiety disorders. It is wholly implausible that homeopathy would deliver any objectively provable benefit at all. To consider the two jointly, is to needlessly muddy the waters.

  The authors reference the US National Center for Complementary and Alternative Medicine (NCCAM), a body set up at the instigation of a pro- CAM legislator to investigate and produce evidence around CAM interventions.

  Dr. David Gorski has been looking closely at NCCAM for some years, along with several colleagues. They have noted that NCCAM has spent in excess of one billion dollars since its inception in 1993. To date, they have failed to validate a single alternative intervention. They have produced supportive evidence for massage therapy (which is scarcely controversial), but not for any of the alternative therapies tested - many of which are by now considered refuted though still doggedly promoted by believers.

  I would suggest the authors do their best in future to unpick the effects of legitimate and medically plausible complementary therapies, from those of alternative therapies. This will reduce the risk of their research being abused by advocates as support for therapies which, of themselves, have little or no provable validity.

  In the light of surveys showing that large numbers of doctors knowingly prescribe placebos, it would also be valuable to understand how many of the doctors using CAM therapies consider them to be valid interventions and administer them on that basis.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 23 November 2015

  Does CAM training for GPs really reduce healthcare costs?

  • Christopher J. Sampson, Health economist

  I read with interest the recent contribution from Baars and Kooreman [1]. The present study is a replication of a previous study, using a different data set, as described by the authors in their introduction. The 2012 study by Kooreman and Baars [2] garnered criticism from me and others [3-5]. Furthermore, the new study was also presented in an earlier form [6], and this also faced criticism [7,8]. Baars and Kooreman provid...

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  I read with interest the recent contribution from Baars and Kooreman [1]. The present study is a replication of a previous study, using a different data set, as described by the authors in their introduction. The 2012 study by Kooreman and Baars [2] garnered criticism from me and others [3-5]. Furthermore, the new study was also presented in an earlier form [6], and this also faced criticism [7,8]. Baars and Kooreman provided response to both of these at the time [9,10].

  The authors have heeded some, if not all, of the criticisms directed at their previous work. In particular, the authors' reporting of their results is somewhat more measured and the limitations of the analysis are more thoroughly presented. It is likely that selection into the two groups at least partially (perhaps fully) explains the observed differences in costs, and the authors are right to identify this as a limitation. The new analysis of mortality data is a welcome improvement.

  In addition to the limitations already outlined by critics of the previous publication - and by the authors themselves - it is unfortunate that the new analysis did not account for the hierarchical structure of the data, with patients clustered by GP practice. It appears that the authors were able to identify this source of clustering in their data, so it is disappointing that a multilevel model was not used to account for this potential source of bias (which might also explain part of the observed difference). It is also regrettable that the results of the log-linear regression of costs appear to have been misreported in Table 4 (Appendix 2).

  Baars and Kooreman's statement that they intend to carry out further analyses on this or similar data with more appropriate estimation strategies is encouraging. Such analyses are crucial due to the limitations of this study. The implementation of better estimation strategies, such as propensity score matching or (as the authors suggest) use of instrumental variables, will be an important part of this. I look forward to reading these potentially enlightening studies once completed.

  References

  [1] Baars EW, Kooreman P. A 6-year comparative economic evaluation of healthcare costs and mortality rates of Dutch patients from conventional and CAM GPs. BMJ Open 2014;4:e005332. doi: 10.1136/bmjopen-2014-005332

  [2] Kooreman P, Baars EW Patients whose GP knows complementary medicine tend to have lower costs and live longer. European Journal of Health Economics 2012;13(6):769-76. doi: 10.1007/s10198-011-0330-2

  [3] Sampson CJ, Whitehurst DGT, Street A. Do patients registered with CAM-trained GPs really use fewer health care resources and live longer? A response to Kooreman and Baars. Eur J Health Econ (2012). 13:769-776. European Journal of Health Economics 2013;14(4):703-5. doi: 10.1007/s10198-013-0466-3

  [4] van Erp P. Alternatieve huisartsen werken 15 procent goedkoper? Een verzinsel!. [Blog] Kloptdatwel? 2013. Available at: http://kloptdatwel.nl/2013/05/10/alternatieve-huisartsen-werken-15-procent-goedkoper-een-verzinsel [Accessed 3 Sep. 2014].

  [5] Sampson CJ, Whitehurst DGT, Street A. Bad science in health economics: complementary medicine, costs and mortality. [Blog] The Academic Health Economists' Blog 2013. Available at: http://aheblog.com/2013/06/05/bad-science-in-health-economics-complementary-medicine-costs-and-mortality [Accessed 3 Sep. 2014].

  [6] Kooreman P, Baars EW. Complementair werkende huisartsen en de kosten van zorg. Economisch Statistische Berichten 2014;99(4678):90-2.

  [7] Pomp, M. Reactie op: Complementair werkende huisartsen en de kosten van zorg. Economisch Statistische Berichten 2014;99(4679):125.

  [8] van Erp P. Verzekerde zorgkosten van pati?nten bij alternatieve huisarts. [Blog] Kloptdatwel? 2014. Available at: http://kloptdatwel.nl/2014/03/05/verzekerde-zorgkosten-van-patienten-bij-alternatieve-huisarts. [Accessed 3 Sep. 2014].

  [9] Kooreman P, Baars EW. Do patients registered with CAM-trained GPs really use fewer health care resources and live longer? A reply to Christopher James Sampson. European Journal of Health Economics 2013;14(4):707-8. doi: 10.1007/s10198-013-0475-2

  [10] Kooreman P, Baars EW. Reactie op: Complementair werkende huisartsen en de kosten van zorg (Naschrift). Economisch Statistische Berichten 2014;99(4679):125.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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