Cambrella European Policy Brief: The Roadmap for European CAM Research

16 Pages·2012·0.35 MB·English

www.cambrella.eu
November 2012
European
Polic y Brief
The Roadmap for
European CAM Research
What is CAM?
“ComplementaryandAlternativeMedicine”(CAM)isanumbrellaterm
fortreatmentpracticesmainlyusedoutsideconventionalmedicine.
ThemostprominentCAMdisciplinesintheEUareherbalmedicine,
acupuncture,homeopathyandmanualtherapies(likemassage,osteopathy
andreflexology),butCAMalsoincludessuchpracticesasanthroposophic
medicineandnaturopathy.CAMispractisedmostlyinprivatepractice
bymedicaldoctorsandpractitionerstrainedinthespecificdisciplines.
The role of CAM in European healthcare
TheWHOglobalatlasoftraditional,complementaryandalternative
medicineconcludesthatCAMishighlyprevalentwithinEurope.Estimates
varyhighlyandgivearangeofbetween10%andover50%ofEuropean
citizenswhouseCAMfortheirhealthcareneeds.CAMisapopular
treatmentstrategyforchronicdiseases,diseasepreventionandhealth
management.Europeancitizensandpatientsperceiveitasahealth
approachthattreatstheirspecifichealthneedsinanindividualisedway,
whichtheyoftenmissinconventionalmedicine.

3 EUROPEAN POLICY BRIEF
The broad scope of CAM is reflected by
the pragmatic definition:
“ComplementaryandAlternativeMedicine(CAM)utilisedbyEuropean
citizensrepresentsavarietyofdifferentmedicalsystemsandtherapies
basedontheknowledge,skillsandpracticesderivedfromtheories,philo-
sophiesandexperiencesusedtomaintainandimprovehealth,aswell
astoprevent,diagnose,relieveortreatphysicalandmentalillnesses.
CAMhasbeenmainlyusedoutsideconventionalhealthcare,butinsome
countriescertaintreatmentsarebeingadoptedoradaptedbyconven-
tionalhealthcare.”ForschKomplementmed2012;19(suppl2).
The problems
– Thereisnoclearterminology–definitionsvaryanddifferfromone
languageandculturetoanother.
– RegulationsandlawsonCAMprovisiondiffergreatly–everymember
andassociatestate,sometimesevenregionswithinonememberstate,
hasdifferentrulesregardinguseandprovision.
– Allstakeholders,includingcitizens,patients,healthcareprovidersand
policymakers,lackaccesstoreliableinformationaboutCAM.
– Thereisalsoalackofreliableresearchdata:weknowfartoolittleabout
thesafetyandeffectivenessofmanyCAMtreatmentsandtheirpossible
cost-benefitinclinicalpractice,nordowehaveaccesstoepidemiological
factssuchastheprevalenceofCAM.Thisappliesalsotothebasicresearch
intotheworkingmechanismsofCAMprocedures.
– CAMisstillnottakenseriouslybyanumberofmedicalscientistswho
regarditasanirrationalapproachtohealthcare;thisviewissharedby
partsofthepublic.
CAM research: more EU focus required
ThereisconsiderableheterogeneitywithinCAMintheEUandalackof
reliabledataonallitsaspects:definitions,use,provision,education,
legislation,regulation,safety,andasregardstheclinicaltopicsofefficacy
andeffectiveness.ItisvitaltoobtainarobustpictureofCAMuseand
reliableinformationaboutitscost,safetyandeffectivenessinrealworld
settings.Thisreportsummarisesthekeydatathathavebeenidentified
bytheresearchprogramme,andfinisheswitharoadmapforfuture
researchintoCAMandaseriesofrecommendations.
www.cambrella.eu
4 EUROPEAN POLICY BRIEF
Key findings: The citizens’ perspective
Itwasonlypossibletostudy18ofthe39memberstatesandassociated
countries,duetoalackofdataintheremaining21.Substantialresearch-
basedknowledgeabouttheneedsofcitizenswithrespecttoCAMis
availableprimarilyfromtheUK.Nevertheless,thefollowingtendencies
canbereported:
Citizens in the EU wish to have access to increased and diverse CAM
provision StudiesindicatethatcitizenswishCAMtobeavailableaspart
oftheirnormalhealthcare,forexampleinhospitalandgeneralpractice
care.TheyalsowishCAMprovisiontobedeliverednotonlybymedical
doctorsand/ordoctorstrainedinCAMspecialities,butalsobyCAM
providerswiththerapyspecifictraining.Thereisawishformore,and
morediverse,CAMprovision.
Barriers in the access to CAM EUcitizensalsoseemtomeetconsider-
ablebarriersintheaccesstoCAM:CAMtreatmentsarepredominantly
paidforprivatelyandaredifficulttoaccessduetolackofavailabilityand
limitedaccessibility.
Citizens express a wish for more support and information regarding
CAM from the medical professionals CAMuseisoftennotdisclosed
bypatientsinothertreatmentsbecauseoftheassumedorknownhostile
attitudeofthemedicalprofessionalstowardsCAMtreatments.
Citizens need easily accessible and trustworthy information European
citizenswishtohaveaccesstoreliableandtrustworthyinformationthat
cansupportaninformeddecisionabouttreatmentoptions.
Citizens require transparent regulation of CAM practice and training
Citizens’confidenceintheprovisionofCAMisenhancedwhenCAMis
providedwithinanexistingframeworksuchasgeneralorhospitalpractice
orwhenthepractitionersaremembersofprofessionalCAMorganisations
thatensureeducationalaswellasethicalstandards.
Prevalence in the EU
There is a lack of reliable data on the prevalence of CAM Whilethere
areafewrigorousprevalencestudiesthatarebasedonnationallyrep-
resentativesamples,thevastmajorityaresmallandofpoorquality.Most
EUcountriesdonothaveanydataatall.ReportedprevalenceratesofCAM
usewerebetween0.3%and86%.Useofherbalmedicinewasthemost
frequentlyreporteduseofCAM.Musculoskeletalproblemswerethemost
reportedcondition.DisappointmentwithWesternmedicinewasamain
reasonforCAMuse,althoughitisnotpossibletoderivedefinitiveconclu-
sionsduetothesmallnumbersofstudiesreportingthisdata.
www.cambrella.eu
5 EUROPEAN POLICY BRIEF
Provision and regulation in the EU
Bothmedicalandnon-medicalpractitionersplayanimportantrolein
theprovisionofCAMwithinthehealthcaresysteminEurope.
CAMprovisionintheEU27+12ismaintainedbymorethan150,000
registeredmedicaldoctors(MDs)withadditionalCAMcertificationand
morethan180,000registeredandcertifiednon-medicalCAMpractitioners.
Thissuggestsupto65CAMproviders(35non-medicalpractitioners
and30physicians)per100,000inhabitants,comparedtotheEUfigures
of95generalmedicalpractitionersper100,000inhabitants.
Acupunctureisthemostfrequentlyprovidedmethod(53%ofallpracti-
tioners)with80,000physiciansand16,000non-medicalpractitioners
trainedinthetherapy,followedbyhomeopathy(27%–45,000and4,500,
respectively).Thesetwodisciplinesaremostlyprovidedbyphysicians.
Herbalmedicineandmanualtherapiesarealmostexclusivelyprovided
bynon-medicalpractitioners.
Naturopathy,ontheotherhand,isdominatedbyapproximately15,000
(mostlyGerman)physicians,asisanthroposophicmedicine(4,500)and
neuraltherapy(1,500).
No common approach can be identified as regards the provision
of CAM practice in Europe Eachofthe39countriesstudiedhasitsown
approach.Teachingandcertificationaresubjecttointernational,national
orinsomecountriesevenregionalregulations.Thereisacompletelackof
coherenceintraining,educationandprovisionofCAM.
No common approach can be identified as regards the regulation
of CAM practice in Europe Theregulatoryenvironmentdetermineshow
aprovidercanbeeducated,certifiedandofferservices.Thereisahuge
varietyinregional,national,Europeanandinternationallegalregulations,
whichmakeanycomparisonofCAMpracticeandprovisioninanyrespect
almostimpossible.Althoughdiversityinhealthcareregulationenablesa
widerchoiceofoptionswithregardtoCAMaspectsofhealthcare,thesame
diversityseriouslyhampersanyeffortstoestablishEU-widepredictable
conditionsforbothtreatmentandresearch.
www.cambrella.eu
6 EUROPEAN POLICY BRIEF
Industry in the EU
ManyCAMtreatmentsare“hands-on”and/orconsultative,withoutsub-
stantialturnoverinmedicinalproductsorequipment.Thelargestindustry
isinherbalandhomeopathicproductsanddietarysupplements.
TherearenoclearfiguresaboutthewholemarketforCAMrelatedpro-
ducts.IMSHealthgivesanestimateofapproximately€6billionforthe
Europeanshareofglobalmarketofherbalmedicationsin2010,whichis
estimatedatmorethan€11billion.1,2
Asregardshomeopathicmedicinalproducts,theEUmarketrepresents
about0.7%oftheEuropeanpharmaceuticalmarket,generatingabout
€1billion(ex-factoryprices)in2010(ECHAMP20113).
An economic perspective
Costsingeneralandcosteffectivenessinparticularhavenotbeenthe
focusoftheCAMbrellaproject.Anumberofhighqualitystudiesindicate
costeffectivenessandevencostsavingsforsingleCAMtreatments,
aswasshowninarecentsystematicreview.4
1 IMSHealth,2010–ref.byBusse,WernerR.
2 Herbalsupplementsandremedies–aglobalstrategicbusinessreport.
GlobalIndustryAnalysts,Inc,March2012:http://www.strategyr.com/
Herbal_Supplements_and_Remedies_Market_Report.asp
3 ECHAMP–EuropeanCoalitiononHomeopathicandAnthroposophic
MedicinalProducts
4 Herman,PM,PoindexterBL,WittCM,etal:Arecomplementarytherapies
andintegrativecarecost-effective?Asystematicreviewofeconomic
evaluations.BMJOpen2012;2:e001046.doi:10.1136/bmjopen-2012-001046
www.cambrella.eu
7 EUROPEAN POLICY BRIEF
Legislation in the EU
19ofthe39countrieshaveagenerallegislationforCAM,ofwhicheleven
haveaspecificCAMlawandeighthavesectionsonCAMincludedin
theirhealthlaws(suchas“Lawonhealthcare”or“Lawonhealthprofes-
sionals”).InadditiontogeneralCAMlegislation,somecountrieshave
regulationsonspecificCAMtreatments.
Obstacles for patients WhenpatientscrossbordersinsearchofCAM
treatment,theymayencountersubstantialdifferencesintheprofessional
backgroundofapparentlyidenticalCAMproviders,whoinadditiontend
toworkundercompletelydifferentreimbursementsystems.Thissituation
influencesCAMpatients’rights,accessandpotentialsafety,andconsti-
tutesachallengetoaharmonizednationalandEuropeanfollow-upofthe
newpatients’rightsaccordingtothecross-borderhealthcareDirective
2011/24/EU.5
Obstacles for practitioners Whenpractitionerscrossborderstheywill
encounterasubstantialvarietyofCAMpracticeinEurope.WhileCAM
professionsinsomecountriesaretightlyregulated,thesameprofessional
categoriesinothercountriesaretotallyunregulated,meaningthatitis
almostimpossibletoestablishprofessionalcommongroundandcross-
borderemployment.
Obstacles for researchers Whenresearcherscrossborderstheywill
experiencethatresearchonefficacyandeffectivenessofCAMisseverely
hamperedbytheheterogeneityofEuropeanregulations.Practicesand
practitionersarenotcomparableacrossnationalboundaries,andany
observationalorexperimentalstudycanthereforebegeneralisedonly
withinanarrownationalorculturalcontext.
5 http://eur-lex.europa.eu/LexUriServ/
LexUriServ.do?uri=OJ:L:2011:088:0045:0065:EN:PDF
www.cambrella.eu
8 EUROPEAN POLICY BRIEF
The roadmap for European CAM research
Thefollowing“RoadmapforEuropeanCAMresearch”describesastrategic
approachtoresearchforthefieldofCAM.Itisbasedonpastexperiences
inCAMresearchanddesignedtoaddressfutureEuropeanhealthcare
challenges.IttakesthefindingsofalltheCAMbrellaworkpackagesinto
account.
CAMbrella´svisionfor2020isthatanevidencebaseisestablishedwhich
enablesEuropeancitizens,healthcareprovidersandotherstakeholdersto
makeinformeddecisionsaboutCAM.Currently,thereistoolittlegeneral
knowledgeaboutthestateofCAMinEurope,especiallyon
– theprevalenceofuseofCAM
– theneedsandattitudesofEUcitizens,patientsandproviders
regardingCAM
– thetypesandmodesofCAMprovision.
PastresearchwithitsfocusontheunderlyingmechanismsofCAMhasn’t
metthemorepressingquestionsaboutCAMaspossiblereasonable
treatmentoptionsinadditionoralternativetoroutinecareprotocols.
Furthermore,theconsiderableheterogeneitywithinCAMintheEU
hashamperedthedevelopmentofpan-Europeanresearchefforts.
Thechallengesnowareto:
– addresstheneedsandattitudesofEUcitizens,patientsandproviders
– getessentialinformationabouttherealsituationasregardsprovisionand
useofCAMinallcountriesofEurope
– createavalidknowledgedatabaseonCAMeffectiveness,costsandsafety
– establishscientificknowledgethatenablesallstakeholdersincluding
citizens,healthcareproviders,policymakersandresearcherstomake
informeddecisionsaboutCAM.
www.cambrella.eu
9 EUROPEAN POLICY BRIEF
Conclusions and recommendations
InordertoconsideremployingCAMaspartofthesolutiontothehealth-
carechallengeswefacein2020,itisvitaltoobtainreliableinformation
onitscost,safetyandeffectivenessinrealworldsettings.Thisresearch
strategyaimstoprovidetheEUanditscitizenswithvaluablescientific
informationforstakeholderdecisionsaboutCAMtreatments.
1. CAM is a neglected area of research – it needs active encouragement
EuropeanresearchinthefieldofCAMislimitedandourknowledgeabout
CAMisverypoor.ThereisalmostnosignificantinvestmentinanyEU
countryinaCAMresearchstructureorstrategy.TheCAMindustryis
relativelysmallandtherearenomajorfinancialor/andindustrialinterests
drivingresearcheffortsinthisfield.Scientificbiashampersthefree
exchangeofideas,concepts,treatmenttechniquesandcomparisonof
clinicaloutcomes.CAMisorganisedmostlyinprivateprovidersettings
(medicalandnon-medical),thustheacademicexperienceamongCAM
providersisscarceandtherearefewacademiccentresofresearch,
resultinginasubstantiallackoffundingforresearchprogrammes.Career
opportunitiesinanacademicsettingarerare.
Inordertopayproperattentiontotherealsituationofuseandprovision
ofCAMinEuropeandtounderstandwhyCAMissopopularwithintheEU,
structuralandsufficientfinancialsupportisneededtogiveactiveencour-
agementtoresearchatalllevels:private,universitybound,nationaland
European.
EuropelagswellbehindotherregionssuchasNorthAmerica,Asiaand
AustraliaintermsofthelevelofinvestmentinCAMresearchandthe
integrationofresearchresultsintohealthpolicyandhealthregulation,
andintoCAMprovisionandpractice.Europealsolacksanequivalentto
internationalstakeholderssuchasAyushinIndia(regulatorybodyfor
Ayurvedicmedicine,Yoga,Unani,SiddaandHomeopathy)andNCCAM
(NationalCenterforCAMintheUS,partoftheNationalInstituteof
Health).
www.cambrella.eu
10 EUROPEAN POLICY BRIEF
2. An EU research strategy for CAM must reflect the needs of the citizens,
patients, providers and other CAM stakeholders
CAMisfrequentlyemployedinprimaryprevention,healthliteracyand
self-managementofchroniclong-termconditions.Thereforeitcouldcon-
tributetotheupcominghealthcarechallengesinEurope.Mosturgently
neededisto
– establishaEuropean-wideapproachfortheassessmentofprevalenceof
useforcoreCAMdisciplines
– addressthediversityoftraining,educationandprovisionofCAMacross
Europe
– identifythemostpromisingCAMtreatmentoptionsforthemostprevalent
healthconditionsinEurope(obesity,chronicdiseaseslikediabetes,cancer,
musculoskeletalproblems,healthyageingandothers)
– quantifytheeconomiceffectsofCAMinEuropeanhealthcare.
StakeholdershavedifferentviewsonCAM;theseviewsshouldbetaken
intoaccountinordertoachievemeaningfulresearchandallowstake-
holderstomakeinformeddecisionsforfuturehealthcareplanning.Thus,
researchhasto:
– identifythecitizens’accesstoandpreferencesforCAMprovisionaswell
astheirperspectivesoneducation,trainingandpracticeofCAMproviders
– determinehowbesttodisseminatescientificallysoundinformationabout
CAMtotheEuropeanpublic,inlinewiththeEUobjectivetoenhance
theabilityofcitizenstomakebetterandinformeddecisionsabouttheir
healthcare
– giveclearguidanceonCAMsafetyissues
– researchandevaluatedifferentmodelsofCAMhealthcareintegration
intoroutinecareprogrammes.
www.cambrella.eu