MadSci Network: Medicine

Re: Is there any research on whether prayer works?

Date: Wed Oct 20 14:38:50 1999
Posted By: Linda J. Weyandt MD/CRNA, Grad student, Psychology/, North Central University
Area of science: Medicine
ID: 939320333.Me

Much written about prayer ( also termed meditation) Thought you ight like to
view the studies so far.

Association Between Use of Unconventional Therapies and Conventional Medical

  Benjamin G. Druss, MD, MPH; Robert A. Rosenheck, MD

Context  The terms alternative and complementary medicine suggest 2
contradictory possibilities. Whether individuals use unconventional
therapies as a substitute for or as an "add on" to conventional medical
treatments is uncertain.

Objective  To determine the association between use of unconventional
therapies and conventional medical care in a national sample.

Design, Setting, and Participants  The 1996 Medical Expenditure Panel Survey
was distributed to a probability sample of the noninstitutionalized civilian
US population. Of 24,676 individuals responding (77.7% response rate),
16,068 adults 18 years or older were included in the analysis.

Main Outcome Measures  Visits to practitioners for unconventional therapies
and conventional medical services, including number of inpatient,
outpatient, and emergency department visits and use of 8 types of preventive
medical services (blood pressure, cholesterol level, physical examination,
influenza vaccination, prostate examination, breast examination,
mammography, and Papanicolaou test).

Results  During 1996, an estimated 6.5% of the US population had visits for
both unconventional therapies and conventional medical care; 1.8% used only
unconventional services; 59.5% used only conventional care; and 32.2% used
neither. Compared with those with only conventional visits, those who used
both types of care had significantly more outpatient physician visits (7.9
vs 5.4; P<.001), and used more of all types of preventive services except
mammography. These groups did not differ significantly in inpatient care, 
prescription drug use, or number of emergency department visits. Individuals
in the top quartile of number of physician visits were more than twice as
likely as those in the bottom quartile to have used unconventional therapies
in the past year (14.5% vs 6.4%; P<.001). The association between
unconventional treatments and physician visits remained after adjusting for
potential confounders and across different types of unconventional

Conclusions  In this sample, use of unconventional therapies was
substantially lower than has been reported in previous national surveys, but
was associated with increased use of physician services. From a health
services perspective, practitioner-based unconventional therapies appear to
serve more as a complement than an alternative to conventional medicine.

JAMA. 1999;282:651-656

Interest in unconventional therapies in both the scientific literature and 
the popular press has increased exponentially during the last decade.1 This
growth has spurred a need both for scientific trials of specific treatments
and health services research examining patterns and correlates of these
services in the "real world."2 From both a clinical and health policy
perspective, one of the most salient issues is the degree to which use of
unconventional therapies is associated with patients' use of mainstream
medical treatment.3, 4

The current nomenclature reflects several potentially contradictory notions
of the relationship between these 2 systems of care. The term alternative
medicine implies that these treatments are substituting for conventional
therapies, whereas the term complementary medicine suggests that the 2 are
used in conjunction. Complementary and Alternative Medicine, the name used
by the new center at the National Institutes of Health overseeing research
in the area, appears to acknowledge both possibilities.5 To avoid the
potential service use implications of these terms, we use the term
unconventional medicine, the label used in the first national survey of
these forms of care,6 throughout this article.

Several studies suggest that many individuals use unconventional therapy in
conjunction with mainstream medical treatment.6-9 Moreover, patients
generally report using such therapies to augment their medical care rather
than as a result of dissatisfaction with mainstream medicine.10-12
Nonetheless, there remains a perception among clinicians and in the popular
press that unconventional treatments represent a rejection of, and challenge
to, the mainstream medical system.13, 14

The Medical Expenditure Panel Survey (MEPS) is the first national
probability survey to gather data about use of visits for unconventional
therapies in the context of a detailed survey including data on health
insurance, health status, and use of different types of medical services.
The sample size is more than 4 times larger than any previous survey of
unconventional therapies in the United States, and the sampling techniques
of this survey make it highly representative of the general US adult
population.15, 16 Using data from that survey, this study examines the
relationship between use of unconventional therapies and conventional
medical care in the United States.


Sampling Frame

The MEPS is conducted to provide nationally representative estimates of
health care use, expenditures, sources of payment, and insurance coverage
for the US civilian noninstitutionalized population. The 1996 MEPS used the
1995 National Health Interview Survey as the sampling frame for the
survey.17 The subsample selected for the 1996 MEPS consisted of 10,597
National Health Interview Survey households who responded. Approximately 4%
of the interviews were administered in Spanish; the remainder were conducted
in English.

Overall, 24,676 individuals responded to the core MEPS household interview,
representing a joint National Health Interview Survey-MEPS response rate of
77.7%. For the purposes of this study, we included all individuals 18 years
or older who responded to the survey (N=16,068).

Unconventional Therapies

All MEPS participants were asked a set of questions about visits to
practitioners of unconventional therapies during the past year. These
included a series of questions about use of chiropractic services. A
separate section asking about use of unconventional therapies began with the
following probe: "In order to get as complete a picture as possible of all
sources of health care, we would also like to ask about the use of other
forms of health care, including treatment you may have previously told me
about, such as the treatments shown on this card. Frequently this type of
care is referred to as complementary or alternative care. During the
calendar year 1996, for health reasons, did you consult someone who provides
these types of treatments?" The card contained the following categories:
acupuncture; nutritional advice or lifestyle diet; massage therapy; herbal
remedies purchased; biofeedback training; training or practice of
meditation, imagery, or relaxation techniques; homeopathic treatment;
spiritual healing or prayer; hypnosis; traditional medicine, such as
Chinese, Ayurvedic, American Indian, etc; and other complementary or
alternative treatments.

If the response was "yes," the respondent was asked to specify which of the
therapies on the list had been received. Multiple types of service use by 1
person were possible. For the purpose of this study, visits in which
unconventional therapies were provided through a physician were considered
to be conventional.

Conventional Medical Services

The total number of conventional outpatient services for 1996 was calculated
as the sum of office-based and outpatient hospital-based physician visits.
MEPS interviewers asked about the number of emergency department visits and
the number of inpatient discharges that occurred during that year.

For each respondent, a series of questions was asked about receipt of
preventive care or screening examinations within the past year, including
the following: blood pressure taken by a physician, nurse, or other health
care professional; cholesterol level; complete physical examination;
influenza vaccination; prostate examination; Papanicolaou test; breast
examination; and mammography.

Health Status

Respondents were asked to rate their physical and mental health according to
the following categories: excellent, very good, good, fair, and poor. In
addition, the instrumental activities of daily living help or supervision
variable was constructed from the following question: "Due to an impairment
or a physical or mental health problem . . . do [you] receive help or
supervision using the telephone, paying bills, taking medications, preparing
light meals, doing laundry, or going shopping?" Difficulty in activities of
daily living was defined as a positive response to the question: "Due to an
impairment or a physical or mental health problem . . . do [you] receive
help or supervision with personal care such as bathing, dressing, or getting
around the house?"

Statistical Analyses

A first set of analyses compared demographic characteristics, health status,
and use of unconventional therapies across individuals in 4 groups: those
who used both conventional medicine and unconventional therapies, 
conventional medicine only, unconventional therapies only, and neither type
of medicine. Second, use of different types of medical services was compared
between individuals who used both conventional medicine and unconventional
therapies and those who used conventional medicine only. Third, to
understand whether high users of conventional care had distinct patterns of
unconventional service use, a set of analyses compared use of unconventional
therapies between individuals in the bottom and top quartile of conventional
service use.

Two-stage multivariate models were constructed to assess the association of
various unconventional therapies with likelihood of any visit and number of
physician visits among conventional service users. The first stage used
logistic regression by modeling any physician visit as a function of a
particular type of unconventional service use. The second stage used linear
regression to calculate least-squares estimates for mean number of physician
 visits associated with each of the unconventional therapies, adjusting for
potential confounders. All models controlled for self-reported physical
health status, age, sex, race, education, geographic region, and insurance

Because of the nonnormal distribution of utilization data, nonparametric
methods were used for all tests comparing continuous variables. For
bivariate comparisons, the Wilcoxon signed rank test was used to generatez
scores for differences between means. In multivariate analyses, continuous
variables were first transformed into ranks, and ordinary least-squares
regression was then used to compare differences between ranked scores.18
SUDAAN (Research Triangle Institute, Research Triangle Park, NC; statistical
package with appropriate weighting and nesting variables) was used for
statistical comparisons and to generate weighted prevalence estimates for
the US population.


During 1996, an estimated 6.5% of the US population had visits for both 
unconventional therapies and conventional medical services, 1.8% used only
unconventional services, 59.5% used only conventional care, and 32.2% used
neither. These percentages are weighted to account for the survey's complex
sampling design.

Table 1 presents the characteristics of individuals using neither, 1, or
both systems of care. Compared with individuals who used conventional
services only, users of both unconventional therapies and conventional
medical services were more likely to be female, white, more educated, and
live in the West. There were no significant differences between the 2 groups
in self-reported physical or mental health, difficulties with activities of
daily living, or difficulties with instrumental activities of daily living.
Those using unconventional therapies did report poorer physical health
status than those using no services (6.2% vs 0.5%; 2=4.5; P=.02).

Chiropractic, which was used by 3.3% of the survey population, was the most
common unconventional therapy reported, followed by massage (2.0%), herbal
remedies (1.8%), spiritual healing (1.4%), nutritional advice (1.1%),
acupuncture (0.6%), meditation (0.5%), homeopathic remedies (0.4%), hypnosis 
(0.1%), biofeedback (0.1%), and other therapies (0.4%) (Table 2).

Compared with those who used unconventional therapies only, those who used
both conventional medical care and unconventional therapies were
significantly more likely to use chiropractic services (42.8% vs 28.1%;
2=9.3; P=.002) and significantly less likely to use spiritual healing (1.3%
vs 22.6%; 2=6.8; P=.009). Use of other unconventional services was similar
between those using 1 or both systems of care.

Only 2.5% of those with practitioner visits for treatments identified as
potentially unconventional had those services provided by a physician. These
services were classified as conventional for all subsequent analyses.

Among users of both unconventional therapies and conventional medical care,
8.8% reported that they had been referred for their unconventional therapies
by a physician. Fewer than one fifth of those who had both types of visits
(19.7%) had told a physician about their use of unconventional services.

Compared with those individuals using conventional services alone, those 
using unconventional therapies and conventional medical care made
significantly more physician visits, and were significantly more likely to
report having obtained 7 of the 8 listed preventive services (Table 3).
There was no significant difference between the 2 groups in emergency
department visits, inpatient discharges, or prescription drug use.

The group in the lowest quartile of use of medical services (low users) made
only 1 physician visit during the previous year, whereas the highest
quartile of medical service users (high users) made 7 or more physician
visits during that time. Compared with low users, high users of medical care
were older more likely to be female, white, less educated, and to have
health insurance. High users reported significantly more impairment on all
measures of health status than did low users (Table 4).

Use of unconventional therapies was more than twice as common among high
users than among low users of conventional services (14.5% vs 6.4%; 2=69.6;
P<.001). Compared with low users, high users were significantly more likely
to use chiropractic therapy, acupuncture, massage, herbal remedies,
meditation, and spiritual healing.

The association between visits for unconventional therapies and physician
visits remained robust across a variety of unconventional treatments, and
after adjusting for potential confounders (Table 5). Overall, having any
visit for unconventional therapies was associated with an approximately
2-fold increase in the odds of having a physician visit. Among those with
physician visits, having a visit for unconventional therapies was associated
with a two-thirds increase in number of physician visits.

Five of 12 unconventional therapies were associated with a significantly
increased likelihood of a physician visit, and 8 therapies were associated
with an increased number of such visits among users. No categories of
unconventional therapy were associated with a significant reduction in
either likelihood or number of conventional services.


The study suggests that practioner-based unconventional therapies serve more
as a complement or add-on than as an alternative to conventional medicine.
Only 1.8% of the population made visits for unconventional therapies in the
absence of visits for conventional medical care, and use of unconventional
therapies was consistently associated with an increased likelihood and
number of physician visits.

The survey found substantially lower rates of use of unconventional
therapies than have been reported in national telephone surveys.6, 7, 10 In
part, this is likely a function of the MEPS focus on practitioner-based
therapies. In addition, the differences in prevalence may reflect the MEPS
sampling design. Because less educated and poorer individuals use fewer
unconventional services than the general population,8 the inclusion of
non-English speakers and individuals without telephones in the MEPS survey
may provide a more representative view of practitioner-based unconventional
therapies in the United States than has been available using telephone

Several mechanisms could explain the consistently positive association 
between unconventional therapies and conventional medical services. First,
the relationship could be causal if physician visits led to greater use of
unconventional therapies or vice versa. However, only a small minority of
such visits occurred as a result of physician referrals, and physicians were
not aware of more than four fifths of visits for those services.

A second possibility is that greater health care needs led individuals to
seek greater use of both unconventional therapies and conventional medical
services. While the study had limited measures of illness burden, there was
no difference in any of the 4 self-reported health measures between
respondents who had physician visits only, and those who had those visits in
conjunction with unconventional therapy. Poor health status appeared to
drive use of health services in general, that is, those using no services
reported better health than those using either conventional medical services
or unconventional therapies. However, poor health was not associated with
increased use of unconventional therapies over and above conventional
medical care.

The literature on "high utilizers" of conventional medical services may 
provide some insights into the association between use of conventional and
unconventional services. In both inpatient19 and outpatient20 settings, less
than 15% of the population uses more services than the remaining 85% of the
population. As in our study, high users tend to be sicker than the general
population, and frequently have mental health problems as well as medical
comorbidity.21 However, self-reported health status has been found to
explain less than 5% of the variance in predicting high-user status, and
adding demographic and other covariates still typically cannot account for
the vast majority of this variance.22 The persistence of these patterns may
be 1 reason that early prevention initiatives in these groups have rarely
been shown to offset their costs though reduction in future health care
expenditures.23, 24 For many of these patients, attitudes and learned
patterns of behavior may be as important as specific health care needs in
driving use of health services.

This study has several limitations. First, there is no consensus in the
scientific community as to which therapies should and should not be
considered unconventional. The original definition (lack of inclusion in
medical schools or availability in US hospitals6) has become a moving target 
as these therapies are increasingly integrated into academic curricula and
insurance packages.25 Although the categories defined as unconventional in
the MEPS are similar to those in other national surveys, including or
excluding particular therapies can substantially change prevalence

Second, the survey examined only unconventional therapies delivered through
a practitioner. Thus, the findings address the interaction between the 2
practitioner-based systems of care, rather than self-administration of
either conventional (eg, over-the-counter medications) or unconventional
(eg, dietary supplements) therapies. Individuals who receive unconventional
therapies on their own might be healthier, might use fewer medical services,
or both, than those receiving that care through a practitioner. Further
research is warranted to examine use patterns of individuals who primarily
obtain unconventional services through self-care.

The findings from this study, in conjunction with the previous literature,
suggest that practitioner-based unconventional therapies are generally not a
substitute for conventional medical care, but that individuals who use 
unconventional services are relatively heavy users of both types of care.
Ultimately, understanding more about this group of patients may help provide
a better understanding of the interface between the 2 systems of care.

Author/Article Information

Author Affiliations: Departments of Psychiatry and Public Health, Yale
University, West Haven, Conn.

Corresponding Author and Reprints: Benjamin G. Druss, MD, MPH, 950 Campbell
Ave/116A, West Haven, CT 06516 (e-mail:
Funding/Support: This study was funded in part by National Institute of
Mental Health grant K08 MH01556.


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 1999 American Medical Association. All rights reserved.

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Dr. Linda J. Weyandt MD/ CRNA

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