An audit of acupuncture in general practice

Transcription

1 An audit of acupuncture in general practice Audit Anthony Day, Rosie Kingsbury-Smith Abstract An audit was conducted to determine the effects of acupuncture treatment used in a dedicated clinic in primary care by a GP, starting shortly after first learning acupuncture. The outcome measure was MYMOP2 which was developed into the MYMOP pictorial during the course of the audit to improve patient compliance. Out of 62 patients enrolled in the audit, 55 completed both the initial and follow-up questionnaires: they had a mean age of 56 years, and included 43 women. The overall mean improvement in symptom 1 was 2.0 (standard deviation 1.6) scale points, and the improvement was significant in 30 patients (55%). Twenty-eight patients reported significant improvement in activity (58% of those reporting this section), and 23 patients (48% of those reporting) obtained a significant improvement in wellbeing. Adverse events were minor, though one patient fainted and fell to the floor. Although the conclusions of this audit are limited by its small size, nevertheless the results were generally encouraging, and the authors recommend that acupuncture should be considered for use in primary care for a wide range of complaints. Keywords Acupuncture, audit, MYMOP2, general practice. Introduction This audit was conducted at Poplar Grove Practice, Aylesbury, Buckinghamshire: a busy urban practice with eight partners and a population of 11,500 from a wide range of social and ethnic backgrounds. The first author (AD) is the only general practitioner (GP) at the practice who is trained to use acupuncture. AD completed the BMAS Foundation Course in December 2001 and gained the BMAS Certificate of Basic Competence in July It was decided that the range of conditions treated should be as wide as possible in order that AD and his partners could get a feel for which conditions seemed to respond best. Requests for acupuncture for certain conditions, such as obesity, were excluded in accordance with the advice given at the BMAS courses. Initially, AD gave acupuncture treatments opportunistically within the normal surgery, or to patients specially booked at the end of surgery. This soon proved unsatisfactory, and the partners agreed that one session per week should be devoted to acupuncture, using two adjacent rooms. In addition, AD still carries out opportunistic treatments. On average, AD performs about a dozen acupuncture treatments per week, half of these in a designated clinic. All GPs within Poplar Grove practice could refer their patients for acupuncture if they considered it was appropriate. Patients could request referral via their own doctor, but could not make direct bookings themselves. Most patients were treated in the designated acupuncture clinic although some were treated opportunistically in ordinary surgery. A literature review, including Acupuncture in Medicine, BMJ, and The Lancet, as well as Cochrane, Medline and Ovid databases, revealed one earlier high quality audit which used MYMOP2 and discussed the practical considerations in conducting such an audit. 1 Other sources of information for planning the audit were the local Buckinghamshire audit guidelines, the World Health Organisation guidelines on acupuncture, and a statistics website. 2 The purpose of this audit was to quantify the benefit of acupuncture treatment for the interest and value of the first author, the practice and the patients themselves. We wanted to assess the improvement in patients symptoms, wellbeing and activities, as well as any reduction in Anthony Day general practitioner Buckinghamshire Rosie Kingsbury-Smith pre-registration house officer Correspondence: Anthony Day dayhappydays@aol.com 87

2 medication and whether the patient considered that important. We also intended originally to make a case for funding from our primary care trust (PCT), by assessing the cost effectiveness of acupuncture, but the Vale of Aylesbury PCT made it clear that they would not fund acupuncture or any other form of alternative therapy. We decided, therefore, not to include an economic evaluation. We did not specifically request data on adverse events from each patient, but adverse events considered significant were recorded in the patient s notes. Methods An audit working party was set up including both authors and the Head of reception at the practice (see Acknowledgements). The audit ran from October 2002 until December Patient Selection The patients included in the audit were treated by appointment in the acupuncture clinic, though not all patients treated with acupuncture were included because of incomplete data collection that occurred at busy times when there were other priorities for practice staff. All patients to be included in the audit received an information pack before their first consultation, including brief background information about acupuncture and its possible side effects, some frequently asked questions and the BMAS website address for more information. Acupuncture Treatment The usual contraindications to treatment were used (eg bleeding disorder severe enough to cause spontaneous bruising). The only point used during pregnancy was PC6, for nausea. Valvular heart disease was regarded as a relative contraindication so patients were informed of the possible risk and the need to report any untoward symptoms. Neither electroacupuncture nor indwelling needles were used. The principles of point selection were: local traditional meridian points, traditional points distant to the affected part, points on a paired meridian, trigger points described by Travell and Simons, 3 segmental needling (using points that stimulate the relevant spinal cord segment), and points of special action (eg ST36 which is said to have a general anti-inflammatory effect). Treatment involved needling to a variable depth, usually 1 to 2cm depending on the site, followed by stimulation to achieve de qi if possible. Paraspinal needling was used when appropriate; periosteal needling was also used (eg lateral epicondylar tapping for tennis elbow). The normal duration of needling was 10 to 20 minutes, though periosteal and trigger point needling were brief. The patients were given a 30 minute initial consultation, followed by 15 minute weekly consultations for the duration of the treatment. The number of sessions was usually limited to three because of workload and availability. Outcome Measurement The main outcome was the MYMOP2 ( Measure Yourself Medical Outcome Profile 2 ) questionnaire developed by Paterson particularly for use in complementary therapies. 4;5 It has the advantage of allowing patients to select the symptom that is most important to them. It has, however, been criticised for being too symptom orientated and for being of limited value in planning the allocation of resources. 6;7 Patients were given a help sheet and an example sheet and asked to complete the first MYMOP2 questionnaire while waiting for their first appointment. However, they often needed help completing form, particularly those who were elderly, or who had low literacy or confidence in completing forms, or for whom English was not the first language. We therefore developed a pictorial version of MYMOP2 (described in another paper in this issue) 8 in consultation with Paterson. This was received with a high degree of satisfaction from the patients. We defined improvement as a one point decrease and significant improvement as a two point decrease in the MYMOP2 score. 5 At least one week after completing their course of treatment, patients were sent the follow up MYMOP2 questionnaire by mail, together with a help sheet and a stamped addressed envelope. The symptoms and activity originally chosen by the patient were completed for them, but patients were not shown their original scores. The data were entered onto an Excel spreadsheet, and descriptive statistics calculated using the 88

3 Table 1 Main symptom ( Symptom 1 ) stated by 55 audit patients in the baseline MYMOP2 Symptom 1 Number of Patients Back pain 11 Neck pain 6 Pain (general) 5 Headache 4 Elbow pain 3 Knee pain 3 Foot pain 2 Leg pain 2 Shoulder pain 2 Paraesthesia 2 Other* 15 *1 case each of: arm pain, chest pain, cough, depression, diverticulitis, gout, head blockage, irritable bowel syndrome, sinusitis, tinnitus, urine incontinence, vaginal software s soreness, vertigo, own whiplash, statistics wrist program pain. and checked using guidance from the Mathworld website. 2 The data were presented as means and standard deviations. Results Sixty two patients were enrolled in the audit and completed the initial MYMOP2 questionnaire, but only 55 replied to the follow-up, despite reminder letters. The initial data from the seven who did not reply were not included in the analysis. There were 43 women and 12 men, with mean age of 56 years, range 23 to 80. Some data were missing for symptom 2, and the section on medication. The average number of acupuncture sessions was 3.6. Symptom scores The patients worst reported symptoms are presented in Table 1, where their own perspectives on their problem can be seen (eg head blockage ), as well as their clear use of medical terminology (eg paraesthesia ). The wide variety of symptoms reflects the stated aim to treat as wide a range of complaints as possible. Changes in MYMOP2 scores are given in Table 2. The overall mean improvement was 2.0 (SD 1.6) scale points; 69% of patients were treated for musculoskeletal symptoms, and had a mean improvement of 2.0 points. The mean improvement for nonmusculoskeletal symptoms was 2.1 points. Some improvement was experienced by 45 (82%) patients, no change by eight (15%), and deterioration by two (4%). The improvement in symptom 1 was significant, ie two points or more, in 30 patients (55%). Table 2 Mean (SD) MYMOP2 scores for main symptom (symptom 1) before and after acupuncture, and the difference, in patients grouped by symptom Symptom 1 N Before treatment After treatment Difference Group Spine (1.1) 2.7 (1.6) 2.2 (2.0) Upper limb (1.4) 1.6 (1.4) 2.1 (1.6) Lower limb (0.9) 3.6 (1.9) 1.3 (1.8) Head (1.4) 2.1 (1.6) 1.6 (1.7) Abdomen (0.5) 3.3 (1.5) 1.5 (1.7) Other (1.2) 2.8 (1.5) 1.9 (1.2) Possible range of scores is zero to 6, with higher scores indicating greater severity. Positive difference indicates improvement. Table 3 Mean (SD) MYMOP2 scores for symptom 2 before and after acupuncture, and the difference, in patients grouped by symptom Symptom 2 N Before treatment After treatment Difference Group Spine (0.7) 2.1 (1.1) 1.7 (1.1) Upper limb (1.4) 2.3 (2.0) 1.9 (1.6) Lower limb (1.1) 2.6 (1.8) 1.8 (1.6) Head (2.0) 1.2 (1.6) 3.2 (1.9) Other (1.9) 2.4 (1.7) 1.5 (1.8) Possible range of scores is zero to 6, with higher scores indicating greater severity. Positive difference indicates improvement. 89

4 Table 4 Mean (SD) MYMOP2 scores for the chosen activity before and after acupuncture, and the difference Activity N Before treatment After treatment Difference Walking (1.2) 2.5 (1.4) 2.3 (1.3) Work (1.4) 2.3 (1.8) 1.3 (2.0) All/Living (0.8) 4.0 (1.6) 1.2 (1.6) Gardening (1.3) 1.8 (2.1) 2.5 (1.9) Sleeping (1.5) 2.0 (1.7) 2.3 (0.6) Housework (1.2) 2.0 (0.0) 1.7 (1.2) Concentrating (0.0) 1.5 (2.1) 2.5 (2.1) Other (1.8) 2.5 (1.9) 1.6 (1.3) Possible range of scores is zero to 6, with higher scores indicating greater severity. Positive change indicates improvement. Table 5 Mean (SD) MYMOP2 scores for symptom 1 before and after acupuncture, and difference, according to duration of symptom Duration of symptom 1 N Before treatment After treatment Difference <2 weeks (1.4) 1.0 (1.4) 3.0 (2.8) 2-4 weeks (0.7) 0.5 (0.7) 4.0 (1.4) 4-12 weeks (1.4) 3.5 (1.2) 0.5 (1.7) 3 12 months (1.1) 2.5 (1.3) 2.1 (1.6) >1 year (1.3) 2.8 (1.7) 1.9 (1.5) Possible range of scores is zero to 6, with higher scores indicating greater severity. Positive change indicates improvement. In total, 36 people recorded a symptom 2 score before and after treatment. Scores and changes are shown in Table 3. An improvement was experienced by 29 patients (82%), no change by eight (15%) and deterioration by two (4%). The improvement was significant, ie at least two points, in 20 (56%) of the patients. The overall mean improvement was 2.1 (SD 2.1). Activity, wellbeing, medication In total, 48 people recorded activity scores before and after treatment, of whom 39 (81%) scored an improvement in activity; 12% experienced no change and 3% reported a deterioration. The mean improvement in activity score was 1.8 (SD 1.3) points; 28 patients (58%) scored an improvement of at least two points. The majority of patients (60%) had experienced their symptoms for more than a year. As shown in Table 5, the greatest improvement appeared to be in patients with symptoms of less than one month, though the numbers were small. In total, 48 people recorded wellbeing both before and after treatment. Wellbeing scores improved in 27 patients (56%), whereas 16 (33%) found no change and 5 (11%) were worse. The mean improvement in wellbeing score was 1.0 (SD 1.3); 23 patients (48% of those reporting) scored an improvement of at least two points. Only one patient reported the name of their medication. Twenty three patients (42%) stated that cutting down medication was important to them, whereas it mattered somewhat to a further 23 and not at all to 16 (29%). Thirty three people completed the medication question in the follow up, of whom seven reported taking more medication, 14 taking the same and 12 taking less. Adverse effects were mostly minor, such as temporary exacerbation of symptoms, nausea and light headedness, and most patients experienced no adverse effects at all. There was one episode of a more serious nature, in which a patient undergoing his second treatment had a syncopal attack and fell from the chair onto the floor, sustaining facial abrasions. He had had no adverse effects during or after the first treatment, which had been given while lying on the examination couch. The patient did not continue with the course of treatment. Discussion The findings of this audit suggest that a wide range of conditions seen in primary care can be improved with acupuncture, and general practitioners should consider this form of treatment. 90

5 A significant number of patients appear to have had a good improvement in their parameters (a reduction of one or two points on the MYMOP2 scale), despite the fact that the number of treatments (an average of 3.6) was fewer than I would generally consider desirable. The age and sex distribution of the audit patients is similar to that of patients presenting in general practice, ie a high proportion of elderly people and women. A wide range of symptoms was included but the majority were musculoskeletal. It was encouraging that there appeared to be good improvements both in these patients and those with other conditions. The improvements in wellbeing scores were generally smaller than the improvements in symptom 1 scores. The change in wellbeing scores was greater in patients whose symptom scores were improved, implying that there was no independent improvement in wellbeing unrelated to symptom improvement. The fact that the majority of patients had conditions which had been present for more than a year probably reflects the fact that this is the first time that acupuncture was available to a large number of patients in whom other treatments have failed. If so, it is particularly gratifying to see improvements. The incident of the patient who collapsed reinforces the importance of treating patients on the examination couch and never leaving them without an appropriate alarm. The audit s conclusions are limited by the relatively low numbers of patients and the short follow up period. It seems likely that the data were accurately recorded because of the good motivation of the patients and staff who took part. A number of practical lessons were learned about the conduct of an audit in general practice. It is difficult and time consuming to carry out an audit in a busy urban general practice where all members of the practice team (including those providing acupuncture) are already working at full stretch. This is particularly true as acupuncture is understandably given a low priority. The practitioner requires the help of one or two committed and enthusiastic members of staff, whose time is difficult to spare from the normal running of the practice. Collating and writing up the results is also time consuming. Most GPs do not have the necessary experience or training and find the task daunting and difficult. Changes to the methods we made during the process of the audit, as a result of the lessons learned: pictures were added to the numerical scale of MYMOP2; the wording of the medication section was changed to that on the website; patients were given help cards when completing the initial form; the follow up forms were sent out with original symptoms and activities already completed; help sheets were sent out with the follow up forms. Compliance appeared to be better after making these alterations. We believe that future audits need to address some issues that we have identified, such as defining the referral criteria more strictly, and recruiting a larger patient sample. Researchers might investigate whether attitudes towards acupuncture differ between cultural groups and ask what treatments had been tried prior to acupuncture. They might consider setting a review date of say, six to twelve months after the end of treatment, to give an indication of duration of effect and relapse rates. 6 Future audits could document side effects, and obtain information Table 6 Mean improvement in wellbeing score, presented according to improvement in symptom 1 score Improvement in Change in Symptom 1 Score Number of patients wellbeing score

6 about cost effectiveness. Finally, an audit might be used to identify measures that would relieve the administrative workload. Conclusion This was a small audit of limited duration, scope and significance. However, the results suggest that acupuncture brings meaningful benefits to a significant proportion of patients with a variety of symptoms. Conducting an audit is a difficult but ultimately a rewarding experience and one that adds to the evidence base of acupuncture in ways such as suggesting conditions and patients who respond best to acupuncture treatment. Acknowledgement Debbie Midgely, head of reception at the practice, applied considerable skill and effort in helping to conduct this audit. Reference list 1. Stellon A. An audit of acupuncture in a single-handed general practice over one year. Acupunct Med 2001;19(1): Mathworld website: 3. Travell JG, Simons DG. Myofascial Pain and Dysfunction. In: The Trigger Point Manual. 2nd ed. London: Lippincott, Williams and Wilkins; Paterson C. Measuring outcomes in primary care: a patient-generated measure, MYMOP, compared with the SF-36 health survey. BMJ 1996;312(7037): MYMOP website: 6. Cairns J. Measuring health outcomes. BMJ 1996;313(7048):6. 7. Jenkinson C. MYMOP, a patient generated measure of outcomes. Research into outcomes has moved away from symptom based assessments. BMJ 1996;313(7057): Day A. The development of the MYMOP pictorial. Acupunct Med 2004;22(2): Acupunct Med: first published as /aim on 1 January Downloaded from on 2 September 2018 by guest. Protected by copyright. 92