An Audit of 500 Acupuncture Patients in General Practice

Transcription

1 An Audit of 500 Acupuncture Patients in General Practice Jonathan Freedman Jonathan Freedman general practitioner St Albans, Hertfordshire gp-e82060.nhs.uk Summary This is an audit of 500 patients treated in a general practice setting. Acupuncture clinics are provided on two evenings each week and are funded by the practice. Short treatment times are favoured but this varies according to condition and response. A wide variety of conditions have been treated the commonest being neck pain, low back pain, shoulder problems, hayfever, knee osteoarthritis, and migraine. An overall improvement of 73% was obtained with 61% classified as significant improvement or cure. Amongst the adverse effects recorded, retained needles and forgotten patients have been the most concerning and have led to changes in practice following critical incident meetings. Keywords Audit, acupuncture, general practice. Introduction The author works as a full time general practice principal at Parkbury House Surgery, a large training practice situated in the centre of St Albans, Hertfordshire, with approximately 17,000 patients. The practice serves a large, mainly urban, population in and around St Albans. Historically there have been no local NHS acupuncture services but it has always been possible to refer patients to the Royal London Homoeopathic Hospital for a variety of complementary therapies, including acupuncture. The author attended a basic introductory course as a GP Trainee in 1993 at the Centre for the Study of Complementary Therapies, Southampton, and started needling straight away. Perhaps this is a predictor of a long-term career in acupuncture. The author pursued further training through conferences and intermediate courses organised by the British Medical Acupuncture Society, leading to an application for the Diploma in Medical Acupuncture. Initially appointments were offered on an ad-hoc basis during routine surgeries but this presented increasing logistic difficulties for patients, practitioner and reception staff. Therefore the option of running a dedicated weekly clinic was taken. This is run in place of a two-hour evening surgery. New patients are still seen in routine surgery time, assessed and offered an appropriate course of treatment in the acupuncture clinic. Currently there is a two-week wait for treatment in most cases. The exception to this is if patients present acutely. If it is likely that acupuncture will help, the patient is generally treated immediately and offered follow-up appointments in the clinic. The author is fortunate to work from ample premises with a number of free rooms in one corridor in the evenings. As a result an average of 10 patients can be seen each hour. Recently, due to increased demand, an additional hour has been added on a separate evening to increase acupuncture clinic time to three hours per week. Treatments are funded entirely by the practice. Over a number of years the practice has been unsuccessful in obtaining Health Authority or latterly Primary Care Trust funding. A small number of private patients attend, mainly from neighbouring practices, and their payments help to support the clinic expenses. The author s normal practice is to favour brief needling for musculoskeletal problems with myofascial trigger point deactivation, but to use longer treatments of between 5 and 20 minutes for other conditions. Length of individual treatment will vary according to the condition and individual response and whilst this is widely 30

2 debated area, the author is against efforts to standardise this. A western scientific approach is used almost exclusively, although the author has benefited from Richard James excellent teaching on traditional acupuncture and hopes to incorporate this into his practice further, in the future. The majority of patients are treated with dry needling and minimal stimulation although again this does vary according to the condition. The author also uses an electrical point stimulator for needle phobes and children although this is generally found to be less effective than needling. The author does not use electroacupuncture or auriculotherapy. Treatments are generally given once a week but occasionally more frequently for acute conditions. The average number of treatments is six, although a number of patients with chronic problems (e.g. migraine, cervical spondylosis) will return monthly or less frequently, for top-ups after an initial course of treatment. Methods The data forming the basis of this audit was mainly extracted from the practice computer system, although for the first two years the author kept a detailed written record of patients and their responses, which has been used in preference. It is all retrospective data, covering the period March 1993 to April With a small number of exceptions the author has not used follow-up questionnaires, but relied on patient feedback during and after treatment. Sometimes this is unavailable or unclear and these have been recorded as no follow-up. Although the patient is often symptom free at the end of treatment, if there is no documentation on longer term follow up these have been recorded as significant improvement. To use the term cure there must be no recurrence of the presenting complaint at follow-up of at least one year, and for chronic problems requiring regular treatment, the condition should be completely absent for the whole duration of treatment. Results The age/sex ratio is illustrated in Table 1. This shows a female:male ratio of 3.5:1, with the majority of treatments for both sexes being between the ages of 26 and 65. Table 1 Age/Sex distribution. Age Sex Totals Female Male Totals The data is set out in table 2. The total numbers of patients is illustrated for each condition categorised as follows; worse, no follow-up, no change, slightly improved, significantly improved, cured. The most frequent conditions treated were neck pain, low back pain, shoulder problems, hayfever, knee osteoarthritis and migraine, making up 65% of the total. Taking this group alone, 65% of patients (211) were categorised as showing significant improvement or cure. The percentages for each category in these conditions has been calculated. Other common but slightly less frequently treated conditions, making up 14% of the total, were elbow epicondylitis, premenstrual syndrome, hyperemesis and chronic fatigue syndrome (CFS). The conditions with the highest percentage significant improvement or cure were premenstrual syndrome and migraine (both 83%). Overall, the results show improvement in 73% of patients and significant improvement or cure in 61%. Adverse events included vasovagal syncope, bruising, forgotten needles and two cases of forgotten patients. Discussion The total of 73% improvement overall was in keeping with the author s impression of the success of his treatments, but it is gratifying to see this impression confirmed by the audit outcome. The female:male ratio of 3.5:1 was quite striking and is not reflected in the demographics of the practice population, but may in part be a reflection of the fact that women of all ages are more likely to consult than their male counterparts. A number of conditions either responded very well to acupuncture or not at all in almost equal proportion (good examples of this are tennis and golfer s elbow and hyperemesis). Generally acute musculoskeletal presentations (i.e. symptoms present for less than three months) responded best and required a shorter course of treatment 31

3 Table 2 Audit results categorised by diagnosis Diagnosis Worse No No Slight Significant Cured Total Follow-up Change Improvement Improvement Neck pain including cervical spondylosis & 7(8%) 8(9%) 16(16%) 57(62%) 5(5%) 93 neck/shoulder/arm pain* Low back pain including 1 2(3%) 15(24%) 3(5%) 40(62%) 3(5%) 64 sciatica & sacroiliitis Frozen Shoulder 1 3(5%) 10(19%) 4(7%) 22(40%) 15(28%) 55 including capsulitis Hayfever 15 5(11%) 7(15%) 18(39%) 1(3%) 46 OA Knee (19%) 26(60%) 1 43 Migraine (81%) 2 26 Tennis and Golfer s Elbow Premenstrual Syndrome Hyperemesis Chronic Fatigue Syndrome Sinusitis Carpal tunnel syndrome Perennial Rhinitis OA Hip Coccydinia Eczema/atopic dermatitis OA Thumb Stress/anxiety 5 5 Costochondritis Tension Headache Irritable Bowel Syndrome 3 3 Infertility Trochanteric Bursitis De Quervain s Tenosynovitis Plantar Fasciitis Repetitive Strain Injury Idiopathic neuropathy Induction of labour Thoracic back pain Trigeminal Neuralgia 2 2 Ulcerative Colitis Rheumatoid arthritis Morton s Neuroma 1 1 Non-specific elbow pain 1 1 Dysmenorrhoea 1 1 Tinnitus 1 1 Asthma 1 1 Phobias 1 1 Hallux rigidus 1 1 Hypertension 1 1 Endometriosis 1 1 Post-herpetic neuralgia 1 1 Scar pain 1 1 OA wrist 1 1 TOTAL (1%) (9%) (17%) (12%) (52%) (9%) (100%) * Cervical root irritation causing pain in neck radiating down arm These treatments were almost exclusively prophylactic 32

4 (perhaps they would have got better spontaneously!) The author s success in treating chronic conditions such as migraine and pre-menstrual syndrome often requires regular attendance by patients (usually on a monthly basis, but sometimes less frequently). These patients may become dependent, but they and the author accept this if they continue to benefit well from treatment for conditions that were previously causing significant distress and debilitation over a long period of time. The author has been able to demonstrate prescribing cost savings for patients with migraine having repeat prescriptions of triptans, an expensive group of drugs. A number of conditions are listed with very few patients being treated in each case. The author is cautious about using the results obtained as a guide to future practice due to the small numbers involved, but has recently gained significant encouragement treating irritable bowel syndrome and eczema. Conditions such as smoking cessation and obesity have not been treated at all. This is partly due to lack of training in auriculotherapy techniques, but also to evidence suggesting that benefits, for smoking cessation in particular, may not be greater than currently available treatments such as nicotine replacement therapy combined with appropriate counselling. With the availability of time and space, and partner support, the author is able to achieve a rapid consultation rate of 10 patients/hour whilst still maintaining flexibility in treatment time and approach. Anecdotally, he believes that other acupuncturists in general practice do not match this rate of consulting. The major disadvantage is shortage of time to talk to patients and deal with other or ongoing issues that may or may not be related to the condition being treated. A possible advantage is that a truer reflection of the benefits of acupuncture may result as a consequence of minimising the non-specific effects related to the consultation. Adverse effects have been rare. The commonest is vasovagal syncope. The lesson was soon learnt that new patients should be on the examination couch for their first treatment! This has rarely led to discontinuation of treatment. Bruising is a problem which is generally unavoidable and occasionally dramatic. One patient who was having monthly treatment for migraine prophylaxis developed severe pain and loss of sensation in one hand after needling LI4 and this persisted for 24 hours before resolving completely. The author had needled this point more than 20 times previously in the same patient, without difficulties. The author has been guilty of two cardinal errors forgotten needles and forgotten patients. The former occurs most frequently with long-haired women having needles inserted in their scalp and neck. Needles are now counted in and out, and patients are also asked to check themselves before they leave the room. The cases of forgotten patients have caused much anxiety. The risk of this is increased by using several rooms, and also competing demands of general practice, such as having to leave the building for an emergency. The author now employs a number of mechanisms to eliminate this problem. First, the establishment of dedicated acupuncture clinics when the author is not on-call for emergencies; secondly, meticulous records are kept of where patients have been left and when they have been retrieved; thirdly, patients are asked to report back to the receptionist on leaving. If they have not reappeared within 30 minutes of being called in the receptionist notifies the doctor (all reception staff have a written protocol explaining these procedures). Finally, the author is considering the use of a cordless telephone so that patients can contact him or the receptionist if there is a problem. This would also give patients extra security if they are anxious or perhaps being treated for the first time. The practice considered forgotten patients as a serious critical incident in our clinical governance meetings and all the partners agreed the above measures. It is fortunate that the patients involved were most forgiving and still attend on a regular basis. Perhaps a salutary tale for any new GP acupuncturists. The author will also include worsening of the condition in this section, because although rare it can be quite dramatic. This has been most often found, in the author s experience, with migraine and CFS and he now adapts his treatment of these conditions very carefully according to how the patient is when they attend. The author is convinced of the importance of obtaining the Diploma in Medical Acupuncture, and of continuing education and the value of 33

5 reaccredidation. He hopes to be able to have the flexibility to treat patients with acute symptoms and children more often, as these are groups that he feels respond well. The author would also like to learn auriculotherapy and electroacupuncture techniques. He hopes to be able to audit his future results in a more robust way, possibly through the use of patient questionnaires and with the aid of acupuncture software now installed on the practice computer. Finally if it were properly resourced and supported the author would greatly value the opportunity to use his clinical experience to participate in research studies to hopefully add to the evidence base of effectiveness of acupuncture, which may ultimately persuade his peers on the PCT that this is a treatment worth funding. Acupunct Med: first published as /aim on 1 January Downloaded from on 18 August 2018 by guest. Protected by copyright. 34