Trends in Alternative Medicine Use in the United States, 1990-1997 Results of a Follow-Up National Survey

Original Contributions Trends in Alternative Medicine Use in the United States, 1990-1997 Results of a Follow-up National Survey David M. Eisenberg, MD; Roger B. Davis, ScD; Susan L. Ettner, PhD; Scott Appel, MS; Sonja Wilkey; Maria Van Rompay; Ronald C. Kessler, PhD Context.—A prior national survey documented the high prevalence and costs of native medicine prevalence, costs, and alternative medicine use in the United States in 1990. patterns of use1 demonstrated that al- Objective.—To document trends in alternative medicine use in the United States ternative medicine has a substantial between 1990 and 1997. presence in the US health care system. 2 Design.—Nationally representative random household telephone surveys using Data from a survey in 1994 and a public opinion poll in 19973 confirmed the ex- comparable key questions were conducted in 1991 and 1997 measuring utilization tensive use of alternative medical thera- in 1990 and 1997, respectively. pies in the United States. An increasing Participants.—A total of 1539 adults in 1991 and 2055 in 1997. number of US insurers and managed Main Outcomes Measures.—Prevalence, estimated costs, and disclosure of care organizations now offer alternative alternative therapies to physicians. medicine programs and benefits.4 The Results.—Use of at least 1 of 16 alternative therapies during the previous year majority of US medical schools now of- increased from 33.8% in 1990 to 42.1% in 1997 (P#.001). The therapies increas- fer courses on alternative medicine.5 ing the most included herbal medicine, massage, megavitamins, self-help groups, National surveys performed outside folk remedies, energy healing, and homeopathy. The probability of users visiting an the United States suggest that alterna- alternative medicine practitioner increased from 36.3% to 46.3% (P = .002). In both tive medicine is popular throughout the industrialized world.6 The percentage of surveys alternative therapies were used most frequently for chronic conditions, in- the population who used alternative cluding back problems, anxiety, depression, and headaches. There was no signiﬁ- therapies during the prior 12 months has cant change in disclosure rates between the 2 survey years; 39.8% of alternative been estimated to be 10% in Denmark therapies were disclosed to physicians in 1990 vs 38.5% in 1997. The percentage (1987),7 33% in Finland (1982),8 and 49% of users paying entirely out-of-pocket for services provided by alternative medicine in Australia (1993).9 Public opinion polls practitioners did not change signiﬁcantly between 1990 (64.0%) and 1997 (58.3%) and consumers’ association surveys sug- (P = .36). Extrapolations to the US population suggest a 47.3% increase in total gest high prevalence rates throughout visits to alternative medicine practitioners, from 427 million in 1990 to 629 million Europe and the United Kingdom.10-13 in 1997, thereby exceeding total visits to all US primary care physicians. An esti- The percentage of the Canadian popula- mated 15 million adults in 1997 took prescription medications concurrently with tionwhosawanalternativetherapyprac- titioner during the previous 12 months herbal remedies and/or high-dose vitamins (18.4% of all prescription users). Esti- has been estimated at 15% (1995).14 The mated expenditures for alternative medicine professional services increased 45.2% wide range of utilization rates can be between 1990 and 1997 and were conservatively estimated at $21.2 billion in 1997, explained, in part, by the disparity in with at least $12.2 billion paid out-of-pocket. This exceeds the 1997 out-of-pocket definitions of alternative therapy and the expenditures for all US hospitalizations. Total 1997 out-of-pocket expenditures re- selection of therapies assessed. lating to alternative therapies were conservatively estimated at $27.0 billion, which The presumption is that alternative is comparable with the projected 1997 out-of-pocket expenditures for all US phy- medicine use in the United States has sician services. increased at a considerable pace in re- Conclusions.—Alternative medicine use and expenditures increased substan- cent years. The purpose of this follow-up tially between 1990 and 1997, attributable primarily to an increase in the proportion national survey was to investigate this presumption and document trends in al- of the population seeking alternative therapies, rather than increased visits per ternative medicine prevalence, costs, patient. disclosure of use to physicians, and cor- JAMA. 1998;280:1569-1575 relates of use since 1990. From the Center for Alternative Medicine Research ALTERNATIVE medical therapies, METHODS and Education, Department of Medicine, Beth Israel functionally defined as interventions Deaconess Medical Center (Drs Eisenberg and Davis, neither taught widely in medical schools Sample Mr Appel, and Mss Wilkey and Van Rompay), and the 1 Department of Health Care Policy, Harvard Medical nor generally available in US hospitals, We conducted parallel nationally rep- School (Drs Ettner and Kessler), Boston, Mass. have attracted increased national atten- resentative telephone surveys in 1991 Reprints: David M. Eisenberg, MD, Center for Alter- tion from the media, the medical com- and 1997. Survey methods were ap- native Medicine Research and Education, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, munity, governmental agencies, and the proved by the Beth Israel Deaconess In- MA 02215. public. A 1990 national survey of alter- stitutional Review Board, Boston, Mass. JAMA, November 11, 1998—Vol 280, No. 18 Trends in Alternative Medicine Use in the United States—Eisenberg et al 1569 ©1998 American Medical Association. All rights reserved. Downloaded from www.jama.com by TedNissen, on February 28, 2007 Both surveys used random-digit dialing conversion rate to all of the refusers and scribed by a doctor. Prayer or spiritual to select households and random selec- weighting the data for the undersam- healing by others was asked about sepa- tionof1householdresident,aged18years pling of initial refusers, we obtained a 60% rately from prayer or spiritual practice or older, as the respondent. Eligibility (41.3% + [31.4% × (100% − 41.3%)]) for individual health concern. Commer- was limited to English speakers in whom weighted overall response rate among eli- cial diet programs were described as cognitive or physical impairment did not gible respondents. “the kind you have to pay for, but not prevent completion of the interview. We including trying to lose or gain weight on asked respondents about their use of al- Interview your own.” A lifestyle diet included ex- ternative therapies during the prior 12 In both years, the interview was pre- amples like vegetarianism or macrobiot- months. We consider the results of the sented as a survey conducted about the ics. Questions regarding energy healing 1991 survey, fielded between January health care practices of Americans by included examples of magnets, energy- and March of that year, representative of investigators from Harvard Medical emitting machines, or the “laying on of 1990, and the results of the 1997 survey, School. No mention was made of alter- hands,” and use of relaxation techniques fielded between November 1997 and native or complementary therapies. The was explained using the examples of February 1998, representative of 1997. substantive questions began by asking meditation or the relaxation response. The sampling scheme was designed about perceived health, health worries, The remaining 9 therapies were asked with a target sample of 1500 in 1990 and days spent in bed, and functional impair- about without interviewer clarification. 2000 in 1997. The latter sample size was ment due to health problems. We then The 1997 survey was longer (average, chosentoprovidepowerinexcessof80% asked respondents about their interac- 30 minutes) than the 1990 survey (aver- to detect an increase from 34% to 39% in tions with a medical doctor, defined as “a age, 25 minutes) because we sought to theproportionofadultswhousedatleast medical doctor (MD) or a doctor of os- explore a number of areas in more depth. 1 form of alternative therapy during the teopathic medicine (DO), not a chiro- All the important questions in the 1990 prior 12 months. The actual numbers of practororothernonmedicaldoctor.”The survey were repeated in 1997. These completed interviews were 1539 in 1990 term medical doctor was used through- replicated questions are the focus of the (67% response rate) and 2055 in 1997 out the remainder of the interview. current report. One major change in the (60% weighted response rate). A secular To document trends we explored the 1997 survey involved replicated ques- trend in lower survey response required following: (1) Respondents in both sur- tions: respondents who reported using us to offer a $20 financial incentive for veys were presented with a list of com- more than 3 alternative therapies were participation in the 1997 survey to main- mon medical conditions and asked if they asked in-depth questions (eg, use of a tain a response rate near the one had experienced each of these conditions practitioner of alternative therapies, achieved in 1990. No financial incentive during the previous 12 months. (2) Re- number of visits, out-of-pocket ex- was used in the 1990 survey. spondents who reported more than 3 penses, reasons for use) for all such The data in each survey were sepa- conditions were asked to identify their 3 therapies in 1990 but only for a random rately weighted to adjust

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