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Anesth Analg 2003;97:1010-1015
© 2003 International Anesthesia Research Society

AMBULATORY ANESTHESIA

The Use of Complementary and Alternative Medicines by Surgical Patients: A Follow-Up Survey Study

Shu-Ming Wang, MD*, Alison A. Caldwell-Andrews, PhD{dagger}, and Zeev N. Kain, MD*,{dagger},{ddagger}

Departments of *Anesthesiology, {dagger}Pediatrics, and {ddagger}Child Psychiatry, Yale University School of Medicine, New Haven, Connecticut

Address correspondence and reprint requests to Shu-Ming Wang, MD, Department of Anesthesiology, Yale School of Medicine, 333 Cedar St., New Haven, CT 06510. Address e-mail to shu-ming.wang{at}yale.edu


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Appendix
 References
 
In a previous study, we indicated that 42% of surgical outpatients are interested in using acupuncture as a treatment modality for preoperative anxiety. We designed this follow-up survey to assess differences in attitude toward complementary-alternative medical therapies (CAM) between patients undergoing outpatient surgeries and those undergoing inpatient surgeries. The results indicate that most surgical patients (57.4%) use some form of CAM, including self-prayer (praying for their own health; 29%), chiropractic treatment (23%), massage therapy (15%), relaxation (14%), herbs (13%), megavitamins (9%), and acupuncture (7%). Inpatient surgical respondents reported using self-prayer more than outpatient surgical respondents, but no other differences in CAM use were found between inpatient and outpatient respondents. More inpatient respondents reported disclosing their usage of CAM to perioperative physicians than did outpatient respondents. Most surgical patients were willing to accept CAM as part of their perioperative management but were not willing to pay out-of-pocket for CAM treatment. The leading CAM therapies that fewer of the respondents were willing to pay for out-of-pocket included relaxation, massage, chiropractic medicine, herbs, and acupuncture.

IMPLICATIONS: Most surgical patients use some form of complementary-alternative medical therapies (CAM) and are willing to accept CAM therapy as part of their perioperative management.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Appendix
 References
 
There is an increased interest in the general public regarding the usage of complementary and alternative medicine (CAM). The term denotes a wide range of variable therapies. CAM includes treatments with established benefits and few if any side effects (e.g., acupuncture (1–7), progressive muscle relaxation (8), music therapy (9–12), or imagery based relaxation (13)) as well as treatments with less established benefits and an increased potential for adverse side effects (e.g., some herbal medicines (14–16) or possibly chelation). A previous survey indicated that one of every three Americans use some form of CAM therapy (17). However, fewer than 40% of CAM users disclose their use of CAM to their physician (17). This is important because some CAM therapies are not free of side effects. For example, several case reports and review articles indicate that some herbal medications can interact with conventional medications and may lead to perioperative adverse effects, such as hemorrhage (16), cardiovascular instability, excessive somnolence (14,18), and photosensitivity (15). Therefore, it is important for perioperative physicians to explore the prevalence and the type of CAM therapy use in all surgical patients.

CAM therapies provide patients with a sense of control over their medical care (19). In addition, increasing amounts of valid scientific data indicate that there are benefits to some CAM therapies regarding certain disease conditions and surgery-related issues (1–7,9,11,20–23). Thus, we were also interested to know which CAM therapies surgical patients would be interested in incorporating into their perioperative medical care.

A previous study conducted by our group showed that 32% of all patients undergoing outpatient ambulatory surgery are currently using some form of CAM therapy and that 42% of these patients would use acupuncture as a medical intervention directed to decrease preoperative anxiety (24). However, this study was criticized because it only included individuals undergoing outpatient procedures (i.e., minor surgery) and did not include individuals undergoing inpatient surgery (i.e., major surgery). This distinction between patient types is important because attitudes toward the use of CAM therapy during the perioperative period may significantly differ between these two populations. For instance, outpatients anticipate a different course of medical treatment than do inpatients, with concomitant differing cognitions, levels of anxiety, and short- and long-term expectations. In addition, most patients undergoing outpatient procedures (i.e., minor surgery) anticipate immediate ambulation and a speedy recovery after surgery, in contrast to persons undergoing inpatient procedures (i.e., major surgery). That is, outpatients may be less willing to incorporate interventions that prolong their sedation or recovery. Hence, the willingness to incorporate perioperative CAM therapy may be different among patients undergoing minor outpatient procedures as compared with those undergoing major surgical procedures that require postoperative hospitalization.

Americans have spent billions of out-of-pocket dollars for CAM therapies (17). In fact, CAM therapies are recognized as "silent mainstream medicine" (25). However, the question as to whether the public is willing to pay out-of-pocket money for CAM therapies that are a part of their perioperative care remains to be answered. We therefore undertook this survey study to (a) assess the prevalence of specific CAM use among patients undergoing major surgery requiring hospitalization (inpatient respondents) and patients undergoing minor ambulatory surgery (outpatient respondents) and (b) address the issue of willingness-to-pay among the respondents of the survey.

As noted above, CAM therapies include a diverse mix of treatments. To be comprehensive, we wanted to include a wide variety of CAM therapies in this survey. We therefore chose to include all the CAM therapies that were noted by a national survey (17), as well as two additional, more recent, CAM therapies (aromatherapy and chelation).


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Appendix
 References
 
From January 2002 to April 2002, an anonymous survey was distributed to all patients presenting for nonemergent surgery at Yale-New Haven Hospital. We excluded patients who were under the age of 18 yr, who were non-English speaking, who had mental retardation, or who had already participated in the 4-mo study period (so as to prevent respondents from participating twice in this study). Two research assistants administered all surveys in the preoperative holding area and were available to answer all questions. The survey was introduced by the investigators as a survey about CAM use (particularly in the interest of perioperative care) that was sponsored by the Department of Anesthesiology and that in the case of this survey, disclosure to medical doctors specifically referred to perioperative physicians. The study was approved by the IRB of Yale University School of Medicine.

The survey used in this study was developed on the basis of a literature search aimed at the types of CAM therapy used in the United States. The initial version of the survey consisted of 17 questions regarding the characteristics of the respondents and their use of CAM therapies. During the pilot phase of the study, the questionnaire was pretested by 50 patients and subsequently revised based on analysis of their responses. The final version of the survey instrument (see Appendix) was limited to 14 questions in four main categories, which are as follows:

  1. Characteristics of the respondent including demographics and details about the underlying condition, the surgery, prescription, and nonprescription medications taken.
  2. Past and present experience with 19 popular CAM therapies (relaxation, herb, massage, chiropractic, acupuncture, biofeedback, self-help, imagery, diet, folk remedies, energy healing, homeopathy, hypnosis, spiritual healing by others, prayer, megavitamins, aromatherapy, and chelation). The survey also offered an opportunity to write in any other CAM therapy used by the respondent.
  3. Reasons for using CAM therapy and willingness to accept CAM therapy in the perioperative setting (including self-pay versus third-party payer).
  4. Disclosure of the use of CAM therapy to the perioperative physicians. Because of the particular perioperative risks associated with herbal medicine, we also asked specifically about disclosure regarding their use.

Data were analyzed with the use of SPSS version 11 (SPSS Inc, Chicago, IL). Demographic data were summarized as the mean and SD for continuous data and frequency for categorical data. We examined differences between inpatient respondents and outpatient respondents using Student’s t-test for continuous data and {chi}2 for categorical data. We also examined current use of CAM and overall use of CAM. Overall use was defined as whether or not the patient reported ever using a CAM therapy, whether the use was recent or long past, short-term, or long-term. These differences between current uses were examined using Student’s t-test for continuous data and {chi}2 test for categorical data. Significance level was accepted at P < 0.05.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Appendix
 References
 
Of the 2000 patients screened, 296 were excluded based on the criteria identified in the Methods section. Of the remaining patients, 1235 returned the questionnaire to the researchers conducting the study. Thus, the response rate of this survey was 71.9%. The mean age was 51 ± 18 yr, and the age range was 18–92 yr (Table 1).


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  		Table 1. Characteristics of Respondents (n = 1235)
 
Data analysis indicated that 706 (57.4%) patients reported that they had used at least one type of CAM therapy (either current or past use). The most popular CAM therapies (past or current use combined) included self-prayer (praying for their own health; 29%), chiropractic treatment (23%), massage/reflexology therapy (15%), relaxation techniques (14%), herbal medicine (13%), megavitamins (9%), and acupuncture (7%) (Table 2). Self-prayer was investigated to obtain estimates of prevalence of use; however, because it is qualitatively different from other CAM therapies, we then excluded self-prayer from this analysis. In addition, so few people used chelation (n = 2) that this form of CAM was also eliminated from all future analyses. We consequently found that 49.1% of all respondents used at least one form of CAM therapy, excluding self-prayer and chelation (range, 0–15).


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  		Table 2. Current CAM use in Outpatient and Inpatient Surgical Respondents
 
We next analyzed the current use of CAM (excluding self-prayer). We found that 25.1% of all respondents were currently using at least one form of CAM therapy, and 10.7% of all respondents were currently using from 2 to 14 forms of CAM therapy. The prevalence of this CAM use in inpatients and outpatients was then compared. We found no difference in current CAM use between inpatient and outpatient respondents (P = 0.82). We also found no difference in overall CAM use (whether patients had ever used CAM) between inpatient and outpatient respondents (P = 0.478).

We then compared specific current CAM therapy use among inpatient and outpatient respondents (Table 2). We found that inpatient respondents used significantly more self-prayer for their own health as compared with outpatient respondents. There were no other significant differences in reported current specific CAM therapy usages between inpatients and outpatients (Table 2).

Respondents who reported currently using CAM (excluding self-prayer) were slightly younger compared with respondents who reported no current use of CAM (49 ± 15 yr versus 52 ± 18 yr; P = 0.022), were more likely to have attended college (72.6% versus 27.4%; P = 0.001), and had a larger income (P = 0.005). The reported existence of a medical condition had no effect on current CAM therapy use (64.9% versus 66.3%; P = 0.65), and there were no differences in CAM therapy use between patients who took prescribed medication and patients who did not (68.6% versus 69.3%; P = 0.80).

Respondents indicated that the main reasons they used CAM therapy were "fewer or no side effects" (35.3%), "it was recommended by a friend or doctor" (18.9%), "keeps me healthy" (13.4%), "works better or as good as traditional medicine" (11.4%), "problem not serious enough to be seen by a doctor" (7%), and "other" (14%).

We next examined patients’ disclosure of CAM therapy use to their perioperative physicians. Although many patients reported that they disclosed their use of CAM to perioperative physicians, a substantial proportion reported that they did not disclose CAM use to perioperative physicians (Table 3). Up to 20% of all respondents reported that they did not disclose their CAM use to physicians unless specifically asked. Also, inpatient respondents were more likely to inform perioperative physicians about CAM use than were outpatient respondents (Table 3).


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  		Table 3. Patients’ Disclosure of CAM use to Perioperative Physicians
 
We found that overall, 76% of all respondents indicated that they would be willing to use some type CAM therapy (excluding self-prayer from the data analyses) as a part of their perioperative medical care (in the hospital or at home). Willingness to incorporate CAM therapy did not differ based on the status of the patient (inpatient versus outpatient). Thirty-five percent of all respondents were willing to incorporate relaxation into their anesthesia care. Respondents were also willing to incorporate acupuncture or acupressure (25%), hypnosis (21%), and herbal medicine (21%) into their anesthesia care. In addition, 24% of respondents were willing to have multiple combinations of CAM therapy as an adjunct to their anesthesia treatment. Analyses based on inpatient and outpatient status did not reveal any differences in this area between the two groups.

Analyses based on the mode of payment (self-pay versus third-party payer versus both) and type of CAM therapy are shown in Figure 1. Relaxation, massage, chiropractic medicine, herbal medicine, and acupuncture are the leading CAM therapies that fewer patients show some willingness to pay for. Patients are more willing to accept CAM therapy when paid for by a third party.



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  		Figure 1. The relationship between payments and the willingness of respondents in using complementary and alternative medical therapies (CAM) during the perioperative period. Self-pay = patients will accept CAM even if payment is out-of-pocket; third-party pay = patients will accept CAM only if insurance pays; both = patients will to accept CAM if insurance pays or if payment is out-of-pocket.

 
Finally, 62% of the respondents who indicated that they were unwilling to incorporate CAM therapy into their care reported that they might change their mind and be willing to accept CAM if perioperative physicians (e.g., anesthesiologists) would provide them with valid scientific support for a perioperative CAM therapy. Also, of the 62% of respondents who were willing to change their mind about CAM use, more reported education beyond the high school level than education at or less than the high school level (60% versus 40%; P = 0.001).


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Appendix
 References
 
Overall, our results underscore the increased acceptance of CAM therapies in the American surgical population. In this survey, we found that a significant portion of all patients presenting for surgery had at one time used some kind of CAM therapy, and over one-fourth of all patients were currently using some form of CAM therapy. Inpatient respondents reported an increased frequency of the use of self-prayer than did outpatients, but our results did not otherwise reveal any differences between outpatient and inpatient respondents in current use patterns for other specific CAM therapies. Although a large number of respondents indicated that they had disclosed current CAM therapy use to perioperative physicians, a substantial number indicated that they either had not disclosed such use or would do so only if asked.

National data also showed that educational level, income, and age significantly affected CAM use (17). Our results were consistent with these data. In addition, we found that of patients who were unwilling to use perioperative CAM therapy, those with some college education were more likely to change their mind as compared with those without some college education if perioperative physicians (e.g., anesthesiologists) were able to supply valid scientific data that supported the use of CAM therapy. Future studies should examine whether incorporating CAM therapy into the perioperative routine affects patient satisfaction or other outcomes.

Interestingly, in our previous study (24), we found that 42% of patients were willing to incorporate acupuncture into their perioperative care, contrasting with the current survey’s findings of only 25%. However, unlike the current survey, in our previous study we (a) offered acupuncture to treat a specific perioperative need, preoperative anxiety, and (b) provided educational information regarding empirically supported benefits of the perioperative use of acupuncture to these patients before inquiring as to their willingness to use this therapy.

Our results add to the literature that underscores the importance of inquiring about patients’ use of CAM therapy. A study involving 831 adults who saw a medical doctor and used CAM therapies indicated that only 28.1% of patients disclosed their use of all CAM therapies to their medical doctor (19). Our study found that nearly 50% of all surgical patients disclosed CAM use to perioperative physicians, and inpatient respondents were more likely to disclose current CAM use to perioperative physicians. The difference in disclosure rates between inpatient and outpatient respondents is likely dependent on the patient’s perceptions regarding their general health status and the intensity of surgery. The more frequent disclosure rates in our study, as compared with the previous study (19), may be a result of the different environments. That is, patients who are undergoing surgery may be more likely to disclose their use of CAM therapies compared with those presenting for a routine medical visit.

Finally, most respondents indicated that they will be willing to use some type CAM therapy as a part of their perioperative medical care, but only a few were willing to pay for CAM therapies out-of-pocket. We surmise that whereas Americans are apparently willing to pay billions of out-of-pocket dollars for CAM therapy in other contexts (17), they likely anticipate third-party payer responsibility for any perioperative care, including empirically supported CAM therapies.

In conclusion, we found that a significant proportion of patients who present for surgery use CAM therapy. This is important because several types of CAM therapies may interact with anesthetic management. Despite our finding that many patients spontaneously disclose their use of CAM therapy, a significant proportion of patients do not disclose this issue unless specifically asked. Thus, the practicing anesthesiologist should incorporate questions regarding the use of CAM therapies (particularly herbal medicines) into their routine preoperative evaluation.


   Appendix
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix
References
 



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   Acknowledgments
 
The authors would like to thank all patients who participated in this survey, as well as the staff at the ambulatory center at Yale-New Haven Hospital.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix
 References
 

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Accepted for publication May 7, 2003.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins and Stanford University Libraries' HighWire Press®. Copyright 2003 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press