CAM Should Be Held to Same Standard as Conventional Medicine, Report Says
A new report from the Institute of Medicine of the National Academies calls for conventional medical treatments and complementary and alternative medicine (CAM) treatments to be held to the same standards for demonstrating clinical effectiveness. The same general research principles should be followed in evaluating both types of treatments, although innovative methods to test some therapies may have to be devised, says the committee that wrote the report.
"Of primary importance to the committee, and underlying all its deliberations, was the question, What do patients and health professionals need to know to make good decisions about use of health care interventions, including CAM?’" says committee chair Stuart Bondurant, MD, interim executive vice president for health sciences and executive dean at Georgetown University Medical Center in Washington, DC. He spoke at a press briefing after the release of the report.
"One answer to that question concerns whether treatments are safe and effective. We recognize that there are extremes of belief about how to judge effectiveness. For some individuals, evidence limited to their own experience or knowledge is all that is necessary to prove that a CAM therapy is effective. For others, no amount of evidence is sufficient. This report will please neither of those extremes."
The report was written to assist the National Institutes of Health in developing research methods and setting priorities for evaluating products and approaches within CAM. The report also assesses what is known about Americans’ reliance on these therapies: Use of CAM is widespread among the U.S. public, with more than one-third of adults reporting that they have pursued some form of these treatments.
The committee reviewed an extensive collection of relevant literature for the report and heard a series of expert presentations, discussions, and public comments in open meetings, Bondurant says. The committee also established a working liaison group composed of 32 leaders of CAM and conventional medical disciplines and held a number of formal and informal interchanges with these groups.
"The intent of the report is not to medicalize or co-opt CAM but to sustain the existing forms of validated CAM therapies, whether integrated into conventional practices or continued as freestanding approaches," Bondurant says. The committee urged that great care be taken to test CAM therapies in the ways that they are used, he adds.
With the use of dietary supplements escalating, the committee recommends the testing of CAM therapies to address a lack of consistency and quality in these products. This inconsistency can hinder health professionals’ abilities to guide patients on the use of supplements and researchers’ ability to study them, the committee says. The report calls on Congress to work with stakeholders to amend the regulation of supplements to improve quality control and consumer protections and to create incentives for research on the efficacy of these products.
The committee promotes randomized controlled trials (RCTs) as the gold standard for providing evidence of efficacy. Other study designs, however, can generate useful information on treatments that do not lend themselves to RCTs. "Observational studies, case control studies, and studies that specifically measure patients’ expectations, emotional states, and other self-healing processes can provide useful data," the committee notes in a statement. "Some conventional treatments, such as psychotherapy, also have similar characteristics that make them incompatible with RCTs, but they have been successfully evaluated via other methods."
Since many CAM products and approaches have not undergone formal testing and since resources to conduct research are limited, the report outlined several criteria to help determine which CAM therapies to prioritize for study. These same criteria also apply to as-yet untested conventional treatments, the committee noted. The criteria include the prevalence and severity of the target health condition; existing evidence that the therapy is effective or may have safety issues; the question of whether a plausible biological mechanism exists by which the therapy might work or the likelihood that research will discover a mechanism; and the likelihood that research will yield unambiguous results. Inability to meet any one of the criteria should not necessarily exclude a therapy from consideration, the report says.
The report also discusses the importance of having CAM practitioners involved in research to ensure that research reflects as much as possible the actual ways in which CAM therapies are administered and used, Bondurant says. "We call for more CAM practitioners to be trained in research. Furthermore, practice guidelines for CAM therapies should be developed by CAM practitioners to foster research and quality.
"The committee believes that health care is in the middle of an exciting time of discovery, a time when an evidence-based approach brings opportunities for the incorporation of the best options from all sources of care —both conventional medicine and CAM," Bondurant says. "The challenge is to avoid parochial bias and to approach each possibility with an appropriate degree of both skepticism and open-mindedness. Only then will it be possible to ensure that informed, reasoned, and knowledge-based decisions are made."