OBJECTIVE -- This study compared the prevalence and pattern of use of complementary and alternative medicine (CAM) in individuals with and without diabetes and identified factors associated with CAM use.
RESEARCH DESIGN AND METHODS -- The 1996 Medical Expenditure Panel Survey, a nationally representative sample of the U.S. noninstitutionalized civilian population, was analyzed. Estimates of CAM use in individuals with common chronic conditions were determined, and estimates of CAM use in patients with diabetes were compared with that in individuals with chronic medical conditions. Patterns of use and costs of CAM use in patients with diabetes were compared with those in nondiabetic individuals. Multiple logistic regression was used to determine independent predictors of CAM use in individuals with diabetes, controlling for age, sex, race/ethnicity, household income, educational level, and comorbidity.
RESULTS -- Individuals with diabetes were 1.6 times more likely to use CAM than individuals without diabetes (8 vs. 5%, P < 0.0001). In the general population, estimates of CAM use were not significantly different across selected chronic medical conditions, but diabetes was an independent predictor of CAM use. Among individuals with diabetes, older age ([greater than or equal to]65 years) and higher educational attainment (high school education or higher) were independently associated with CAM use.
CONCLUSIONS -- Diabetes is an independent predictor of CAM use in the general population and in individuals with diabetes. CAM use is more common in individuals aged [greater than or equal to]65 years and those with more than high school education.
Diabetes is a chronic debilitating medical condition that affects [sim]16 million individuals in the U.S.; [sim]2,200 new cases of diabetes are diagnosed each day (1). Diabetes is associated with significant morbidity and mortality. It is the leading cause of end-stage renal disease and amputation of the lower extremity in the general population and the leading cause of new cases of blindness in individuals aged 20-74 years. In addition, diabetes is the seventh leading cause of death in the U.S. (2). Furthermore, diabetes imposes significant financial burden on individuals with the disease. The annual medical cost associated with diabetes is [sim]98 billion dollars, including direct and indirect medical costs and lost productivity (3).
Complementary and alternative healthcare and medical practices, i.e. complementary and alternative medicine (CAM), are functionally defined as treatments and healthcare practices that are not taught widely in medical schools and are not generally available in U.S. hospitals (4). The National Center for Complementary and Alternative medicine (NCCAM) defines CAM as those healthcare and medical practices that are not currently an integral part of conventional medicine (5). The NCCAM definition restricts the term "conventional medicine" to medicine practiced by holders of MD (medical doctor) or DO (doctor of osteopathy) degrees, some of whom may also practice CAM (5).
There is evidence that an increasing number of individuals in the U.S. use one or more CAM remedies for the treatment of common medical conditions (4,6). There seem to be differences in CAM usage, based on age, sex, income level, and educational status. Eisenberg et al. (6) reported that CAM use was highest in individuals with college education, women, adults aged 35-49 years, and individuals with household incomes > $50,000, whereas CAM use was lowest in African Americans. Bausell et al. (7) found higher prevalence of CAM use in adults aged 30-49 years, women, individuals living in the Midwest, and whites compared with individuals of other racial or ethnic groups. In addition, several studies have observed an increased use of CAM in individuals with chronic medical conditions (6-8).
Current data suggest that most patients use CAM in addition to conventional medical treatments (6,9). However, data are sparse on the types of CAM used by individuals with diabetes. In addition, it is unknown whether individuals with diabetes use CAM more than those with common chronic medical conditions or what factors are associated with CAM use in individuals with diabetes. The Medical Expenditure Panel Survey (MEPS), which is a nationally representative survey of the U.S. population, collected data on CAM use for the first time in the 1996 survey. The MEPS provides a unique opportunity to answer several of these questions because it collected data on medical conditions, health insurance, demographic information, and health care use and expenditures.
To provide preliminary data for future studies, we sought to ascertain 1) whether individuals with common chronic medical conditions, including diabetes, were more likely to use CAM than individuals without such chronic conditions; 2) whether CAM use in individuals with diabetes was higher than CAM use in individuals with other common chronic medical conditions; and 3) the pattern of use, costs, and factors independently associated with CAM use in individuals with diabetes.
RESEARCH DESIGN AND METHODS
Study design
We combined data from the household and medical conditions components of the 1996 MEPS to determine the prevalence and pattern of use of alternative care in individuals with diabetes. The household component of MEPS is a survey of the U.S. civilian, noninstitutionalized population, drawn from the National Health Interview Survey sample with oversampling of Hispanics and blacks. This survey, sponsored by the Agency for Health Care Research and Quality, provides national estimates of health care use, health conditions, health status, insurance coverage, and access to care (10). In 1996, questions on prevalence, pattern, and costs associated with CAM were incorporated into the survey. A total of ~21,571 individuals were surveyed, and the overall response rate for 1996 was 77.7%.
Medical conditions
For the medical conditions component of MEPS, interviewers recorded verbatim the medical conditions and procedures as reported by the respondents. Then, professional coders used the verbatim text to assign fully specified 1996 International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) codes, including medical conditions and V codes. The error rate for any coders did not exceed 2.5% on verification. Assigned codes were verified by contacting medical providers and pharmacies that were identified by the respondents during the interview. To protect the confidentiality of respondents, fully specified ICD-9-CM codes were collapsed to three digits. For example, the ICD-9-CM code 250 (diabetes) represented diabetes, high blood glucose, juvenile diabetes, and adult-onset diabetes or diabetes neuropathy (11).
CAM
The MEPS defined CAM as "approaches to health care that are different from those typically practiced by medical doctors in the U.S." This definition, which is similar to the NCCAM definition of CAM, included acupuncture, nutritional advice or lifestyle diets, massage therapy, herbal remedies, biofeedback, meditation, and imagery or relaxation techniques. Other treatments included in this definition of CAM were homeopathic treatment, spiritual healing or prayer, hypnosis, and traditional therapies such as Chinese, Ayurvedic, and Native American medicine. A card with the list above was presented to respondents. Then, the interviewer read the following statement verbatim to each respondent: "In order to get as complete a picture as possible of all sources of health care, we would also like to ask about the use of other forms of health care, including treatments you may have previously told me about, such as the treatments shown on this card. Frequently, this type of care is referred to as "complementary or alter native care." During the calendar year 1996, did you consult someone who provides these types of treatment?" Individuals who responded affirmatively were asked to indicate the specific treatment, the type of CAM providers visited, and the number of visits to such providers. Respondents were also asked to indicate the cost of CAM visits, percentage of CAM costs covered by health insurance, and out-of-pocket costs for CAM.
Demographic variables
