In recent days, journalists across the world had a field day (mis)reporting that doctors practising integrative medicine were doing something positive after all. I think that the paper shows nothing of the kind – but please judge for yourself.
The authors of this article wanted to determine differences in antibiotic prescription rates between conventional General Practice (GP) surgeries and GP surgeries employing general practitioners (GPs) additionally trained in integrative medicine (IM) or complementary and alternative medicine (CAM) (referred to as IM GPs) working within National Health Service (NHS) England.
They conducted a retrospective study on antibiotic prescription rates per STAR-PU (Specific Therapeutic group Age–sex weighting Related Prescribing Unit) using NHS Digital data over 2016. Publicly available data were used on prevalence of relevant comorbidities, demographics of patient populations and deprivation scores. setting Primary Care. Participants were 7283 NHS GP surgeries in England. The association between IM GPs and antibiotic prescribing rates per STAR-PU with the number of antibiotic prescriptions (total, and for respiratory tract infection (RTI) and urinary tract infection (UTI) separately) as outcome. results IM GP surgeries (n=9) were comparable to conventional GP surgeries in terms of list sizes, demographics, deprivation scores and comorbidity prevalence.
Statistically significant fewer total antibiotics were prescribed at NHS IM GP surgeries compared with conventional NHS GP surgeries. In contrast, the number of antibiotics prescribed for UTI were similar between both practices.
The authors concluded that NHS England GP surgeries employing GPs additionally trained in IM/CAM have lower antibiotic prescribing rates. Accessibility of IM/CAM within NHS England primary care is limited. Main study limitation is the lack of consultation data. Future research should include the differences in consultation behaviour of patients self-selecting to consult an IM GP or conventional surgery, and its effect on antibiotic prescription. Additional treatment strategies for common primary care infections used by IM GPs should be explored to see if they could be used to assist in the fight against antimicrobial resistance.
The study was flimsy to say the least:
- It was retrospective and is therefore open to no end of confounders.
- There were only 9 surgeries in the IM group.
Moreover, the results were far from impressive. The differences in antibiotic prescribing between the two groups of GP surgeries were minimal or non-existent. Finally, the study was financed via an unrestricted grant of WALA Heilmittel GmbH, Germany (“approx. 900 different remedies conforming to the anthroposophic understanding of man and nature”) and its senior author has a long track record of publishing papers promotional for anthroposophic medicine.
Such pseudo-research seems to be popular in the realm of CAM, and I have commented before on similarly futile projects. The comparison, I sometimes use is that of a Hamburger restaurant:
Employees by a large Hamburger chain set out to study the association between utilization of Hamburger restaurant services and vegetarianism. The authors used a retrospective cohort design. The study population comprised New Hampshire residents aged 18-99 years, who had entered the premises of a Hamburger restaurant within 90 days for a primary purpose of eating. The authors excluded subjects with a diagnosis of cancer. They measured the likelihood of vegetarianism among recipients of services delivered by Hamburger restaurants compared with a control group of individuals not using meat-dispensing facilities. They also compared the cohorts with regard to the money spent in Hamburger restaurants. The adjusted likelihood of being a vegetarian was 55% lower among the experimental group compared to controls. The average money spent per person in Hamburger restaurants were also significantly lower among the Hamburger group.
To me, it is obvious that such analyses must produce a seemingly favourable result for CAM. In the present case, there are several reasons for this:
- GPs who volunteer to be trained in CAM tend to be in favour of ‘natural’ treatments and oppose synthetic drugs such as antibiotics.
- Education in CAM would only re-inforce this notion.
- Similarly, patients electing to consult IM GPs tend to be in favour of ‘natural’ treatments and oppose synthetic drugs such as antibiotics.
- Such patients might be less severely ill that the rest of the patient population (the data from the present study do in fact imply this to be true).
- These phenomena work in concert to generate less antibiotic prescribing in the IM group.
In the final analysis, all this finding amounts to is a self-fulfilling prophecy: grocery shops sell less meat than butchers! You don’t believe me? Perhaps you need to read a previous post then; it concluded that physicians practicing integrative medicine (the 80% who did not respond to the survey were most likely even worse) not only use and promote much quackery, they also tend to endanger public health by their bizarre, irrational and irresponsible attitudes towards vaccination.
What is upsetting with the present paper, in my view, are the facts that:
- a reputable journal published this junk,
- the international press has a field-day reporting this study implying that CAM is a good thing.
The fact is that it shows nothing of the kind. Imagine we send GPs on a course where they are taught to treat all their patients with blood-letting. This too would result in less prescription of antibiotics, wouldn’t it? But would it be a good thing? Of course not!
True, we prescribe too much antibiotics. Nobody doubts that. And nobody doubts that it is a big problem. The solution to this problem is not more CAM, but less antibiotics. To realise the solution we do not need to teach GPs CAM but we need to remind them of the principles of evidence-based practice. And the two are clearly not the same; in fact, they are opposites.
I hesitate to critique such a bizarre paper and wonder if the upload to the BMJ Open site was not on April 1st.
The research’s stated ‘Objective’ was “To determine differences in antibiotic prescription rates between conventional General Practice (GP) surgeries and GP surgeries employing general practitioners (GPs) additionally trained in integrative medicine (IM) or complementary and alternative medicine (CAM) (referred to as IM GPs) working within National Health Service (NHS) England.”
There is no specialty of ‘integrative medicine’ in the UK – simply some doctors who additionally endorse and even apply a range of CAMs (camistry). They pander to patients who are gullible and vulnerable and who do not appreciate the nature of camistry. These practitioners do not obtain fully informed consent and many people might regard them as quacks.
In the paper, there was no discussion directed to the stated aim, but rather the authors assumed who in the practices might have been prescribing. They ascribed lower anti-biotic rates to the so-called ‘IM’ practitioners. The practice rate might well have been a function of prescribing by its conventional practitioners – we simply do not know.
The authors’ statement: “The lower antibiotic prescription rates of IM GPs are in line with the current national guidance aimed at reducing antibiotic usage and antimicrobial resistance. IM GPs might possible comply more closely with this guidance (sic) ” , introduces a false premise – their study was of GP practices, not individual practitioners.
The authors do honestly admit:
“The small proportion of NHS IM GPs in England asks for careful interpretation of the results.”
And to the funding for their efforts: “This research was supported in part by an unrestricted grant of WALA Heilmittel GmbH, Germany.
(They then claim: “Competing interests – None declared.”)
[From its website: “WALA, founded in 1935 in Ludwigsburg by Dr. Rudolf Hauschka – manufacturer of the anthroposophical, homeopathic WALA medicines, the Dr.Hauschka range of natural skin care products and the natural Dr.Hauschka Med health and hygiene products.”]
A glaring gap in the data is any consideration of clinical outcomes. Did the IM GPs have better or worse outcomes for infections? But the statistical noise in this study would no doubt preclude any analysis of that.
I don’t think I want to know how bad the media reporting of this study is. Nor what the world of quackery is making of it.
Antibiotic prescribing rates for two very broad conditions is not indicative of anything in particular. It certainly isn’t a measure of outcomes of treatment. Prescribing data is very limited in terms of what fields it contains – basically what was prescribed, what month year it was prescribed, what it cost and GP practice.
I would have thought that the prescribing of certain antibiotics would be a better signifier of AMR prevalence?
Some readers will be aware of my fairly rough and ready analysis of NHS England GP prescribing of homeopathic medicines. https://ukhomeopathyregulation.blogspot.co.uk/2017/12/nhs-homeopathy-3-analysis-gp.html The key finding is that GPs who routinely prescribe homeopathic medicines tend to be Anthroposophists and generally are in breach of locally agreed formulary and policy. IIRC correctly, the real enthusiasts for homeopathy/anthroposophical medicine either work outside of the NHS or offer their magic treatments as a private sideline to being a GP. Steiner schools and Camphill communities certainly use them but whether they get paid or not is unknown.