When a Whole Practice Model is the Intervention: the leading edge Dodds/Herman research design for the U Arizona Center for Integrative Health

An important pilot project for Triple Aim outcomes of integrative care, the University of Arizona Integrative Health Center, in Phoenix, has partnered with a top-flight research team to design and capture outcomes. Sally Dodds, PhD, and Patricia Herman, ND, PhD, are the team leaders. One unusual outcome of this partnership is the publication of methods to test “fidelity” of their model. The paper is entitled When a Whole Practice Model Is the Intervention: Developing Fidelity Evaluation Components Using Program Theory-Driven Science for an Integrative Medicine Primary Care Clinic. The authors note that the 2009 Institute of Medicine Summit on Integrative Medicine and the Health of the Public called on researchers to “move beyond evaluation of CM therapies toward studies of integrative healthcare systems.”

The Center’s clinical inputs “combine disease management, prevention, and health promotion by attending to the prevention or treatment of acute and chronic illnesses while emphasizing reduction of modifiable risk factors.” These are engaged via a range of practitioners: integrative medicine-trained family physicians and a physician assistant, nurses, an acupuncturist for traditional Chinese medicine, a chiropractor for manual medicine, a behavioral health clinician for mind-body medicine, a nutritionist, and a health coach. In addition, complicating the evaluation, the Center is financed “by a hybrid revenue structure combining health insurance reimburs

by John Weeks, Publisher/Editor of The Integrator Blog News & Reports

When a Whole Practice Model is the Intervention: the leading edge Dodds/Herman research design for the U Arizona Center for Integrative Health

An important pilot project for Triple Aim outcomes of integrative care, the University of Arizona Integrative Health Center, in Phoenix, has partnered with a top-flight research team to design and capture outcomes. Sally Dodds, PhD, and Patricia Herman, ND, PhD, are the team leaders. One unusual outcome of this partnership is the publication of methods to test “fidelity” of their model. The paper is entitled When a Whole Practice Model Is the Intervention: Developing Fidelity Evaluation Components Using Program Theory-Driven Science for an Integrative Medicine Primary Care Clinic. The authors note that the 2009 Institute of Medicine Summit on Integrative Medicine and the Health of the Public called on researchers to “move beyond evaluation of CM therapies toward studies of integrative healthcare systems.”

The Center’s clinical inputs “combine disease management, prevention, and health promotion by attending to the prevention or treatment of acute and chronic illnesses while emphasizing reduction of modifiable risk factors.” These are engaged via a range of practitioners: integrative medicine-trained family physicians and a physician assistant, nurses, an acupuncturist for traditional Chinese medicine, a chiropractor for manual medicine, a behavioral health clinician for mind-body medicine, a nutritionist, and a health coach. In addition, complicating the evaluation, the Center is financed “by a hybrid revenue structure combining health insurance reimbursement with membership fees paid by patients and/or employer contributions.”

Comment: The integrative medicine and health community needs to be invested, deeply, in this kind of thinking and practice.  This article partners nicely with the piece below on “mixed methods” studies and with Bradley’s critique of the un-real simplicity in NCCAM’s summary execution of dietary supplements as of any value to people with diabetes. One most relish the brilliance of the title: When a Whole Practice Model is the Intervention. When will the members of the Advisory Council on Complementary and Alternative Medicine begin to realize that engaging the methods, program, funding and review issues associated with this reality of integrative care is their fundamental responsibility? 

Ryan Bradley, ND, MPH challenges NCCAM’s dismissal of dietary supplements for people with diabetes

On November 15, 2013, the NIH NCCAM issued a Clinical Digest on Type 2 Diabetes and Dietary Supplements which concluded that “Overall, there is not enough scientific evidence to show that any dietary supplement can help manage or prevent type 2 diabetes” and that “there is no strong evidence that any herbal supplement can help to control diabetes or its complications.” Because supplements are routinely utilized by integrative practitioners of all kinds in working with people with diabetes, I asked clinician-researcher and whole person care expert for people with diabetes Ryan Bradley, ND, MPH, for his perspective. Bradley is the former director of the Center for Diabetes and Cardiovascular Wellness at Bastyr University and the author of the exceptional whole-practice Adjunctive Naturopathic Care for Type II Diabetes: Patient-Reported and Clinical Outcomes after One Year.

After commenting on NCCAM’s “overly simplified” and “reductionist” perspective, Bradley challenged their citations on magnesium and more generally the assumption that the population is getting a sufficient level of dietary nutrients through food. He writes, for instance, that the NCCAM statement that “there is no evidence from clinical trials that magnesium is beneficial in managing diabetes in the absence of magnesium deficiency … downplays the importance of magnesium generally without citing the statistic that 48% of the general US population consumes less than the recommended intake of magnesium in the diet.” Bradley’s useful comments are published in full in The Integrator as Ryan Bradley, ND, MPH Challenges NCCAM’s Dismissal of Dietary Supplements for Treatment of People with Diabetes.

Comment: First, kudos to Bradley for speaking his voice directly, in earshot of the NIH, on a hot topic issue. The failure of the NIH to work in earnest to bridge the gap between their drug-induced reductionism and the whole person thinking Bradley represents is an immense barrier to our learning about whether or not supplements may, in fact, be part of the solution for people with diabetes. US Senator Harkin and his colleagues directed NCCAM to examine real world complementary and alternative medicine “modalities, systems and disciplines” in Section C of the NCCAM mandate. In a world in which the NIH seeks proactively to fulfill on this Congressional intent, significant dollars would be looking at the real world of integrative practice for people with this condition. We have multiple examinations of whether the populations of people with diabetes are positively or negatively impacted by using the kind of whole person care that typically includes supplements.

Bradley’s own mixed methods research with Dan Cherkin, PhD and others provides interesting evidence that there may be significant value to human health here. This is particular clear when one considers the remarkable impact of this treatment as shown in a follow-up paper from Erica Oberg, ND, MPH, Braley, Cherkin and others published on the patient experience of this form of treatment. Best bet is that the public health suffers from NCCAM’s greater adherence to its own reductionism than examining these in the real-world context of integrative practice.


A question of self esteem?
Report finds just 4% of CAM studies in 2012 used “mixed methods” models

A recently published systematic review of 10 high-impact complementary and alternative medicine journals found that in 2012 just 95 out of 2349 (4%) used “mixed methods” models. The authors concluded that “most strikingly, none of the mixed methods studies addressed the philosophical tensions inherent in mixing qualitative and quantitative methods.” The importance of this work is captured by the authors in this brief review of some issues in integrative health and medicine research:

“Quantitative research methods have long dominated conventional medical research: randomized clinical trials (RCTs) produce the highest levels of evidence and occupy the pinnacle of methods hierarchies. In complementary and alternative medicine (CAM) research RCTs and methods hierarchies are more contentious, not least due to perceived fundamental differences between CAM and biomedicine. Unlike new pharmaceutical therapies CAM is already being provided, practiced, and used in the community; many CAMs are best conceptualized as multifactorial complex interventions; CAMs can have diverse and unanticipated effects on people; and the underlying mechanisms of many CAMs are still being researched. These characteristics of CAM (a) make it difficult to design good clinical trials and (b) emphasize the need to understand patients’ perspectives. CAM methodologists have thus called for greater plurality in research methods in general and more use of qualitative research methods in particular.

Comment: The most significant conclusion from this study is that researchers in integrative health fields are effectively a colonized bunch: speaking and formulating their truths in a language and practice never meant for their culture. What is remarkable is that this low percentage is not of the “CAM” studies that made it into the journals of the colonizing system of reductive medicine. These are in “our journals.” When will our editors and our researchers begin prioritizing the work that is best suited to capturing the value of whole-person, individualized interventions? When will our teachers of methods put mixed methods in the center of attention? When will we realize that the Triple Aim era in which we live demands mixed methods? This finding of 4% is a dismaying indicator of the lack of self-esteem in our fields. Credit the British team of Felicity L. Bishop and Michelle M. Holmes for highlighting these deficits and areas of necessary attention.

The Institute for Integrative Health receives $1-million to explore nature’s effect on wounded warriors

The Institute for Integrative Health (TIIH), led by Brian Berman, MD and Sue Berman, has received a $1 million grant from the TKF Foundation “to create an outdoor healing space and study its impact on wounded warriors who spend time there.” Titled the “Green Road Project”, the initiative will, according to this TIIH newsletter, “turn a swath of woodland into an oasis of respite on the campus of Naval Support Activity Bethesda, home of Walter Reed National Military Medical Center.” States Berman: “While helping service members and their families restore their bodies, minds and spirits, the Green Road Project aims to expand the evidence base for using the natural environment as a tool for healing.”

Fred Foote, MD, is the TIIH scholar who conceived the Green Road Project. He notes that “holistic therapies, such as art-making and encounters with nature, aren’t fully accepted because scientists haven’t had a way to measure their effects, but that’s changing.” He expects that by 2016, the team will have “prove(d) by direct measurement that exposure to nature can heal the human body.” The projects array of collaborators include: Consortium for Health and Military Performance at the Uniformed Services University of the Health Sciences (Department of Defense), NIH Clinical Center’s Pain and Palliative Care Service, and the University of Arizona Institute on Place and Wellbeing (comprised of the Arizona Center for Integrative Medicine, College of Medicine, and the UA College of Architecture, Planning and Landscape Architecture, University of Arizona at Tucson. Funds for this project were provided by the TKF Foundation as part of the National Open Spaces Sacred Places Initiative.

Comment: Terrific collaboration. An early introduction to me of such a topic was the therapeutic modality recommended by Father Kneipp, of walking barefoot in the morning dew. Most mornings when I take my short morning walk, barefoot, to my reflection and journalizing perch above our rental home here in Rincon, Puerto Rico, I think of Kneipp. What a lucky fellow I am to have my bare feet on the earth on a daily basis! Here’s hoping Foote, Berman and the team can find appropriate research methods. Whatever the research findings, the warriors will benefit. Trust me on this! Hopefully the TIIH team will touch base with the Dodds-Herman group, noted above. Here, to paraphrase the Dodds/Herman title: When the whole practice model called nature is the intervention…