Review articleDefining integrative medicine in narrative and systematic reviews: A suggested checklist for reporting☆
Introduction
The term integrative medicine (IM, also called integrative/integrated healthcare) is frequently used in different healthcare sectors/systems, education, research, and clinical practice. There is no standard definition. The terminology has evolved over the last 20 years from “unconventional medicine” to “holistic”, to “complementary and alternative medicine (CAM)”, reflecting the dynamic state of this field. The term IM, is often used for example in palliative care. For this paper, IM was considered as a holistic approach that involves CAM.
In western countries, various IM practices are emerging, with current literature focusing on IM models and strategies for integration within health care settings and systems [3], [4], [5]. In the West, the clinical evidence for IM consists largely of studies of individual CAM practices. However, the research evidence on the effectiveness of IM provided as a package of care is limited due to its complex nature and definition, lack of standardization and challenges in methodological design [6], [7], [8], [9], [10]. IM in the west has generally been an ad hoc development, which has been gradually emerging and is available in different forms and in different settings.
In the UK, healthcare is provided by the National Health Service (NHS). Integration within the NHS is unusual although many patients choose to use CAM privately alongside their conventional NHS care [11], [12]. For example, in the primary care setting there are three forms of IM: referral between the primary health care team and local CAM practitioners; CAM practitioners working directly within the same setting as the primary health care team; or a primary health care team member with training in CAM, such as acupuncture [13], [14]. In the secondary care setting, there may be statutory registered health professionals who have undertaken additional training in a CAM modality, such as in the clinical delivery at the Royal London Hospital for Integrated Medicine [15], where autogenic training is provided [16].
In the US, the National Institutes of Health (NIH)’s started an Office of Research on Unconventional Medical Practices which subsequently became the Office of Alternative Medicine (OAM) in 1992. It changed to the National Center for Complementary and Alternative Medicine (NCCAM) in 1998; as of 2014, its new name is – the National Center for Research on Complementary and Integrative Health (NCRCI) [17]). Initially, the OAM focused on practices not typically taught or provided in conventional medical settings, and not covered by most insurance. Over time, as CAM therapies were integrated into curricula, care, and insurance plans, this definition has proved problematic. For example, by 2005, acupuncture was offered in over 1/3 of academic pediatric pain programs in North America [18]. Professional organizations have developed interest groups or committees focusing on CAM since 1990s [19], [20], [21]. In primary care and in various specialty settings, a combination of biomedical and mental health care is regarded as IM. There are many similar examples which focus on using treatments in parallel or in combination. Such approaches consider patients’ needs and require careful coordination, such as: nutrition (e.g. prenatal vitamins are universally recommended; folate supplements being advised for use by pregnant women; older adults are advised to take vitamin D), and therapies routinely provided in a rehabilitation setting such as acupuncture and physiotherapy, etc. Insurance coverage and licensure for chiropractic is universal in all US states. Professional licensing has also grown; acupuncture is licensed in over 85% of US states, and naturopathic physicians are licensed in 19 states, districts and territories in the US. In 1999 NCCAM funded 14 training programs at medical schools and teaching hospitals [22]. By 2013, over 20 family medicine residency programs offered tracks in IM and, in 2014, five pediatric residencies began offering similar IM training programs. Meanwhile the formation of the Consortium of Academic Health Centers for Integrative Medicine was founded at the most recent turn of the century with 8 centers, and has grown to include over 54 North American programs and centers [23].
In Australia, the integration of some CAM within conventional medical and healthcare settings remains largely ad hoc and informal [24], despite interest in CAM amongst some GPs, midwives and other health professionals [25]. Recent research suggests referral networks and communications between doctors and CAM practitioners are still often poor [26]. However some health professionals, midwives and nurses in particular, do appear to be engaging in direct integrative practice whereby they are trained and practicing another therapy [27].
IM in China always refers to the integration of Traditional Chinese Medicine (TCM) and Western medicine. The Chinese integrative health care system was purposively created and promoted by Mao Zedong in 1956, “to integrate the knowledge of Chinese medicine and materia medica with the knowledge of western medicine and pharmacology, to create our unique new medicine and new pharmacology” [28]. Subsequently, integration developed within education, licensing, clinical practice, research and policy. It is embedded in Chinese culture as it is a part of a long-term policy in China and is extensively used throughout China. Both TCM and Western medicine are regulated and supported by the Chinese government and national funding executive agencies. They coexist and share methods of diagnosis and treatment based on both TCM and Western medicine theories [28]. Due to its political stance, IM in China has been a planned development, rather than growing organically as in the west. In China, IM is actively practiced in the Chinese medicine departments in western medicine hospitals, all departments of Chinese medicine hospitals, as well as all departments of integrative medicine hospitals for various conditions [29]. China is the only country with medical licensing in IM, allowing clinicians to practice both conventional and TCM [28]. In most cases, the same clinician can provide both an IM diagnosis and treatment using the knowledge from both disciplines. They also have opportunities to cross refer to multidisciplinary collaborative teams as a result of the unifying paradigm which is shared jointly with other clinicians.
Problems emerge when trying to identify and synthesize studies on IM [6], [10]. A wide range of search terms are necessary to identify all potential IM studies due to the absence of standardized terminology or a recognized definition of IM. The lack of a shared conceptual framework and taxonomy for IM models is also problematic. There are further challenges due to differences between countries and manuscripts published in different languages, often extensive work is required in order to identify search terms and synthesize findings [10]. Difficulties include the fact that many studies are not labeled as IM so may not be captured in searches using IM keywords or MeSH terms; and many studies purport to be ‘IM’ but this may not be the case [6], [10].
These problems have been previously identified for complex interventions, suggesting it is not useful or problematic to conduct systematic reviews for such interventions [6]. A realistic review, explaining rather than judging and using qualitatively narrative synthesis, may be more appropriate [6]. This paper reports results from such a qualitative narrative review of IM definitions in literature from the US, UK, Australia, and China and aims to identify the key elements of defining IM. Rather than attempting to review all examples of IM worldwide it provides a starting point to begin to explore the issues faced when synthesizing IM research and practice for research purposes.
Various checklists for researchers and reviewers have been developed to enhance the quality of reporting in clinical studies, e.g. Consolidated Standards of Reporting Trials (CONSORT) [30] and the Consolidated criteria for reporting qualitative research (COREQ) [31]. However, many of these checklists may not be suited to complex interventions such as IM. Some extensions have already been developed to adapt these checklists for alternative interventions, such as Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) [32] and the complex interventions extension for CONSORT [33]. The second purpose of this paper was to begin to develop a guide for reporting IM (along the lines of CONSORT), which could be further developed for research purposes.
Section snippets
Method
A range of data sources, including government, key authorities, academic organizations, representative clinical sites, academic journals, relevant textbooks (those viewed as authorities on IM, with either integrated or integrative in their title, but not condition specific, were selected by the authors), and relevant research papers (Table 1) were selected from four countries (US, UK, Australia, and China) and were searched for definitions of IM (1990–2014). These four countries were chosen (as
Key elements of defining integrative medicine
A total of 54 sources were searched (Table 1). Thirty seven sources did not have a specific definition of IM. Seventeen definitions from 17 sources were identified and extracted. These were identified from the US (13), China (2), UK (1), and Australia (1) [1], [2], [45], [47], [48], [57], [58], [63], [80], [81], [82], [83], [84], [85], [86], [87], [88]. Thirteen (out of 17) emphasized the integration of CAM and conventional approaches [45], [47], [48], [57], [58], [63], [80], [82], [83], [84],
Determining the defining elements of IM
In this review, 17 definitions were identified, the majority from the US. IM may be interpreted differently depending on the country and its healthcare practices over time, with no standard definition it may be appropriate to have different definitions which incorporate a cultural context. Moreover, the dynamic nature of the rapidly changing and growing field means that it is hard to create an enduring definition that works across all cultures and times. However, from the definitions identified
Conclusion
This paper identified thirteen key elements defining IM and provides the basis for a potential reporting checklist for future IM studies. This may benefit researchers who are designing clinical research or conducting systematic reviews on IM practice. It may also help reviewers and health practitioners to determine whether an intervention is really IM. Though the acceptability of the term IM and the elements determining the definition vary between countries, recommendations for reporting IM
Conflict of interest statement
There is no conflict of interest as there are no direct financial or other connections with other people or organizations or that can inappropriately influence our work. All research has done by the authors. There was no financial support and no conflict of interest and all authors contributed equally to the drafting of this article.
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This article belongs to the Special Issue: Traditional and Integrative Approaches for Global Health.