Patient benefit survey: Tunbridge Wells Homoeopathic Hospital

Patient benefit survey: Tunbridge Wells Homoeopathic Hospital

British Homeopathic Journal (2000) 89, 68±72 ß 2000 Macmillan Publishers Ltd All rights reserved 0007±0785/00 $15.00 www.nature.com/bhj ORIGINAL PAPE...

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British Homeopathic Journal (2000) 89, 68±72 ß 2000 Macmillan Publishers Ltd All rights reserved 0007±0785/00 $15.00 www.nature.com/bhj

ORIGINAL PAPER

Patient bene®t survey: Tunbridge Wells Homoeopathic Hospital A Clover1* 1

Homoeopathic Hospital, Church Road, Tunbridge Wells, TN1 1JU, United Kingdom We report an outcome study concerning patients treated by homeopathic medicine at the Tunbridge Wells Homoeopathic Hospital for the whole of 1997. The study aimed to assess: (a) the range of diagnoses presented by patients, and (b) patients' own impressions of bene®t. 1372 questionnaires were completed by patients after consultations to record their impressions of the effects of homeopathic treatment. Patients were asked to score their responses on a ‡ 3 to 7 3 scale. The three main diagnostic groups were, dermatology, musculo-skeletal disorders, and malignant disease, especially carcinoma of the breast. Overall, 74% of patients recorded positive bene®ts, with 55% recording scores of ‡ 3 or ‡ 2. British Homeopathic Journal (2000) 89, 68±72. Keywords: homeopathy; patient bene®t survey; NHS; Tunbridge Wells; 1997

Introduction The Homoeopathic Hospital in Tunbridge Wells, England, is one of the ®ve hospital units in the UK offering homeopathy as a specialist Consultant-led service within the National Health Service (NHS). Originally it provided both in- and out-patient facilities for patients coming from a wide area of South East England. In keeping with the national trend in the NHS the in-patient facilities were steadily reduced from the early 1980s whilst the requirement for outpatient clinics expanded. As a result the service for homeopathy within this hospital has been entirely outpatient-based for the last 15 years. In 1997 a small number of patients attending the department, less than 5%, also received acupuncture. The service for acupuncture within the department has expanded subsequently to account for almost 10% of consultations. The department is part of the acute medical division of the Kent and Sussex Weald NHS Trust. Like all departments within such Trusts, we are required to conduct regular clinical audits of our work. Personally I welcome this as it is helping all of us re-appraise our practice and examine more closely our apparent successes and failures. All the patients seen at the hospital are referred by their general practitioners or other hospital doctors. *Correspondence: Anne Clover, Homoeopathic Hospital, Church Road, Tunbridge Wells, TN1 1JU, United Kingdom.

Over the last 20 years we have seen a gradual change in the referrals indicating the changing attitudes of doctors towards homeopathic medicine. In the early 1980s most of the referrals were patient initiated, that is, they came from GPs responding to requests presented by patients for homeopathic treatment. Occasionally a GP advised the referral; it was even more rare for hospital consultants to make the suggestion. There has been a shift towards increasing numbers of medical initiated referrals, re¯ecting the increased awareness of many medical colleagues of the contribution homeopathy can make in modern medicine. Doctors who have seen patients respond well to homeopathy for a particular clinical need often ask who else they could usefully refer. This question, and our own commitment to audit led all of us working in the department to set up the review of patient outcome. We therefore decided to conduct a survey to assess the range of medical problems for which patients were referred and their reports of success or failure. A short questionnaire was devised to be completed by all follow-up patients. It asked the patient to state his=her own assessment of the degree of change in the medical problem for which they have received homeopathic treatment, selecting from:    

‡ 3 Much better ‡ 2 Moderately better ‡ 1 Slightly better 0 Unchanged

Patient bene®t survey A Clover

 7 1 Slightly worse  7 2 Moderately worse  7 3 Much worse. The patients were asked to complete the questionnaire with the clinic clerk after his=her follow-up consultation. We emphasised that this should be in the absence of a doctor or nurse. The doctor completed a separate form for each out-patient session recording, (for all follow-up patients) the dominant diagnosis presented, unless classi®ed as `multiple symptoms', and the prescription. The study period was January to December 1997.

Results The total number of consultations during this period was almost 1000 new patients and almost 2500 follow-ups. The total number of returned questionnaires was 1372. The shortfall was probably related to two major factors: (1) some patients asked to take forms home for consideration before completion, and (2) There was dif®culty collecting forms from clinics held by the department away from the main hospital base. Of the completed forms 58 (4%) referred to consultations that included acupuncture. These were mainly for migraine and osteoarthritis. Age and sex distribution

The male : female ratio was 332 : 1040. The age distribution of the patients is shown in Table 1.

subgroups. It should be noted that the groups relate to chronic rather than acute forms of disease. This re¯ects the nature of the service with prebooked appointments. We do not claim to offer an acute service. The preponderance of dermatological and musculoskeletal problems is not surprising due to the chronicity and resistance to conventional therapy shown by many common disorders within these diagnostic categories. The high number of patients with malignant disease re¯ects the specialist commitment to complementary cancer therapy of one of the consultants. We will move on from this overall review to consider the diagnostic subgroups, mainly noting those with 10 or more patient consultations reported. Patient-assessed responses in dermatological conditions are shown in Table 4. Eczema is a particularly common presenting disorder for all age groups and it was no surprise that amongst the patients seen at Tunbridge Wells Homoeopathic Hospital (TWHH) this was by far the commonest diagnostic group. We do not have a detailed breakdown of the age distribution but we are aware that many of the patients are children where parents are seeking to reduce the need for topical steroids. The policy is initially to add homeopathic medicine alongside conventional therapy and to advise reducing the latter when a sustained improvement has been shown. The ®gures illustrating bene®t for treatment of psoriasis were a positive surprise as our expectation had previously been that this is a presenting problem where we achieved little bene®t. The surprising

69

Total assessments across all patients

The percentages of patients reporting for each grade of response are shown in Table 2. Total number of consultations for each diagnostic group

We present data for diagnostic groups (Table 3) and Table 1 Age distribution of patients Age (year)

No. of patients

< 16 16 ± 30 31 ± 45 46 ± 60 61 ± 75 > 75

255 98 268 380 289 82

Table 3 Diagnostic groups Diagnostic group Dermatology Musculoskeletal Malignant disease Respiratory Ear, nose, throat Neurological Gynaecology Gastrointestinal Psychiatric Cardiovascular Genitourinary Endocrine Other Total a

Table 2 Global questionnaire Grade of response ‡3 ‡2 ‡1 0 71 72 73

response

of

patients

completing

the

Percentage of patients 31% 24% 19% 17% 4% 3% 2%

No. of patients

Percentage of patientsa

238 178 162 147 133 114 103 78 60 50 17 17 89

17% 13% 12% 11% 10% 8% 7.5% 6% 4% 3% 1% 1% 6.5%

1372

Percentages add up to > 100% owing to counting up=down.

Table 4 Patient-assessed responses in dermatological conditions (n ˆ 238) Grade of response

Eczema Psoriasis Acne Urticaria

Total

‡3

‡2

‡1

0

71

72

73

105 40 18 12

38 10 6 3

24 9 3 2

22 8 4 4

15 5 4 2

5 2 1 0

1 5 0 0

0 1 0 1

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Patient bene®t survey A Clover

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positive results are themselves an illustration of the importance of such audit. Patient-assessed responses in musculo-skeletal and rheumatological conditions are shown in Table 5. In relation to these ®gures our main surprise was the preponderance of patients presenting with osteo or rheumatoid arthritis and the relatively low number with chronic back pain. In relation to malignant disorders, we will note ®rst the range of diagnoses presented by patients attending the department (Table 6) and second the more speci®c presenting complaints of the largest subgroup, that is, those with carcinoma of the breast (Table 7). The high proportion of patients with hot ¯ushes relates to the growing awareness that homeopathic medicine can help this problem and the increasing

Table 5 Patient-assessed response in muscule-skeletal and rheumatological conditions (n ˆ 178) Grade of response

Osteoarthritis Rheumatoid arthritis Chronic back pain

Total

‡3

‡2

‡1 0

78 20 12

21 6 3

25 4 5

18 6 2

71

72

73

5 0 0

2 0 1

1 1 0

6 3 1

Table 6 Primary tumours in patients attending with diagnosis of malignant disease (n ˆ 162) Grade of response

number of referrals of such patients from oncologists. This can be particularly relevant when patients have been advised not to take HRT. Several patients were also taking tamoxifen. These results have led us to set up a further study to assess in more detail the bene®ts of homeopathic medicine in this situation. Patient-assessed responses in respiratory syndromes are presented in Table 8. We were encouraged by these ®gures as most of the patients seeking help for asthmatic symptoms have experienced them long term and either had dif®culties managing the more conventional therapy or found it insuf®cient for their needs. The policy is to prescribe the homeopathic medicine alongside the more conventional therapy, only considering reduction in the latter subsequent to clear improvement in the presenting disorder. The ®gures in Table 9 represent patient-assessed response in ear, nose and throat syndromes. They suggest bene®ts of homeopathic medicine in common disorders with considerable morbidity, often when there has been very limited help from conventional medication. Table 10 shows patient-assessed response in neurological syndromes. For patients presenting with multiple sclerosis the main bene®ts reported were alleviation of cramps, bladder urgency and affective reactions. Patient-assessed responses in gynaecological symptoms are shown in Table 11. The main surprise here Table 8 Patient-assessed response in respiratory syndromes (n ˆ 147) Grade of response

Total ‡ 3 ‡ 2 ‡ 1 0 7 1 7 2 7 3 Breast 103 Lymphoma 12 Prostate 7 Oesophagus 4 Bronchus 3 Cervix 3 Ovary 3 Pleura 3 Rectum 3 Malignant melanoma 3 Mestatic unknown 3 primary All others 15

57 7 3 2 1 1 2 0 2 1 0

21 0 2 2 1 1 1 2 1 1 0

12 5 2 0 0 0 0 1 0 1 1

7 0 0 0 0 0 0 0 0 0 0

3 0 0 0 1 1 0 0 0 0 1

3 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 0

8

2

3

1

1

0

0

Table 7 Main presenting symptoms and consultations for carcinoma of the breast

response

in

Grade of response

Total ‡ 3 ‡ 2 ‡ 1 0 7 1 2 7 3 Asthma 67 Asthma ‡ eczema=hay fever 63

24 17

14 15

7 12 14 11

4 3

5 2

1 1

Table 9 Patient-assessed response in ear, nose and throat syndromes (n ˆ 133) Grade of response Total ‡ 3 ‡ 2 ‡ 1 0 7 1 7 2 7 3 Chronic catarrh Hay fever Perennial rhinitis Chronic sinusitis Reccurrent Upper Respiratory Tract Infection Glue ear=chronic otitis medis

44 17 16 15 14

9 8 4 7 7

14 2 4 3 4

10

5

4

9 2 3 0 1

2 1 0 0 0

1 2 0 0 0

1 2 0 0 0

0 0 0 0 0

0 0

0

0

0

Total ‡ 3 ‡ 2 ‡ 1 0 7 1 7 2 7 3 Hot ¯ushes 47 18 Depression 14 9 Anxiety 11 9 Unspeci®ed 9 6 Tiredness 8 8 Chemotherapy side effects 7 3 Bone metastatis pain 2 1 Lymphoedema 2 2 Post operative scar pain 2 0 Radiotherapy side effects 1 1 Total 103 57 British Homeopathic Journal

13 3 0 1 0 2 1 0 1 0 21

7 1 1 0 0 2 0 0 1 0 12

4 0 1 2 0 0 0 0 0 0 7

2 1 0 0 0 0 0 0 0 0 3

3 0 0 0 0 0 0 0 0 0 3

0 0 0 0 0 0 0 0 0 0 0

Table 10 Patient-assessed response in neurological syndromes (n ˆ 114) Grade of response

Chronic headache Multiple sclerosis Migraine

Total

‡3

‡2

56 25 16

16 5 5

17 8 5

‡1 0 9 1 3

9 8 2

71

72

73

3 3 0

2 0 1

0 0 0

Patient bene®t survey A Clover

was the data concerning patients presenting menopausal symptoms. Although 41 out of 52 reports (79%) indicated improvement, nine reports of no change (17%) and two worse (4%) were higher ®gures than we expected. It showed the need to improve our assessment and prescribing here. In Table 12, patient-assessed responses in gastroenterological syndromes are presented. We were surprised that the ®gures concerning effects of in¯ammatory bowel disease (IBS) appear better than for irritable bowel syndrome. This may relate to patients presenting with relatively mild forms of Crohn's Disease and ulcerative colitis or more refractory problems with IBS. Patient-assessed responses in psychiatric syndromes are shown in Table 13. The relatively lower numbers than might have been expected in this group may be in¯uenced by the working situation of the department within an acute NHS trust and a local policy decision not to encourage referrals for established chronic psychiatry. Table 14 presents data relating to cardiovascular syndromes. It should be explained here that these ®gures relate to patients' experience of symptomatic bene®t. Of course we also look for reduction in the measured blood pressure and if this is not also present would advise the concomitant use of conventional hypotensives. Patient-assessed responses in genitourinary syndromes are shown in Table 15. A relatively small Table 11 Patient-assessed symptoms (n ˆ 103)

response

in

gynaecological

Grade of response Total ‡ 3 ‡ 2 ‡ 1 0 7 1 7 2 7 3 Menopausal symptoms Vaginitis=thrush Dysmenorrhoea Pre-menstrual Tension

52 12 8 8

18 2 3 5

16 3 2 3

7 5 2 0

9 2 0 0

1 0 0 0

0 0 0 0

1 0 1 0

Table 12 Patient-assessed response in gastroenterological syndromes (n ˆ 78)

Table 14 Patient-assessed syndromes (n ˆ 50)

response

Hypertension

Total

‡3

‡2

‡1

0

71

72

73

28

14

7

4

2

1

0

0

Table 13 (n ˆ 60)

5 3 6

6 4 1

15 4 2 1 0 2

0 0 0

Discussion All of us involved in this study are aware that it gives only an indication of bene®t and is not a de®nitive research project. However, it has yielded data that can assist our assessments of the therapy offered for the range of patients seen and their presenting problems. We regard it as an important piece of audit assisting re¯ection on our own work. We are aware that recording the reported response alongside a medically applied diagnostic term might appear to contradict Hahnemanns insistence on avoiding restrictive diagnostic terms and instead always noting the totality and individuality of the symptom pro®le presented by a patient.1 However, Hahnemann himself also reminds us, we can reduce this hazard by prefacing the diagnosis by the phrase `kind of . . . '.2 Pursued in this way, we argue that appraisal of the form presented here is continuing the close observation of disease and therapy recurrently advocated by Hahnemann. We have been impressed by the degree of correlation between these ®gures and the results of a similar study conducted at the Bristol Homoeopathic Hospital presented at the International Conference. `Improving Table 15 Patient-assessed syndromes (n ˆ 17)

response

0 0 0

1 0 0

Anxiety depression

‡2

24

2

8

‡1 0 6

5

genitourinary

Recurrent cystitis= irritable bladder

Total

‡3

‡2

‡1

0

71

72

73

12

4

2

2

4

0

0

0

Table 16 Patient-assessed response in other conditions seen relatively frequently (n ˆ 89) Grade of response

Grade of response ‡3

in

Grade of response

Patient-assessed response in psychiatric syndromes

Total

71

group of patients are represented but the ®gures indicate useful bene®t for an unpleasant and often refractory disorder. The ®gures in Table 16 show patient-assessed responses in other conditions, and again imply useful bene®t for disorders that often baf¯e colleagues and patients, and appear resistant to more conventional therapy.

Total ‡ 3 ‡ 2 ‡ 1 0 7 1 7 2 7 3 31 10 9

cardiovascular

Grade of response

Grade of response

Irritable bowel syndrome Crohns disease Ulcerative colitis

in

Total ‡ 3 ‡ 2 ‡ 1 0 7 1 7 2 7 3

71

72

73

1

1

1

Chronic fatigue syndrome Post viral syndrome Multiple symptoms

29 28 29

4 6 3

3 6 3

11 9 7 7 4 5

1 1 2

1 1 2

0 0 1

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the Success of Homoeopathy' held in London 1999.3 The outcome study conducted with patients attending for follow-up after homeopathic treatment in Bristol showed results remarkably similar to those presented here. Close comparison with an audit of responses reported from a NHS Community Clinic in Cleveland is dif®cult as that study concerned a much smaller group of patients and used a different assessment scale.4 However, reported levels of bene®t are broadly similar to those reported in larger studies. As stated at the outset of this presentation, one of the questions often presented by general practitioners interested in referring patients for homeopathic treatment, is who can they usefully refer. The ®gures presented here and those from similar studies are already proving helpful in responding to this question. We therefore present them here in the hope that they may prove similarly useful to colleagues.

British Homeopathic Journal

Acknowledgments I am grateful to all the staff of the Tunbridge Wells Homoeopathic Hospital for their participation in this study and to the staff of the Audit department, Kent and Sussex Hospital, for their help in analysing the data.

References 1 Hahnemann S. Organon of Medicine, 6th edn. New Delhi : B. Jain Publishers 1970, p. 12. 2 Hahnemann S. Organon of Medicine, 6th edn. New Delhi : B. Jain Publishers 1970, p. 88. 3 Spence D. Clinical outcome audit: Bristol Homoeopathic Hospital. Br Hom J 2000; 89(Suppl 1): (in press). 4 Neville-Smith R. Community Hospital Homoeopathy Clinic: Audit of the ®rst 12 months activity. Br Hom J 1999, 88: 20 ± 23.