There is little published descriptive data on naturopathic practice. Yet, as Coulter aptly put it, “It would be difficult to exaggerate the importance of the descriptive studies for CAM. Until we know more about the practice, scope of practice, patient characteristics, utilization rates, and patient numbers, it is difficult to design appropriate studies or to even know which issues are worth studying.“(1). The published studies listed here are those with recent data descriptive of naturopathic practice in the US or Canada and include work on patient characterisitics and numbers, physician characteristics and surveys, practice settings and workflow. The list below is not complete and we solicit readers' submissions of additional studies that meet inclusion criteria for this section.

1. Coulter ID, Khorsan R. Is health services research the Holy Grail of complementary and alternative medicine research? Altern Ther Health Med. 2008 Jul-Aug;14(4):40-5.

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Can J Public Health. 2010 Nov-Dec;101(6):475-80.
Naturopathic medicine and aboriginal health: an exploratory study at Anishnawbe Health Toronto.
Walji R, Weeks L, Cooley K, Seely D.
Source
Department of Research & Clinical Epidemiology, The Canadian College of Naturopathic Medicine, Toronto, ON.
OBJECTIVE:
To explore the experiences and perceptions of providing and receiving naturopathic care within the Aboriginal community served by community health centre Anishnawbe Health Toronto.
METHODS:
This is an exploratory study using a descriptive qualitative approach to enable better understanding of the care provided to Aboriginal patients by naturopathic interns and clinician supervisors at Anishnawbe Health Toronto (AHT). We conducted semi-structured interviews with 3 naturopathic supervisors, 7 naturopathic interns, and 7 Aboriginal patients to gain an in-depth understanding of participants' experiences and perceptions of naturopathic medicine at AHT. We also conducted 3 confirmatory interviews with Naturopathic Doctors practicing in other Aboriginal communities. RESULTS:

Naturopathic medicine is perceived to fit with health care philosophies in Aboriginal communities, as it emphasizes spiritual, mental and emotional aspects of health. Specifically, strengths of naturopathic medicine within the Aboriginal community relate to the philosophical suitability of naturopathic medicine, the ability to meet a wide range of health needs, the lack of power imbalance in the patient-practitioner relationship, and the cultural sensitivity of the practitioners. While AHT is highly regarded by patients and practitioners, certain limitations at the local setting regarding privacy and inter-professional communication were evident. Further, to facilitate trust, naturopathic interns require enhanced training in specific health issues that face the Aboriginal population to allow them to better engage with the culture and practices of the Aboriginal community. CONCLUSION:

The naturopathic clinic at AHT contributes to positive patient outcomes and satisfaction and helps address unmet health needs in this population. Naturopathic medicine may be well suited to address Aboriginal health care needs through its holistic and respectful approach to care and a foundation of traditional knowledge and research evidence for treatment of a person's mind, body and spirit.
PMID: 21370784

J Womens Health (Larchmt). 2009 Aug;18(8):1133-43.
Preventive screening of women who use complementary and alternative medicine providers.
Downey L, Tyree PT, Lafferty WE.
Department of Health Services, School of Public Health and Community Medicine, University of Washington
BACKGROUND: Many women use complementary and alternative medicine (CAM). Although CAM use has been associated with reductions in conventionally recommended pediatric preventive care (e.g., vaccination), little is known about associations between CAM use and receipt of recommended preventive screening in women. METHODS: Using Washington State insurance data from 2000 to 2003, the authors generated clustered logistic regression models, examining associations between provider-based CAM use and receipt of screening tests for Chlamydia trachomatis, breast cancer, and cervical cancer: (1) contrasting women who used CAM providers only (alternative use) and women who used both conventional and CAM providers (complementary use) with women who used conventional care only and (2) testing associations between screening and use of four specific CAM provider types-naturopathic physicians, chiropractors, massage therapists, and acupuncturists. RESULTS: Both alternative and complementary use was associated with reduced Chlamydia screening. Cancer screening increased with complementary use but decreased with alternative use of CAM. Use of naturopathy was associated with decreased mammography, whereas all four CAM therapies were positively associated with Papanicolaou testing. CONCLUSIONS: When used in conjunction with conventional care, use of provider-based CAM may signal high interest in various types of health-promoting behavior, including cancer screening. Negative associations between CAM and Chlamydia screening and between naturopathy and mammography require additional study. Interventions with CAM providers and their patients, aimed at improving rates of conventionally recommended screening, might encourage greater focus on preventive care, an important task when CAM providers serve as women's only contact with the healthcare system.
PMID: 19630554

Vaccine. 2008 Jul 30.
Attitudes towards vaccination among chiropractic and naturopathic students.
Busse JW, Wilson K, Campbell JB.
Department of Clinical Epidemiology and Biostatistics, McMaster University
We have investigated the attitudes towards vaccination of undergraduate chiropractic and naturopathic students in the two major complementary and alternative medicine colleges in Canada. While the majority of the students were not averse to vaccination, we found in both colleges that anti-vaccination attitudes were more prevalent in the later years of the programs. Reasons for this are discussed, and we provide suggestions for strategies to address the situation.
PMID: 18674581

J Altern Complement Med. 2008 May;14(4):445-8.
Interest of naturopathic physicians in pediatric research.
Weber W, McCarty RL.
School of Naturopathic Medicine, Bastyr University
OBJECTIVES: Naturopathic physicians' interest in participating in pediatric observational studies or clinical trials is unknown. Complementary and alternative medicine research may need to be conducted in the settings where these therapies are commonly used to fully understand their effects. Optimally, naturopathic physicians will participate in the research of naturopathic medical practice. A survey was conducted to ascertain naturopathic physicians' interest in participating in pediatric research studies and characteristics of those most interested. DESIGN, SETTING, AND SUBJECTS: In July 2004, a survey designed to assess pediatric research interests and a one-dollar incentive was mailed to all Washington state- licensed naturopathic physicians with in-state mailing addresses (n = 513). A second survey and one-dollar incentive were sent to nonresponders in November 2004. Surveys were collected through January 2005. RESULTS: From the 499 surveys delivered as addressed, 251 completed surveys were returned (50.3%). Of the 204 naturopathic physicians in current practice who completed surveys, 59 (28.9%) indicated they would not recommend or advertise an observational, open-label, or placebo-controlled trial to their pediatric patients, and 85 (41.7%) indicated they had no interest in being involved with research studies themselves. Of the 204 respondents in practice, 83 (40.7%) would recommend placebo-controlled trials to their pediatric patients, and 52 (25.5%) were willing to recruit for such a trial in the office. CONCLUSIONS: Characteristics of naturopathic physicians most interested in active pediatric research involvement included fewer years in practice, greater number of pediatric patients treated per week, and having shared office space.

PMID: 18435598

BMC Complement Altern Med. 2008 May 31;8:24.
Attitudes towards fibromyalgia: a survey of Canadian chiropractic, naturopathic, physical therapy and occupational therapy students.
Busse JW, Kulkarni AV, Badwall P, Guyatt GH; Medically Unexplained Syndromes Study Group.
Department of Clinical Epidemiology and Biostatistics, McMaster University
BACKGROUND: The frequent use of chiropractic, naturopathic, and physical and occupational therapy by patients with fibromyalgia has been emphasized repeatedly, but little is known about the attitudes of these therapists towards this challenging condition. METHODS: We administered a cross-sectional survey to 385 senior Canadian chiropractic, naturopathic, physical and occupational therapy students in their final year of studies, that inquired about attitudes towards the diagnosis and management of fibromyalgia. RESULTS: 336 students completed the survey (response rate 87%). While they disagreed about the etiology (primarily psychological 28%, physiological 23%, psychological and physiological 15%, unsure 34%), the majority (58%) reported that fibromyalgia was difficult to manage. Respondants were also conflicted in whether treatment should prioritize symptom relief (65%) or functional gains (85%), with the majority (58%) wanting to do both. The majority of respondents (57%) agreed that there was effective treatment for fibromyalgia and that they possessed the required clinical skills to manage patients (55%).Chiropractic students were most skeptical in regards to fibromyalgia as a useful diagnostic entity, and most likely to endorse a psychological etiology. In our regression model, only training in naturopathic medicine (unstandardized regression coefficient = 0.33; 95% confidence interval = 0.11 to 0.56) and the belief that effective therapies existed (unstandardized regression coefficient = 0.42; 95% confidence interval = 0.30 to 0.54) were associated with greater confidence in managing patients with fibromyalgia. CONCLUSION: The majority of senior Canadian chiropractic, naturopathic, physical and occupational therapy students, and in particular those with naturopathic training, believe that effective treatment for fibromyalgia exists and that they possess the clinical skillset to effectively manage this disorder. The majority place high priority on both symptom relief and functional gains when treating fibromyalgia.

PMID: 18513441

Complement Ther Clin Pract. 2008 May;14(2):98-104. Epub 2008 Jan 4.
Survey of parents on the use of naturopathic medicine in children--characteristics and reasons.
Leung B, Verhoef M.
Department of Community Health Sciences, University of Calgary
This cross-sectional study assessed the sociodemographic characteristics of families whose children used naturopathic medicine, the reasons for use, and whether naturopathic and conventional medicine were combined in treating children's conditions. Data were collected in British Columbia, Alberta and Ontario, Canada. Ninety-eight completed questionnaires were analyzed. The results showed that participants (parents) were most likely to be females, university educated, had household income >$60,000, and also saw a naturopathic doctor for themselves. The most common conditions for which children saw a naturopathic doctor included allergies, digestive problems and skin problems, and the most important reasons for use included using all possible options and having a more holistic approach to care. Most parents reported combining naturopathic and conventional care for their children. Study limitations, in particular, selection bias, were discussed.

PMID: 18396253

Pediatrics. 2007 Jul;120(1):e142-6.
Frequency and characteristics of pediatric and adolescent visits in naturopathic medical practice.
Weber W, Taylor JA, McCarty RL, Johnson-Grass A.
School of Naturopathic Medicine, Bastyr University
OBJECTIVES: This work sought to identify naturopathic physicians in Washington State who frequently provide pediatric care and to describe the conditions treated and therapies recommended for children. PATIENTS AND METHODS: A mailed survey of licensed naturopathic physicians residing in Washington State collected demographic information and practice descriptions. For naturopathic physicians treating > or = 5 pediatric patients per week, data were collected on the conditions seen and treatments provided to children during a 2-week period. RESULTS: Of 499 surveys delivered to providers, 251 surveys were returned (response rate: 50.3%). Among the 204 naturopathic physicians currently practicing, only 31 (15%) saw > or = 5 children per week. For these pediatric naturopathic physicians, pediatric visits constituted 28% of their office practice.
Pediatric naturopathic physicians were more likely to be licensed midwives (19.4% vs 0.6%) and treated significantly more patients per week (41.6 vs 20.2) than naturopathic physicians who provided less pediatric care. Eighteen of the 31 pediatric naturopathic physicians returned data on 354 pediatric visits; 30.5% of the visits were by children < 2 years old, and 58.5% were by those < 6 years old. The most common purpose for presentation included health supervision visits (27.4%), infectious disease (20.6%), and mental health conditions (12.7%). Pediatric naturopathic physicians provided immunizations during 18.6% of health supervision visits by children < 2 years old and 27.3% of visits by children between the ages of 2 and 5 years. CONCLUSIONS: Although most naturopathic physicians in Washington treat few children, a group of naturopathic physicians provide pediatric care as a substantial part of their practice. Based on the ages of children seen and the conditions treated, pediatric naturopathic physicians may provide the majority of care for some children. Efforts should be made to enhance collaboration between naturopathic physicians and conventional providers so that optimal care can be provided to children.
PMID: 17606541
Free full text: http://pediatrics.aappublications.org/cgi/content/abstract/120/1/e142

Soc Sci Med. 2006 Jul;63(2):409-17. Epub 2006 Feb 17.
The scope of naturopathic medicine in Canada: an emerging profession.
Verhoef MJ, Boon HS, Mutasingwa DR.
Department of Community Health Sciences, The University of Calgary, Alta., Canada.
In Canada, naturopathic medicine is an emerging profession that is gaining formal recognition, including provincial/territorial regulation. While naturopathic medicine has undergone significant growth and legitimization, it still faces substantial challenges to acceptance as a full-fledged health care profession within the Canadian health care system. For example, professionalization theories indicate the importance of clear professional boundaries as well as the need for 'new' groups to find a place in the system of professions. This has been problematic for naturopathic practitioners who continue to practice within a broad scope of practice that encompasses many different therapeutic modalities. Development of statutory regulation also requires delineation of a specific, well-defined scope of practice. The purpose of this study was to describe naturopathic practitioners' perception of their training and their current scope of practice. Two thirds (n = 315) of all licensed Canadian naturopathic practitioners responded to the survey. The results showed that naturopathic practitioners are trained in, and practice, a wide range of therapeutic modalities and diagnostic procedures. Practitioners disagreed about their scope of practice, as 57% thought it was too restrictive, 31% felt it was about right and 13% thought it was too broad. A large majority felt there was some or a great deal of overlap with other practitioners' scope of practice. We conclude that multiple challenges are facing naturopathic medicine, including scope of practice, overlap with other professions, social closure, scarcity of vacancies and lack of cohesion. The future of naturopathic medicine will depend on how effectively the profession will use available strategies to overcome barriers to statutory self-regulation.
PMID: 16487639

J Altern Complement Med. 2006 Jan-Feb;12(1):71-7.
Complementary and alternative provider use by insured patients with diabetes in Washington State.
Lind BK, Lafferty WE, Grembowski DE, Diehr PK.
Department of Health Services, University of Washington
OBJECTIVES: The authors investigated whether insurance coverage for complementary and alternative medicine (CAM) providers is associated with increased medical care use among diabetes patients. Predictors of CAM use and how CAM affects health care use and expenditures under insurance coverage were examined. DESIGN: Claims data from two large insurers in Washington State were obtained for 2002. Types of providers used, comorbid medical conditions, number of visits, and expenditures were calculated for the study sample and compared to a nondiabetic matched group. RESULTS: Of the 20,722 adults with diabetes, 3605 (17.4%) had one or more visits to any licensed CAM provider (mostly chiropractors). This was lower than the 20% CAM use in the comparison group. Diabetes patients who used CAM were more likely to have multiple other medical problems than CAM nonusers. CAM users had a higher average number of annual outpatient visits compared to nonusers (28 versus 16), and higher average annual expenditures (8,736 dollars versus 7,356 dollars); however, after adjustment for disease load and other factors, CAM use was not a significant predictor of expenditures. CAM use was <2% of the overall mean medical expenditures for diabetes patients. Quality of conventional care was similar for CAM users and nonusers. CONCLUSIONS: CAM provider usage when covered by insurance is lower among diabetes patients than in adults without diabetes and represents a small proportion of diabetes care costs. Very few CAM visits were related directly to diabetes care. CAM-using patients often have heavy disease burdens and high total expected resource use compared to those not using CAM. PMID: 16494571

Nutr J. 2005 Jan 26;4:3.
The treatment of migraines and tension-type headaches with intravenous and oral niacin (nicotinic acid): systematic review of the literature.
Prousky J, Seely D.
The Canadian College of Naturopathic Medicine
BACKGROUND: Migraine and tension-type headaches impose a tremendous economic drain upon the healthcare system. Intravenous and oral niacin has been employed in the treatment of acute and chronic migraine and tension-type headaches, but its use has not become part of contemporary medicine, nor have there been randomized controlled trials further assessing this novel treatment. We aimed to systematically review the evidence of using intravenous and/or oral niacin as a treatment for migraine headaches, tension-type headaches, and for headaches of other etiologic types. METHODS: We searched English and non-English language articles in the following databases: MEDLINE (1966-February 2004), AMED (1995-February 2004) and Alt HealthWatch (1990-February 2004). RESULTS: Nine articles were found to meet the inclusion criteria and were included in this systematic review. Hypothetical reasons for niacin's effectiveness include its vasodilatory properties, and its ability to improve mitochondrial energy metabolism. Important side effects of niacin include flushing, nausea and fainting. CONCLUSION: Although niacin's mechanisms of action have not been substantiated from controlled clinical trials, this agent may have beneficial effects upon migraine and tension- type headaches. Adequately designed randomized trials are required to determine its clinical implications.
PMID: 15673472
Free full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC548511/?tool=pubmed

J Altern Complement Med. 2004 Dec;10(6):1001-8.
The effect of mandating complementary and alternative medicine services on insurance benefits in Washington State.
Watts CA, Lafferty WE, Baden AC.
Department of Health Services, University of Washington
OBJECTIVES: Washington was the first state to require insurance companies to cover all categories of licensed providers. The purpose of this paper was to examine the effect of Washington's law on coverage decisions of major health plans. DESIGN: The study uses literature and document review as well as key informant interviews. SETTINGS/LOCATION: The study focuses on legislation and other legal activity in the state of Washington. The key informant interviews are focused on the decisions of three major health plans. RESULTS: Although the law had a major effect on complementary and alternative medicine (CAM) coverage in Washington, the impact on the use of CAM services and expenditures has been bounded by changing market forces. CONCLUSIONS: CAM providers face scientific tests of measurable efficacy and market tests of consumer value. In this economic environment, CAM stakeholders will have to work hard to maintain their political gains.

PMID: 15673994

J Altern Complement Med. 2004 Oct;10(5):891-7.
Complementary and alternative medicine in multiple sclerosis: survey of licensed naturopaths.
Shinto L, Calabrese C, Morris C, Sinsheimer S, Bourdette D.
Oregon Health & Science University
OBJECTIVE: This paper describes the treatments and treatment outcome measures used by licensed naturopathic physicians in the United States who treat people with multiple sclerosis (MS). DESIGN: A cross-sectional mail survey was used. SUBJECTS: The participants were licensed naturopaths who were members of the American Association of Naturopathic Physicians. OUTCOME MEASURES: Outcome measures included practitioner demographics; patient demographics by practitioner report; recommended therapies; perceived effectiveness of treatments for MS; methods for measuring treatment effectiveness. RESULTS: Forty three percent (43%) of the respondents (166/385) had treated at least one patient with MS while 56.9% (291/385) had never treated MS. 63.3% had treated 1-10 patients with MS, 19.9% had treated 11-20 patients with MS, and 16.8% had treated > or =20 patients with MS. Among the naturopaths, 68.1% communicated with an M.D. about their patient(s)' care and the majority of patients with MS were diagnosed by an M.D. (mean % = 96.3). The mean number of therapies recommended for M.S. was 3.91 (standard deviation [SD] =2.01, range 1-10). The most frequently recommended therapies included, diet (52.4%), essential fatty acid supplementation (44.6%), vitamin/mineral supplementation (33.7%), homeopathy (30.7%), botanicals (22.3%), and antioxidants (18.1%). Respondents perceived their treatments as "very effective" for the following stages of MS: early stage (57.2%); middle stage (25.3%); and late stage (3.0%). Respondents perceived their treatments as "very effective" for the following disease-related outcomes: improved quality of life (59.0%); decrease relapse rates (48.2%); decreased symptom severity (45.8%); prevention of disease progression (41.6%). The methods used "most often" for measuring treatment effectiveness included, patient report (88.0%); physical examination (27.1%); medical records/laboratory testing (13.3%). The mean estimated percentage of patients not taking conventional disease-modifying medication was 51.2% (SD = 42.7%). CONCLUSIONS: Naturopaths use both a broad range and multiple complementary and alternative medicine CAM therapies for treating MS and report treatment effectiveness on the following outcomes: quality of life; symptom severity; relapse rates; and disease progression. Further research on single CAM therapies and holistic CAM systems is warranted in MS.
PMID: 15650479

BMC Complement Altern Med. 2004 Oct 20;4:14.
Practice patterns of naturopathic physicians: results from a random survey of licensed practitioners in two US States.
Boon HS, Cherkin DC, Erro J, Sherman KJ, Milliman B, Booker J, Cramer EH, Smith MJ, Deyo RA, Eisenberg DM.
University of Toronto
BACKGROUND: Despite the growing use of complementary and alternative medicine (CAM) by consumers in the U.S., little is known about the practice of CAM providers. The objective of this study was to describe and compare the practice patterns of naturopathic physicians in Washington State and Connecticut. METHODS: Telephone interviews were conducted with state-wide random samples of licensed naturopathic physicians and data were collected on consecutive patient visits in 1998 and 1999. The main outcome measures were: Sociodemographic, training and practice characteristics of naturopathic physicians; and demographics, reasons for visit, types of treatments, payment source and visit duration for patients. RESULT: One hundred and seventy practitioners were interviewed and 99 recorded data on a total of 1817 patient visits. Naturopathic physicians in Washington and Connecticut had similar demographic and practice characteristics. Both the practitioners and their patients were primarily White and female. Almost 75% of all naturopathic visits were for chronic complaints, most frequently fatigue, headache, and back symptoms. Complete blood counts, serum chemistries, lipids panels and stool analyses were ordered for 4% to 10% of visits. All other diagnostic tests were ordered less frequently. The most commonly prescribed naturopathic therapeutics were: botanical medicines (51% of visits in Connecticut, 43% in Washington), vitamins (41% and 43%), minerals (35% and 39%), homeopathy (29% and 19%) and allergy treatments (11% and 13%). The mean visit length was about 40 minutes. Approximately half the visits were paid directly by the patient. CONCLUSION: This study provides information that will help other health care providers, patients and policy makers better understand the nature of naturopathic care.
PMID: 15496231
Free full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC529271/?tool=pubmed

Gen Hosp Psychiatry. 2004 May-Jun;26(3):171-7.
Mental health visits to complementary and alternative medicine providers.
Simon GE, Cherkin DC, Sherman KJ, Eisenberg DM, Deyo RA, Davis RB.
Center for Health Studies, Group Health Cooperative
The objective of this study was to examine the characteristics of mental health visits to Complementary and Alternative Medicine (CAM) providers. A representative sample of acupuncturists, chiropractors, massage therapists, and naturopathic physicians in four states reported on 8933 consecutive visits, including demographic characteristics; presenting complaints; referral source; treatments provided; disposition; and other sources of care for the presenting problem. The proportion of visits for a mental health complaint ranged from 7% to 11% for acupuncture, massage, and naturopathic physicians to less than 1% for chiropractors. For acupuncturists, massage therapists, and naturopaths, 69-87% of patients making mental health visits were self-referred. The CAM provider discussed care with a conventional medical provider in 6-20% of cases and was aware of concomitant conventional medical care in an additional 10-30%. Only 1-5% were subsequently referred to conventional providers. For acupuncturists, massage therapists, and naturopaths, the proportion of visits for mental health concerns is similar to that in conventional primary care. Mental health visits to chiropractors are much less common, but this may reflect differences in true prevalence or differences in presentation. Among those seeking CAM care for mental disorders, concomitant treatment by conventional medical providers is common, but communication or coordination of care is rare.
PMID: 15121344

Cancer. 2004 Apr 1;100(7):1522-30.
The use of complementary and alternative medical providers by insured cancer patients in Washington State.
Lafferty WE, Bellas A, Corage Baden A, Tyree PT, Standish LJ, Patterson R.
Department of Health Services, University of Washington
BACKGROUND: Insurance coverage of complementary and alternative medicine (CAM) is expanding. However, to the authors' knowledge, little is know concerning CAM utilization among cancer patients under the insurance model of financing. In this study, the authors evaluated CAM provider utilization by cancer patients in a state that requires the inclusion of alternative practitioners in private, commercial insurance products. METHODS: An analysis was carried out of year 2000 claims data from two large Washington State insurance companies. RESULTS: Of 357,709 claimants, 7915 claimants (2.3%) had a cancer diagnosis. Among cancer patients, 7.1% had a claim for naturopathy, acupuncture, or massage; and 11.6% had a claim for chiropractic during the study year. The use of naturopathy (odds ratio [OR], 2.0; P<0.001) and acupuncture (OR, 1.4; P<0.001) were more common, and the use of chiropractic was less common (OR, 0.9; P<0.001) for cancer patients compared with those without cancer. No significant differences were noted in the use of massage between the two groups. Except in 2 individuals (0.03%), cancer patients also had at least 1 conventional provider claim during the year. Factors associated with nonchiropractic alternative provider use were female gender, the presence of metastatic cancer, hematologic malignancy, and the use of chemotherapy. Increased use of naturopathic physicians accounted for much of this trend. Musculoskeletal pain was the most common diagnosis at the CAM provider visit. Billed amounts for alternative services were <2% of the overall medical bills for cancer patients. CONCLUSIONS: A substantial number of insured cancer patients will use alternative providers if they are given the choice. The cost of this treatment is modest compared with conventional care charges. For individuals with cancer, CAM providers do not appear to be replacing conventional providers but instead are integrated into overall care. Copyright 2004 American Cancer Society.

PMID: 15042688

Can Fam Physician. 2003 Nov;49:1481-7.
Visiting family physicians and naturopathic practitioners. Comparing patient-practitioner interactions.
Boon H, Stewart M, Kennard MA, Guimond J.
Faculty of Pharmacy, University of Toronto
OBJECTIVE: To explore similarities and differences in patient visits with family physicians (FPs) and naturopathic practitioners (NPs). DESIGN: Exploratory study combining quantitative and qualitative methods. SETTING: Southern Ontario. PARTICIPANTS: A purposeful sample of 10 practitioners (five FPs and five NPs matched for age, sex, and number of years in practice): each agreed to recruit three consecutive patients with new complaints to participate in the study. MAIN OUTCOME MEASURES: Patient and visit characteristics; qualitative (content analysis of audiotaped interactions) and quantitative (ie, patient-centred care scores) information was gathered and analyzed. RESULTS: Qualitative analysis revealed that information gathering and treatment planning were very similar whether patients were visiting FPs or NPs. Most important differences were length of interaction (mean 54 minutes for NPs and 16.5 minutes for FPs) and patients' reasons for visits. Naturopathic practitioners were more likely to recommend medications (usually natural health products) than FPs. Quantitative data suggested that patients perceived no differences in patient-centred care from FPs and NPs. CONCLUSION: Overall, there were more similarities than differences in visits to the two types of practitioners.
PMID: 14649987
Free full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2214143/

J Am Board Fam Pract. 2002 Nov-Dec;15(6):463-72.
Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians.
Cherkin DC, Deyo RA, Sherman KJ, Hart LG, Street JH, Hrbek A, Davis RB, Cramer E, Milliman B, Booker J, Mootz R, Barassi J, Kahn JR, Kaptchuk TJ, Eisenberg DM.
Center for Health Studies, Group Health Cooperative
BACKGROUND: Despite growing popularity of complementary and alternative medical (CAM) therapies, little is known about the patients seen by CAM practitioners. Our objective was to describe the patients and problems seen by CAM practitioners. METHODS: We collected data on 20 consecutive visits to randomly sampled licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians practicing in Arizona, Connecticut, Massachusetts, and Washington. Data were collected on patient demographics, smoking status, referral source, reasons for visit, concurrent medical care, payment source, and visit duration. Comparative data for conventional physicians were drawn from the National Ambulatory Medical Care Survey. RESULTS: In each profession, at least 99 practitioners collected data on more than 1,800 visits. More than 80% of visits to CAM providers were by young and middle-aged adults, and roughly two thirds were by women. Children comprised 10% of visits to naturopathic physicians but only 1% to 4% of all visits to other CAM providers. At least two thirds of visits resulted from self-referrals, and only 4% to 12% of visits were from conventional physician referrals. Chiropractors and massage therapists primarily saw musculoskeletal problems, while acupuncturists and naturopathic physicians saw a broader range of conditions. Visits to acupuncturists and massage therapists lasted about 60 minutes compared with 40 minutes for naturopathic physicians and less than 20 minutes for chiropractors. Most visits to chiropractors and naturopathic physicians, but less than one third of visits to acupuncturists and massage therapists, were covered by insurance. CONCLUSIONS: This information will help inform discussions of the roles CAM practitioners will play in the health care system of the future.

PMID: 12463292

J Am Board Fam Pract. 2002 Sep-Oct;15(5):378-90.
Characteristics of licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians.
Cherkin DC, Deyo RA, Sherman KJ, Hart LG, Street JH, Hrbek A, Cramer E, Milliman B, Booker J, Mootz R, Barassi J, Kahn JR, Kaptchuk TJ, Eisenberg DM.
Center for Health Studies, Group Health Cooperative
BACKGROUND: Despite the growing popularity of complementary and alternative medical (CAM) therapies, little is known about the professionals who provide them. Our objective was to describe the characteristics of the four largest groups of licensed CAM providers in the United States and to compare them with the characteristics of conventional physicians. METHODS: Random statewide samples of licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians living in Arizona, Connecticut, Massachusetts and Washington were interviewed by telephone. Sociodemographic, training, and practice characteristics of CAM providers were elicited and compared with data on conventional physicians published by the American Medical Association. RESULTS: More than 160 providers in each profession were interviewed. Participation rates ranged between 78% and 94% except for Arizona chiropractors (61%). The proportion of female respondents was highest for massage therapy (85%) and acupuncture and naturopathy (almost 60%) and was lowest for chiropractic (about 25%) and conventional medicine (23%). Except for acupuncturists, only 5% of CAM providers were nonwhite. CAM providers were more likely than conventional physicians to practice solo (51%-74% vs 26%, respectively), and less than 10% practiced with medical physicians. Massage therapists saw the fewest patients per week (about 14), and chiropractors and conventional physicians the most (about 100). Chiropractors and conventional physicians saw about 3 patients per hour compared with roughly 1 patient per hour for the other CAM professions. Interstate differences were small. CONCLUSIONS: This characterization of CAM providers will help inform decisions about the future role of CAM providers PMID: 12350060
PMID: 12350060

Altern Ther Health Med. 2002 Sep-Oct;8(5):68-70; 72-5.
Complementary and alternative medical treatment of breast cancer: a survey of licensed North American naturopathic physicians.
Standish LJ, Greene K, Greenlee H, Kim JG, Grosshans C.
Bastyr University Research Institute
CONTEXT: Complementary and alternative medicine (CAM) use is on the rise in the United States, especially for breast cancer patients. Many CAM therapies are delivered by licensed naturopathic physicians using individualized treatment plans. OBJECTIVE: To describe naturopathic treatment for women with breast cancer. DESIGN: Cross-sectional mail survey in 2 parts: screening form and 13-page survey. SETTING: Bastyr University Cancer Research Center, Kenmore, Wash. PARTICIPANTS: All licensed naturopathic physicians in the United States and Canada (N=1,356) received screening forms; 642 (47%) completed the form. Of the respondents, 333 (52%) were eligible, and 161 completed the survey (48%). MAIN OUTCOME MEASURES: Demographics of naturopathic physicians, development of treatment plans, CAM therapies used, perceived efficacy of therapeutic interventions. RESULTS: Of those respondents screened, 497 (77%) had provided naturopathic care to women with breast cancer, and 402 (63%) had treated women with breast cancer in the previous 12 months. Naturopaths who were women were more likely than men to treat breast cancer (P < or = .004). Of the survey respondents, 104 (65%) practiced in the United States, and 57 (35%) practiced in Canada; 107 (66.5%) were women, and 54 (33.5%) were men. To develop naturopathic treatment plans, naturopathic physicians most often considered the stage of cancer, the patient's emotional constitution, and the conventional therapies used. To monitor patients clinically, 64% of the naturopathic physicians used diagnostic imaging, 57% considered the patient's quality of life, and 51% used physical examinations. The most common general CAM therapies used were dietary counseling (94%), botanical medicines (88%), antioxidants (84%), and supplemental nutrition (84%). The most common specific treatments were vitamin C (39%), coenzyme Q-10 (34%), and Hoxsey formula (29%).
PMID: 12233805

Focus Altern Complement Ther 2002; 7: 114

The scope of naturopathic practice: an emerging profession

Verhoef MJ, Boon HS, Smith M, Mutasingwa DR
Faculty of Medicine, University of Calgary
Objective: A specific challenge to the professionalisation of naturopathic practitioners is the degree of overlap between their practice and the practice of other therapists. Therefore, we examined naturopathic practitioners’ perspectives and opinions about their scope of practice. Materials and methods: A survey of all (473) licensed naturopathic practitioners in Canada. Data were collected by means of a seven-page mailed questionnaire. Results: The response rate was 63%; 41% were male and the mean age was 42 years (SD 10.9 years). Ninety-seven per cent were in active clinical practice. The most common health problems seen by participants were gastrointestinal complaints, women’s health issues, fatigue and allergies. Out of a list of 35 treatment modalities, 23 were practised by more than 30% of respondents (most commonly botanical medicine, homoeopathy, nutritional counselling and supplementation, and psychological counselling). Seventy-five per cent indicated there were modalities other than the 35 listed that they would like to be able to offer their patients, 56% felt that the scope of practice for naturopathic doctors was too restrictive and 92% identified overlap with the practice of other practitioners. More than 90% of respondents referred to MDs, chiropractors, massage therapists and other naturopathic practitioners.
Discussion: Naturopathic practitioners often deal with chronic, difficult-to-treat conditions, which require multiple modalities. While respondents appeared to be open to referring to other professionals, they generally felt that their scope of practice was too limited. This may pose a major problem in the process of professionalisation, as this type of practice is difficult to codify when seeking regulation.
PMID: 16487639

Can J Clin Pharmacol. 2000 Spring;7(1):45-9.

Attitudes and practices of physicians and naturopaths toward herbal products, including use during

pregnancy and lactation.

Einarson A, Lawrimore T, Brand P, Gallo M, Rotatone C, Koren G.
The Motherisk Program, The Hospital for Sick Children, Toronto, Canada.
BACKGROUND: The popularity of complementary therapies continues to grow, and physicians are asked increasingly by their patients for information regarding these modalities. PURPOSE: To assess the impact of these trends on physicians and medical students, and compare their attitudes and practices with those of the naturopaths and their students, with particular interest in the use of herbal products during pregnancy and breastfeeding. MATERIALS AND METHODS: A detailed questionnaire was distributed by a medical student and a naturopathic student to a randomly selected group of physicians, medical students, naturopaths and naturopathic students. They were asked a variety of questions about their background, attitudes and practices concerning herbal products. RESULTS: Thirty-eight per cent of the questionnaires were returned, with a total of 242 respondents. Fifty-four per cent of physicians discussed complementary therapies with their patients, whereas 100% of naturopaths discussed conventional medicines with their patients. The most popular product recommended by both medical doctors and naturopaths was echinacea, followed by St John's Wort. Eighty-six per cent of physicians, 74% of medical students, 66% of naturopaths and 50% of naturopathic students think that complementary medical education should be incorporated into the standard medical curriculum. Only one physician actually recommended a herbal product to a pregnant patient compared with 49% of the naturopaths who felt comfortable doing so. CONCLUSIONS: Complementary medicine has become a reality, and physicians are recommending herbal products to their patients, although on a smaller scale than are naturopaths. However, the two most popular herbal products are the same in each group. Physicians are less likely to recommend herbal products to pregnant and breastfeeding women than are naturopaths.
PMID: 10822213

Arch Pediatr Adolesc Med. 2000 Jan;154(1):75-80.

Homeopathy and naturopathy: practice characteristics and pediatric care.

Lee AC, Kemper KJ.

Center for Holistic Pediatric Education and Research, Children's Hospital, Harvard Medical School

OBJECTIVE: To describe the practice characteristics and pediatric care of homeopathic practitioners (HPs) and naturopathic doctors (NDs). DESIGN: Cross-sectional, descriptive survey. SETTING: Homeopathic and naturopathic practices in Massachusetts. PARTICIPANTS: Homeopathic practitioners (N = 42) and NDs (N = 23) identified from the yellow pages, regional and national society membership lists, schools, magazine advertisements, and by word-of-mouth. The response rate was 55% (23/42) for HPs and 65% (15/23) for NDs. MAIN OUTCOME MEASURES: Demographics, practice characteristics, fee structure, and amount of pediatric care. Practitioners were asked for their approach to childhood immunizations and to treating a febrile neonate. Data were analyzed using simple descriptive statistics. RESULTS: Almost all respondents were white. Among the HPs, 13 (57%) were licensed medical doctors. Naturopathic doctors and HPs reported having an average of only 25 to 40 patient visits per week, but children and adolescents accounted for up to one third of these visits. Nearly all reported treating children, but fewer than half of the practitioners reported any formal pediatric training. Initial patient visits typically lasted more than 1 hour and cost $140 to $150. Follow-up visits were scheduled every 4 to 6 weeks and lasted more than 30 minutes on average. Insurance covered less than one third of the patient visits, and sliding scale payments were offered by less than half of the respondents. Most practitioners reported that they did not actively recommend immunizations and fewer than half of the nonphysician practitioners reported that they would refer a 2-week-old neonate with a fever to a medical doctor or emergency medical facility. CONCLUSIONS: Many patients using homeopathy and naturopathy are children. Visits to these providers are frequent and fees are primarily paid out-of-pocket. Failure on the part of these providers to recommend immunizations or recognize potentially serious illnesses is cause for concern.
PMID: 10632255
Free full text: http://archpedi.ama-assn.org/cgi/content/full/154/1/75

Cancer Prev Control. 1999 Feb;3(1):77-82.

Complementary health practitioners' attitudes, practices and knowledge related to women's cancers.

Gray RE, Fitch M, Saunders PR, Wilkinson A, Ross CP, Franssen E, Caverhill K.
Toronto-Sunnybrook Regional Cancer Centre
OBJECTIVE: To document the attitudes, practices and knowledge of 3 groups of complementary practitioners (naturopathic doctors, chiropractors and massage therapists) regarding women's cancers in general and ovarian cancer specifically. DESIGN: A mailed survey questionnaire was followed by a reminder card and a second mailing of the questionnaire. SETTINGS: National samples were obtained for naturopathic doctors and chiropractors. The massage therapist sample was drawn from Ontario only because of the absence of a national listing of massage therapists. MAIN OUTCOME MEASURES: Practitioners reported response to patients' suspicious symptoms. Practitioners' perceptions of patients' motivations for seeking treatment. Practitioners' satisfaction with interactions with conventional practitioners. Practitioners' perceptions of their role in the care of women at risk of, or diagnosed with, cancer. Practitioners' perceptions of their knowledge regarding women's cancers. Practitioners' knowledge specific to ovarian cancer. RESULTS: A total of 894 completed questionnaires were returned, providing a response rate of 56%. The vast majority of practitioners who saw women with symptoms possibly related to cancer referred them to a family physician or a cancer specialist. Motivations that practitioners most frequently heard expressed by women seeking complementary treatments were "maximizing quality of life," "seeking natural approaches to healing" and "looking to stay well when disease is in remission." Most respondents were dissatisfied with patient-related communication with both family physicians and cancer specialists. The majority of complementary practitioners indicated that they have an important role to play in the postdiagnostic care of women with cancer. Considerable interest was expressed in further education concerning ovarian cancer. CONCLUSIONS: Whereas the professions reached through this survey differ in important ways from each other, they share an interest in being involved in the care of women with cancer, as well as an enthusiasm for the development of continuing professional education programs to help them better serve their clients.
PMID: 10474756

Soc Sci Med. 1998 May;46(9):1213-25.

Canadian naturopathic practitioners: holistic and scientific world views.

Boon H.
Faculty of Pharmacy, University of Toronto
This paper describes naturopathic practitioners with two different world views--holistic and scientific, and explores the relationship of practitioners' socialization experiences and practice patterns with these two world views. Data were gathered by a variety of methods including: (1) a 14-page questionnaire mailed to all 296 naturopathic practitioners licensed in Canada; (2) a participant observation study at the Canadian College of Naturopathic Medicine (CCNM); and (3) open-ended interviews with 16 students attending CCNM and 41 naturopathic practitioners which were audio-taped and transcribed verbatim. Individuals with both holistic and scientific world views entered naturopathic training and none of the practitioners who were interviewed reported a change in world view while at naturopathic college. However, practitioners reported a new-found appreciation of the "other" world view on completion of their training, indicating the occurrence of a socialization effect. Many decisions involved in setting up a practice and seeing patients were affected by the practitioners' world views. For example, there were distinct differences in the way the practitioners with different world views who were interviewed chose treatment modalities. Practitioners with scientific world views reported choosing treatments based on the available "scientific evidence", while practitioners with holistic world views included a careful exploration of the patient's spirituality and their own intuition in their treatment decisions. In addition, practitioners with holistic world views reported significantly longer patient visits than practitioners with scientific world views. The data presented here suggest that one's world view influences one's perceptions of socialization experiences and social situations, and modulates the effects of both on practice patterns.
PMID: 9572611 

Clinical and Physician Descriptive Data

Cost studies describe the costs associated with naturopathic care and may evaluate the economic efficiency of naturopathic practice. Few cost studies of naturopathic practice have been published. A few more studies have been done on complementary and alternative care in general; publications listed here have at least some part of the reported data specifically about naturopathic care.

This listing of naturopathic cost studies here is incomplete. Please inform us of published studies that meet the criteria above that are not included here by sending a citation and abstract to the Executive Director of NPRI.

J Altern Complement Med. 2010 Apr;16(4):411-7.
Comparison of health care expenditures among insured users and nonusers of complementary and alternative medicine in Washington State: a cost minimization analysis.
Lind BK, Lafferty WE, Tyree PT, Diehr PK.
University of Washington
OBJECTIVES: The purpose of this analysis was to compare health care expenditures between insured patients with back pain, fibromyalgia syndrome, or menopause symptoms who used complementary and alternative medical (CAM) providers for some of their care to a matched group of patients who did not use any CAM care. Insurance coverage was equivalent for both conventional and CAM providers. DESIGN: Insurance claims data for 2000-2003 from Washington State, which mandates coverage of CAM providers, were analyzed. CAM-using patients were matched to CAM-nonusing patients based on age group, gender, index medical condition, overall disease burden, and prior-year expenditures. RESULTS: Both unadjusted tests and linear regression models indicated that CAM users had lower average expenditures than nonusers. (Unadjusted: $3,797 versus $4,153, p = 0.0001; beta from linear regression -$367 for CAM users.) CAM users had higher outpatient expenditures that which were offset by lower inpatient and imaging expenditures. The largest difference was seen in the patients with the heaviest disease burdens among whom CAM users averaged $1,420 less than nonusers, p < 0.0001, which more than offset slightly higher average expenditures of $158 among CAM users with lower disease burdens. CONCLUSIONS: This analysis indicates that among insured patients with back pain, fibromyalgia, and menopause symptoms, after minimizing selection bias by matching patients who use CAM providers to those who do not, those who use CAM will have lower insurance expenditures than those who do not use CAM.

PMID: 20423210

Evid Based Complement Alternat Med. 2009 Sep;6(3):297-304. Epub 2007 Dec 5.
Cost effectiveness of natural health products: a systematic review of randomized clinical trials.
Kennedy DA, Hart J, Seely D.
The Canadian College of Naturopathic Medicine
Health care spending in North America is consuming an ever-increasing share of Gross Domestic Product (GDP). A large proportion of alternative health care is consumed in the form of natural health products (NHPs). The question of whether or not NHPs may provide a cost-effective choice in the treatment of disease is important for patients, physicians and policy makers. The objective of this study was to conduct a systematic review of the literature in order to find, appraise and summarize high-quality studies that explore the cost effectiveness of NHPs as compared to conventional medicine. The following databases were searched independently in duplicate from inception to January 1, 2006: EMBASE, MEDLINE, CINAHL, BioethicsLine, Wilson General Science abstracts, EconLit, Cochrane Library, ABI/Inform and SciSearch. To be included in the review, trials had to be randomized, assessed for some measure of cost effectiveness and include the use of NHPs as defined by the Natural Health Products Directorate. Studies dealing with diseases due to malnutrition were excluded from appraisal. The pooled searches unveiled nine articles that fit the inclusion/exclusion criteria. The conditions assessed by the studies included three on postoperative complications, two on cardiovascular disease, two on gastrointestinal disorders, one on critically ill patients and one on urinary tract infections. Heterogeneity between the studies was too great to allow for meta-analysis of the results. The use of NHPs shows evidence of cost effectiveness in relation to postoperative surgery but not with respect to the other conditions assessed. In conclusion, NHPs may be of use in preventing complications associated with surgery. The cost effectiveness of some NHPs is encouraging in certain areas but needs confirmation from further research.

PMID: 18955290
Free article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722206/?tool=pubmed

Altern Ther Health Med. 2008 Mar-Apr;14(2):32-9.
Cost-effectiveness of naturopathic care for chronic low back pain.
Herman PM, Szczurko O, Cooley K, Mills EJ. University of Arizona
OBJECTIVE: To determine the cost-effectiveness of naturopathic care (acupuncture, relaxation exercises, exercise and dietary advice, and a back care booklet) compared to standardized physiotherapy education and a back care booklet (control treatment) for low back pain in a sample (N = 70) of warehouse workers. DESIGN: Economic evaluation based upon the results of a pragmatic randomized controlled trial to determine the cost-effectiveness of naturopathic care to society as a whole, to the employer, and to participants. RESULTS: Naturopathic care (as compared to the control treatment) significantly improved quality-adjusted life-years over the 6-month study period (3-month intervention period and 3-month follow-up period) by 0.0256 (95% CI: 0.0075, 0.0437)--roughly equivalent to 9.4 "perfect health" days. Naturopathic care also significantly reduced societal costs by $1212 per participant. From the perspective of the employer, the intervention cost $154 per absentee day avoided (compared to employer costs of lost productivity of $172 per day) and had a return on investment of 7.9% under the healthcare coverage limits set by this employer and assuming the employer paid the full cost of naturopathic care. Participants experienced savings in adjunctive care of $1096 per participant. CONCLUSIONS: This economic evaluation alongside a pragmatic randomized control trial shows naturopathic care to be more cost-effective than a standardized physiotherapy education regimen in the treatment of chronic low back pain. Further studies of the economic impact of naturopathic medicine are warranted.

PMID: 18383988

Cancer. 2004 Apr 1;100(7):1522-30.
The use of complementary and alternative medical providers by insured cancer patients in Washington State.
Lafferty WE, Bellas A, Corage Baden A, Tyree PT, Standish LJ, Patterson R. Department of Health Services, University of Washington
BACKGROUND: Insurance coverage of complementary and alternative medicine (CAM) is expanding. However, to the authors' knowledge, little is know concerning CAM utilization among cancer patients under the insurance model of financing. In this study, the authors evaluated CAM provider utilization by cancer patients in a state that requires the inclusion of alternative practitioners in private, commercial insurance products. METHODS: An analysis was carried out of year 2000 claims data from two large Washington State insurance companies. RESULTS: Of 357,709 claimants, 7915 claimants (2.3%) had a cancer diagnosis. Among cancer patients, 7.1% had a claim for naturopathy, acupuncture, or massage; and 11.6% had a claim for chiropractic during the study year. The use of naturopathy (odds ratio [OR], 2.0; P<0.001) and acupuncture (OR, 1.4; P<0.001) were more common, and the use of chiropractic was less common (OR, 0.9; P<0.001) for cancer patients compared with those without cancer. No significant differences were noted in the use of massage between the two groups. Except in 2 individuals (0.03%), cancer patients also had at least 1 conventional provider claim during the year. Factors associated with nonchiropractic alternative provider use were female gender, the presence of metastatic cancer, hematologic malignancy, and the use of chemotherapy. Increased use of naturopathic physicians accounted for much of this trend. Musculoskeletal pain was the most common diagnosis at the CAM provider visit. Billed amounts for alternative services were <2% of the overall medical bills for cancer patients. CONCLUSIONS: A substantial number of insured cancer patients will use alternative providers if they are given the choice. The cost of this treatment is modest compared with conventional care charges. For individuals with cancer, CAM providers do not appear to be replacing conventional providers but instead are integrated into overall care. Copyright 2004 American Cancer Society.

PMID: 15042688 

Cost Studies

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