Small Acupuncture Graphic Patients Vote An Overwhelming "Yes" for Acupuncture
by Claire M. Cassidy
for "Meridians"


Preliminary results are in. The first-of-its-kind "Patients' Own Words" research project tells us what acupuncture users nationwide think of their treatment, if they get what they come for, what they think of their practitioners, the costs-and more. In a nationwide survey of acupuncture users,

These are just a few of the extraordinary findings in the largest survey to date of acupuncture patients.

The first results are in after more than four years of designing, testing, and conducting research. At six clinics in five states [Table 1], 575 people participated in the research, and almost all of them reported that acupuncture helps them to feel and function better. Respondents also reported that they were very satisfied with acupuncture care, with its cost, and with their individual practitioners. Many also said that with acupuncture they were saving money on their overall health-care costs.

This brief report summarizes responses to key questions on the survey instrument and describes how the survey was designed and conducted. Then it looks forward and describes other information we hope to develop from the survey responses.

What kinds of complaints did respondents bring for care?

Although 63% of patients reported that they used acupuncture care to keep them healthy, most also reported that they used it to care for a wide range of complaints, ranging from depression to diabetes, from colds, sinus infections and allergies to neck and back pain, from HIV and hepatitis to insomnia, PMS, and infertility.

Thus, though many people who haven't tried acupuncture think of it primarily as a means to control pain, it was clear that users viewed its real utility as much broader.

What happened to symptoms?

On the questionnaire, respondents could report separately what happened to up to four symptoms or complaints. When we added up all the responses, we learned that

The numbers of people reporting disappearance or improvement of symptoms are too high to be the result of chance or bias alone--people did experience health improvements with acupuncture care.

When we look in more detail at what people say changed, we see that they reported improvements in what are usually called the physical and emotional aspects. Many also reported having more energy, or experiencing spiritual awakening. Many people indicated they felt better socially. They reported that they got along with others better; they liked their co-workers more; they could control their tempers at work, and so on.

Table 2 lists results after respondents were asked how well several sentences fit their own experiences. The most popular answers-"most of the time" and "some of the time"-indicate that these patients experienced important improvements in their daily functioning.

What makes this result especially striking is that respondents were using a variety of health-care modalities, yet commonly attributed the improvements in their health specifically to acupuncture. On average, respondents used 3.5 different forms of health care--acupuncture, MDs [biomedicine/conventional medicine], chiropractic, massage therapy, psychotherapy, and so forth.

Despite this multiple usage, a majority of respondents claimed that acupuncture was "what made the difference": 57.0% said their improvement "definitely" was due to acupuncture; 19.9% said it was "probably" acupuncture; and only 17.5% said "it was a combination of factors."

Another important point: In the cases where people reported improvement but not disappearance of their symptoms, they often added handwritten comments, noting that what really mattered to them was that they now lived with their limitations more easily. Rather than interpreting their symptoms as "sickness" and/or "failures" of medical and self-care, they had begun to reinterpret symptoms as friendly warnings when they were overstepping the boundaries of their strength. Respondents repeatedly praised their practitioners for teaching them self-care and the attentiveness to their inner and outer selves that helped them achieve this change in perception.

Were survey respondents satisfied with acupuncture?

The answer to this question is an unqualified "yes."

Asked to say how satisfied they were with their acupuncture care, practitioners, and costs, the large majority chose "extremely" or "very" satisfied for all three categories. Satisfaction with biomedical treatments, practitioners, and cost is also shown.

Satisfaction graph

What's interesting about these data is that the distribution for acupuncture satisfaction is, to use statistical language, "skewed toward satisfaction." However, among users of alternative medicine, the distribution for biomedical satisfaction is not skewed toward dissatisfaction as anticipated by some observers, but presents as a normal, bell-shaped distribution. This means that most respondents say they are "satisfied" with biomedicine; smaller numbers report that they are highly satisfied or highly dissatisfied.

Combining these data with information in personal stories, we know that acupuncture patients are not abandoning biomedicine. Instead, they use it with discrimination for what it does best--diagnostic tests, trauma care, surgery, antibiotics, vaccinations, and similar services.

Respondents were asked to say what kind of relationship they had with their acupuncture practitioners. They were asked this question partly because other research has shown that close and warm patient-practitioner relationships are in themselves healing. Offered nine words, five of which were more authoritarian, and four more relational, respondents overwhelmingly favored the relational words, especially "friend," "guide," and "partner." The only popular authoritarian word was "doctor," and it was preferred only when the practitioner had a doctoral degree (Ph.D. or O.M.D.).

Who uses acupuncture care?

Because our survey took place in schools and private clinics, we knew from the beginning that our sample would consist mainly of middle-class people who could pay for their own care and who owned and drove their own cars. Beyond that, the demographic picture of acupuncture users at the six clinics turned out to be much like that found by other researchers who have studied the population that uses alternative medicine:

Compared to the whole population of the United States, acupuncture users were:

This pattern-more women, people who are highly educated and mobile-is what one expects of users of a "new" practice, because first users tend to be experimental people willing to take a risk on something unfamiliar, and have enough money to do so.

Note that this pattern is unlikely to hold much longer, for the use of acupuncture is growing fast, spreading to a wide spectrum of Americans. First users seem to be selling acupuncture by word of mouth, and other forces also are at work. The judiciary system, for example, is introducing acupuncture to people via court-ordered detox programs. A survey taken just five years from now probably will find acupuncture used by a nationally-normative range of people.

How much did acupuncture care cost?

Although it is important to understand the cost of acupuncture care compared to other modalities, we found it difficult to calculate because relatively few respondents could tell us how much their MD/biomedical costs were. In the end, we were able to estimate biomedical costs for only one-third of the sample.

On the other hand, more than 80% of our respondents could report acupuncture costs accurately for the previous three months of acupuncture care. In three months, most patients saw their acupuncture practitioner six times or less [Table 3]. The average cost for all respondents for three months of visits was $238.52 (combining all sites, including the lower costs of school clinics with the usually higher costs of private clinics).

Of the respondents who had seen both an MD and an acupuncturist in the three months preceding the survey, 155 were able to report the costs of both. We compared these costs for this group [Table 3]. For these patients, acupuncture costs totaled 64.6% of the costs of biomedical care. We can't say much more at present, because to know whether either system was "effective" or even "more effective than the other" would require a different type of research than we conducted for this study.

The survey also asked respondents if they thought they used various costly forms of health care less often while using acupuncture care. Again, for the subsample of patients for whom the questions mattered, the strong perception was that they were avoiding costly care. For example:

Did respondents report harm from acupuncture needles?

In no case did a respondent report serious harm from an acupuncture needle. This is excellent news, given the millions of needles used yearly in the United States. Seventy-two percent reported they had never experienced harm from the needles. Another 24.6% said they had experienced a small bruise or a drop of blood at the needle site. Only 3.6% said they had experienced something more serious, such as a pimple or rash.

Those who commented on the harm they had experienced unanimously downplayed its importance. Two respondents said they fainted in the presence of needles; several noted a bruise or sore spot but noted it had happened "only once"; and the one person who reported a rash said it turned out to be an allergy to the alcohol used to clean his skin.

The great majority of respondents reported that their practitioners use only sterile, disposable needles. Only 8.3% reported they were treated with reusable needles (usually patients provided their own set).

A perspective on the survey

The data just reported provide a snapshot view of acupuncture users at six clinics. Because the goal of the research was descriptive rather than experimental (that is, we were not testing an hypothesis), we were not concerned with issues such as randomized sampling; however, we did follow a systematic and scientific protocol described in Table 4.

The large sample collected in the clinics tested out as "representative," which means we are confident that the collected data accurately represent users of the six participating clinics. To the extent that those clinics are typical, our data probably represent the wider audience of acupuncture users in the United States. We cannot generalize, however, until we do a repeat survey at a different set of clinics.

In researchers' language, this survey is an exploratory survey that produced descriptive data. Why did we do this type of survey? The first answer is that it hadn't been done before. In the United States, acupuncture is a "new" health-care practice, and no one had conducted a large-scale survey of acupuncture users. Apart from clinical observational data, we had no "big picture" knowledge of the people using acupuncture.

With this research, we have a first database that provides insight on the demographics, epidemiology, cost recall, and outcomes of acupuncture treatment as reported by acupuncture users. These data already are providing a valuable service by helping patients see how their experience compares with that of others, by highlighting shortcomings and strengths for practitioners, and by identifying to researchers areas that will reward further research.

There is a second reason for the particular shape of our survey-it was driven by the research goals of the Traditional Acupuncture Institute. When TAI personnel set out to do research in 1991, they agreed that their deep interest lay in finding out what patients feel they are receiving, and how this fits with what practitioners think they are delivering. To phrase the research goal this way is exciting because it puts the patient at the center of the research process. To emphasize the experiential side of the project, Robert Duggan, President of TAI, named the undertaking "The Patients' Own Words Project." This survey is the second step in that project, which is ongoing.

TAI wanted to gather experiential data precisely enough to meet scientific standards. The approach I chose was to do a survey that produced both statistical and narrative data-or, as promised at an evening seminar three years ago, "both histograms and metaphors."

The questionnaire used in this survey meets those criteria. It contains 29 questions. Most are in the familiar and quickly completed "check-off" form that produces quantitative data. Some questions allow respondents to add written comments to their check-off answers, so their opinions and perceptions can show through. The final question asks patients to "tell your own story" in longhand about their experiences of acupuncture. These handwritten answers provide the narrative data which can be analyzed systematically, and which provide the experiential data sought by TAI.

What's coming next?

We haven't finished analyzing the data from the six-clinic survey. This report includes the first cut of data, and more is coming.

The personal stories will take the longest time to analyze. Several TAI students and I are working on them right now. By studying the stories we hope to be able to report on such questions as:

Summary

By gathering a combination of quantifiable and narrative information from a large sample of acupuncture patients, we believe we are on our way to better understanding the outcomes patients experience from acupuncture. We also believe that the method used in this study could open up a new way to look at the effects of health care on those who use it-those who, in the end, must be satisfied with what they perceive they receive for their health-care dollars.


Author, Claire M. Cassidy, Ph.D., designed and conducted the innovative "Patients' Own Words" research project. Director of research at the Traditional Acupuncture Institute, she heads her own consulting firm, Paradigms Found, in Bethesda, Maryland, and is author of numerous articles about research and medical anthropology. Most recently she contributed a chapter on the cultural context of medical systems to Fundamentals of Complementary and Alternative Medicine (Churchill Livingstone, 1996), a text developed particularly for medical schools.

Research like this cannot be accomplished without the commitment and care of many people, including the 575 generous souls who completed the question-naire. As well, special thanks to Laura and Alan Klein, and Paula Derry, who offered invaluable help with data analysis.
-Claire Cassidy

Claire Cassidy


Personal Stories

On the last page of the research survey, respondents were invited to "tell your own story." Below are four from 422 stories collected, which will be analyzed in the next stage of the research project-stories that make the statistics come alive:

"I spent my life running to every medical doctor (includes MDs, psychologists, nutritionists, neurologists) I could find for generally feeling ill, weak, tired and scared, without ever getting significant help. Was always told not much wrong with me. Began improving immediately after first several acupuncture treatments. Acupuncture has helped me through [an]other health crisis--specifically, kidney stones--and also through several life crises involving my family. My general health and strength has improved, anxiety problem is mainly gone, and I've been able to make other changes in life--using homeopathy, herbs, and bodywork to improve my life. I'd say that the acupuncture is the mainstay of my health maintenance, and has supported the other positive changes in my life. My dependence (every 3-6 months) upon medical intervention has ceased, and the quality of my life has significantly improved." -Woman, 41-50, Baltimore private clinic

"I started acupuncture 8 or 9 years ago. I was looking for a means of managing stress and dealing with my HIV diagnosis. Acupuncture had immediate effects on my levels of stress. I simply was not the same person at work. Co-workers could not believe the difference in my disposition. Clients continually comment on my relaxed nature given the stressful environment I have put myself in (CPA, working with taxes). I believe it has helped me stay healthy over the last 9 years despite being HIV-positive for 14 years." -Man, 31-40, San Francisco private clinic

"I had lost an ovary at 23 and had chronic reproductive problems, numerous surgeries, hormone and drug therapies for the next 10 years. I said, "NO MORE!" to my gynecologist, who said he had patients who were reporting good results with acupuncture. He referred me for treatment 10 years ago. Not only did my physical symptoms improve, but my mental health and spiritual awareness have been very good. I use acupuncture now prophylactically and as a first line of defense when I'm ill. I use herbs suggested by my practitioner. I regularly encourage others to seek this health care. I have learned so much from my practitioners (I've had three--each brings unique gifts) and consider them to be lifelines to wellness. I can work with the ebb and flow of life much more easily now. But-I still have not conquered my nicotine addiction despite a lot of directed treatment." -Woman, 31-40, Baltimore private clinic

"I came here and found real help. Was able to afford the treatment (thanks to a sliding fee scale). Learned a lot about the healing process. Feel more balanced. Have more energy. Thanks!" -Woman, 41-50, Seattle school clinic


TABLE 1:

Clinics Participating in the Survey
Clinic Name Location Type Acupuncture Style1
Centre for Traditional Acupuncture Columbia, MD Private Five-Element
Ruscombe Mansion Baltimore, MD Private Five-Element
New England School of Acupuncture Boston, MA School TCM2/Japanese
Northwest Institute of Acupuncture & Oriental Medicine Seattle, WA School TCM
Gipson Specialty Center Memphis, TN Private TCM
Chinese Medicine Works San Francisco, CA Private Eclectic
1-Each site identified its own primary acupuncture styles; other styles may be practiced at this site.
2-Traditional Chinese Medicine

TABLE 2:

How Respondents Describe Their Experience
"For each sentence check the word that best describes your experience with acupuncture."
Percentages none a little some most of the time
I feel better 0.4 2.3 21.1 76.2
I can work better 1.6 4.5 30.2 63.6
I have more energy 1.1 6.4 34.3 58.2
I am more focused 1.2 7.4 33.3 58.2
I have less pain 1.9 5.9 28.4 63.8
I miss fewer work days 9.4 3.0 16.6 71.0
I get along better with others 2.3 4.8 24.1 68.8

TABLE 3:

Cost Comparison Biomedical Costs Acupuncture Costs
Average Number of Visits (in 3 months) 2.2 6.0
Average Total Cost $409.09 $264.40

TABLE 4:

Details of Data Collection
"Scientific" research meets certain criteria, including systematic data collection and efforts to minimize oddities of response or interpretation ("bias"). This survey took the following precautions to ensure that the data were interpretable and of high quality:

Questionnaire development

  • To help create the questionnaire, we analyzed 60 in-depth interviews and conducted two pilot tests.

Data collection protocol

  • Only general service clinics were invited to participate; all multi-practitioner clinics met the patient-flow criterion of more than 80 patients per week.
  • Patients were informed of the survey beforehand and urged to schedule extra time to complete the questionnaire.
  • Clinics collected data for 14 consecutive working days, offering the questionnaire to all patients scheduled in the survey period.
  • No patient was required to complete the questionnaire.
  • All questionnaires were anonymous.

Representativeness of sample

  • Within clinics, there was no significant difference (by sex or acupuncture experience) between those who completed questionnaires and those who did not.
  • Between clinic types, school clinics had more inexperienced patients (patients new to acupuncture), and the Baltimore and Columbia clinics had more experienced patients (probability less than .001).
  • Conclusion: For the issues discussed in this article, clinic differences were small enough to make it reasonable to group the data from all six sites.


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