Model Whole Practice Study Finds Treatment by Naturopathic Doctors Effective & Cost-Saving for Canada Post Employees with Cardiovascular Disease

Summary: Preliminary results from a randomized controlled pragmatic trial of the whole practice of naturopathic medicine for Canada Post employees with elevated cardiovascular risk found treatment by integrative naturopathic doctors to be both effective and cost-saving. Naturopathic treatment produced an overall $1025 cost benefit per participant. The results were reported by Dugald Seely, Bsc, ND, MSc and economist Patricia Herman, MS, ND, PhD, on August 12, 2010 at the conference of the American Association of Naturopathic Physicians. The methods for researching this whole practice, individualized treatment are a model for all integrative practitioners, whether integrative MDs/DOs, broad scope DCs, AOM practitioners or other multi-modal care-givers for whom reductive trials fail to capture their practices. The model provides critical information for healthcare decision makers. For many in the naturopathic profession, the outcomes are celebrated as a potential game-changer in their efforts to expand inclusion of their services by employers, public agencies and insurers.


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Major employer backs study

Preliminary results from a randomized controlled pragmatic trial of the whole practice
of naturopathic medicine for patients with elevated cardiovascular risk
found treatment by integrative naturopathic doctors to be both effective and cost saving. The study was engaged by researchers associated with the Canadian College of Naturopathic Medicine (CCNM) for Canada Post, the Canadian postal service.


The Canada Post employees who were patients of naturopathic doctors showed significant reductions in levels of
cardiovascular risk and incidence of metabolic syndrome. They also found benefits across numerous biometric and
self-reported health-related markers. The “total societal cost savings”
during the year were estimated to be $1025 per employee.

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CCNM’s Seely: Lead researcher for the study on Canada Post employees

The data were reported on August 12, 2010 at the annual conference of the American Association of Naturopathic Physicians. The principal researcher on the study was Dugald Seely, BSc, ND, MSc, director of research for CCNM. Seely’s report was entitled “Naturopathic Treatment for the Prevention of
Cardiovascular Disease: A Whole System Randomized Pragmatic Trial.”

Economist Patricia Herman, MS, ND, PhD, led the cost analysis and
reported her findings as “Cost-Effectiveness of Naturopathic Treatment
for the Prevention of cardiovascular Disease.” Herman co-authored the
economics paper for the 2009 Summit on Integrative Medicine and the Health of the Public.

Concluded Herman: “If we examine only direct costs, it looks like the cost of naturopathic care per unit reduction in the risk of cardiovascular disease is somewhere between that of aspirin and that of statin drugs.” The significant overall cost savings to the employer were found once factors such as absenteeism and presenteeism were included.

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At a Glance:

Cost & Effectiveness of the Whole Practice of Naturopathic Doctors
in Preventing Cardiovascular Disease
– Preliminary Findings

Study led by Dugald Seely, BSc, ND, MSc & Patricia Herman, ND, PhD

General Information    
Partner/Subjects   Canada Post/Canadian Union of Postal Workers
Research institution   Canadian College of Naturopathic Medicine
Principal investigator

  Dugald Seely, BSc, ND, MSc
Lead cost investigator   Patricia Herman, MS, ND, PhD
Study type   Randomized controlled pragmatic  trial
Total subjects   246 (124 to treatment, 122 usual care)
Recommended therapies  
Suggestions individualized to each patient

with a focus on dietary, lifestyle and
supplement interventions. Some key
examples include nutrition (whole foods
focus), fish or fish oil consumption,
sleep (7 hr/night), counseling, stress
reduction (deep breathing), exercise

(30 minutes/day for
5 days/wk)

Adherence: “About 80%”

Naturopathic visits   7 in one year; weeks 0, 4, 8, 18, 26, 35, 52

Clinical Measures

   
Measures  
  • Framingham cardiovascular risk profile
  • Incidence of metabolic syndrome (MS)
  • MYMOP patient-centered outcomes

Clinical Outcomes    
Clinical outcomes
(primary)
 
  • 27% favorable difference in MS
  • 3.6% favorable difference in risk
  • ND group 5.5 years younger in “CV years”

Clinical outcomes

(secondary)

  Self-reports via MYMOP found improvement
in multiple areas: fatigue, sleep, weight,
stress, allergic symptoms, hypertension,
coffee consumption, muscoloskeletal problems,

etc.

Est. impact on 10 year risk
of cardiovascular disease

 
  • 3.3 fewer works out of 100 will not have a

           
major event

  • “at least 1 person who would

           have died will not have died.”

Cost Measures    
Direct cost measures

 
  • Direct medical costs of ND services

           (prescribed supplements included)

  • Visits to conventional physicians (MDs)
  • Visits to other practitioners (DC, PT, 

           massage, acupuncture

  • Medications
  • Supplements patients use on their own

Indirect cost measures  

Cost Outcomes    
 Direct costs for 1 year per each
healthy year of life
saved over
the next 10 years
   $1477 Naturopathic treatment

Compared to:
$4239-$7829 smoking cessation programs
$626 aspirin

$6631 anti-hypertensive medications
$6134 statins

 Indirect costs

  Absenteeism: up 10 hours/yr/participant
for treatment; up 2 hours/yr for usual care

Presenteeism:

Gained the equivalent of
just over 7 additional productive days
(57 hours)  per year per participant
for treatment; gained 2 hours/yr for
usual care

 
Total societal cost savings

   

$1025/participant


All data from notes of August 12, 2010 presentations by
Seely & Herman at the AANP convention.

 
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The study was the 4th in a
series that Seely’s team has
engaged through a collaboration with the management and union of Canada
Post. The relationship was established
through CCNM president Bob Bernhardt, PhD. (See #3 at this link
for notes on an earlier back pain study with economic outcomes that was
part of this study series and presented at a conference of the Institute for
Health and Productivity Management
.)

Herding cats: Individualized treatment around suggested best practices

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Herman: Led cost analysis

A challenge in examining the whole practice of
naturopathic physicians is convincing doctors to use a
standardized protocol. First, naturopathic care is philosophically
oriented toward individualizing treatment based on the doctor’s read of the patient and such issues as the patient’s readiness
for change. In addition, given the diversity of therapeutic options available to
naturopathic physicians, and the individual dispositions of the
practitioners themselves, the whole person protocols of different doctors often offer a wide variety of approaches and treatments.

Seely’s team approached these challenges with a unique strategy. First,
they intentionally chose to use doctors with just 2-5 years in their
practices. This group was expected to be more open to modifying treatment than clinicians
who have been in practice longer. The researchers then required the involved doctors
to attend a training session
in which 4 respected cardiovascular experts presented information on
best practices in naturopathic treatment for reducing cardiovascular risk.

Once
the training was completed, however, the practitioners were allowed to practice as
they felt most appropriate. The researchers promoted a lifestyle-oriented approach with specific targets in some areas, yet protocols were not mandated. Seely indicated
that the participating doctors were comfortable with this method. No
information was presented as to whether the strategy, in fact, drew the
practitioners toward a mean.

Discussion elements and “decision research”

Seely
noted that while practitioners were allowed to individualize
treatment, a strong focus was on lifestyle issues: “We wanted to examine
holistic, naturopathic care. We had a very, very strong dietary focus.”

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Canadian College of Naturopathic Medicine: Study’s research institution

Herman explained the value of including the cost
dimensions: “Cost effectiveness adds another dimension for decision makers considering alternative CVD prevention strategies.” In this
case, the primary audiences who may use the outcomes for
decisions about their healthcare strategy are Canada Post and the postal
workers union.

Herman
cautioned repeatedly that the findings were preliminary. She also noted
that the cost outcomes are limited, given the limitations of the
one-year time frame. What long-term impact might
these lifestyle-oriented interventions have? In addition,
Seely noted that the findings were limited due to the “surrogate
measures” that were utilized: “Estimating risk is not a hard outcome.” 
The researchers are preparing the outcomes for submission to a peer-reviewed journal. Seely noted that he and his team are in discussion with Canada Post on a follow-up study.

Comments:
A common denominator of much of integrative practice is a desire for
greater acceptance, coverage, use and inclusion. This is true whether we
speak of the whole practices of integrative medicine by MDs/DOs,
multi-modal care from broad scope chiropractors, holistic approaches of nurses, applications of acupuncture
and Oriental medicine practitioners or, as here, the work of naturopathic physicians. In order to advance, these fields need to develop data that helps decision-makers on coverage and inclusion.

   
  The message to employers is not about
lifestyle interventions or fish oil but rather:

Send
your employees to naturopathic
doctors, and you get effective and
 cost-effective treatment in the very
 costly area of cardiovascular
disease.

It is in this context that I refer to this study as a model. First, the Canada Post trial is not only randomized and controlled. It is also pragmatic. The attempt was to capture the real world practice of naturopathic doctors. The message to employers is not about lifestyle interventions or fish oil but rather: Send your employees to naturopathic doctors, and you get effective and cost-effective treatment in the very costly area of cardiovascular disease.

Note that the elements that support decision-makers are not just whether the treatments are effectiveness, but whether they are cost-effective. Notably, the costs included should also be sensitive to the interests of employers as decision-makers. Examined are not merely direct costs but also absenteeism and most importantly, presenteeism. This latter measure, virtually absent from the whole body of NIH NCCAM-funded work, has been estimated to reflect 60% of the health-related costs to employers according to Ron Goertzel, PhD of the Cornell University Institute for Health and Productivity
Studies
.

The report of these outcomes was greeted with great excitement by the
members of naturopathic profession. Carlo Calabrese, ND, MPH, executive director of
the Naturopathic Physicians Research Institute,
declared the report the most significant news of the convention. Others
spoke of the Seely-Herman data as potentially a “game-changer” in the profession’s efforts
to make its case as a health-creating and cost-saving discipline.

The integrative practice fields would serve their own missions by embracing this example of what might be called decision research. Each field could make exceptional use of a dozen such game-changer studies. Variations on this model with diverse conditions and practitioner types would be the optimal research agenda for quickly understanding how and in what ways whole person, integrative practices can make a significant difference in our health care delivery.
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Disclosure: Both Seely and Herman are Scientific and Clinical Advisers to the Naturopathic Physicians Research Institute on which I serve in a leadership capacity.

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