True North: Clinical & Cost Outcomes in Depression Pilot in an Integrative Center

Summary: Integrative centers boast a good deal of promise. Benefits based on published outcomes are harder to find. Maine’s True North integrative center offers a rare examination and sharing of outcomes with this retrospective examination of 80 of the center’s patients who had been diagnosed with depression. Most saw only a functional medicine practitioner (MD or ARNP), some saw only a “CAM” practitioner while others saw a combination, with an average 1.8 practitioner types per patient. The center’s executive director Tom Dahlborg shared patient self-report outcomes and ACP satisfaction outcomes plus cost and visit data with the Integrator. He then responded with additional details to follow up queries. All are reported here. Take a look. There are some surprises. This sharing continues True North’s long-standing pattern of leadership in advancing the integrative center model.

ImageSo what goes on inside these integrative and functional medicine centers? Funds are rarely available to do major studies such as the Institute for Functional Medicine has recently engaged in Florida in an academic setting. Short of that, few practitioners or clinics take the time to gather data on what is going on. Or is it just that fewer still share these data?  

In this context, the Integrator recently received a welcome note from Tom’s
Dahlborg
, executive director of the True North: A Healthier Model of Health Care asking if the Integrator might be interested in publishing rough data from a retrospective analysis of depression patients at the Center.

Yes! was the answer. Dahlborg sent a first iteration of data. I asked some questions. He provided more information. I wrote this article up a first time and sent it back with some additional questions. Dahlborg provided some answers. The clinical and cost findings, plus other data on average visits, are reported below.

________________________________


The Efficacy of Complementary
and Alternative Medicine Approaches for the Treatment of Depression in an
Integrative Healthcare Setting

True North Center
Tom Dahlborg, Executive Director


Image

Tom Dahlborg

Site: True North is a 501(c)(3) nonprofit organization “dedicated to creating a
healthier model of health care by conducting outcomes-based research,
offering patient education, providing access to integrative care in a
relationship-centered setting and physician recommended supplements
through our store.”
 

Type of Study: A retrospective study of 80
patients diagnosed with depression (as validated via MSQ tool) conducted over a one year period from January 16, 2007 through January 16, 2008. 

Types of integrative practitioners seen: Functional
Medicine (MD & APRN), Family Practitioner (MD), Psychiatrist, Psychologist,
Licensed Acupuncturist, Licensed Naturopathic Doctor, Energy Medicine/Healing Touch, Shaman, Licensed Massage Therapist, Fitness
Trainer. (Note: In the True North model, all practitioners are considered “integrative.”)

Tool:
Medical Symptoms
Questionnaire (MSQ) (Pilot Study)


Clinical Outcomes

  • 80% of patients surveyed showed
    dramatic overall health status improvement scores



  • The mean starting score was 53.4 and mean ending score was 32.1
    , an average improvement of -21.4 points.
  • 52.5% showed
    improvements in Depression Specific MSQ score

  • For those
    who improved their Depression Specific MSQ score, average improvement was
    -1.8
    (Note: specific MSQ line item scores range from 0 – 4.)
______________

Integrator: Is there anything you can say about the 20% who didn’t improve?

Dahlborg: We have made note of some very
interesting data points for those who didn’t improve.
Those
who worsened had 8.3 visits over 151.5 days; those who had no change had
13.0 visits over 209 days. This is compared with those who improved had 9.6 visits
over 127.9 days.
Another
way to look at it is those who worsened averaged 1.7 visits per month;
those who had no change averaged 1.9 visits per month; and those who
improved averaged 2.3 visits per month.
Those
who worsened spent 62% of their total expense on visits while those who
improved spent 77% of their total expense on visits (the remaining
expenses were primarily spent on supplements)
. Interestingly
those who worsened saw more practitioners during the study period than
those who improved (2.33 to 1.81)
. We
also found that a higher percentage of Males showed improvement compared
to Females (83% of Males improved as compared with 79% of Females).

________________


Other Outcomes

  • The greater
    number of visits (on average 60-90 minutes each) over a shorter time period
    (less # of days) netted the best results. 

  • Patients who had
    more visits over a longer amount of time did not show the same dramatic
    positive impact

  • Patients who
    spent more on human contact and less on store purchases showed better outcomes

  • Not only did a
    larger percentage of Males show improvement compared to Females but Males also showed
    greater improvements in MSQ scores than Females (-29.3 to -19.9)

Length of Treatment & Cost

  • 128 days = average number of days
    in treatment for those who saw positive change
  • 9.6 = average number of visits for those who showed improvement
  • $1,300 was average cost for
    services for those who saw positive change
  • ~$1,000 =
    amount of money expended for visits with practitioners during the study period
  • ~$ 300 =  amount of money expended on supplements and other store
    purchases (books, cd’s, etc.) during the study period


Types of Practitioners Seen by Those Who Improved:

  • 24% (15) of those
    who improved saw Functional Medicine practitioner and CAM practitioner(s)
    during the study period

  • 19% (12) of those
    who improved saw CAM practitioners only during the study period

  • 56% (36) of those
    who improved saw Functional Medicine practitioner only during the study period
  • The average
    number of integrative practitioners seen by each patient who improved during
    study period was 1.81. 

______________


Integrator
: Alone these data say little to nothing and perhaps are misleading. For instance, this could look like those who only saw CAM practitioners fared worse when, possibly 100% of those in that category might have done well.
How many in each category did NOT improve?

Dahlborg:

Great point.  Here
is additional information:

Types of Practitioners Seen by Those Who Worsened:


  • 27% (4) of those who worsened saw Functional Medicine
    practitioner and CAM practitioner(s) during the study period
  • 27% (4) of those who worsened saw CAM practitioners only
    during the study period


  • 46% (7) of those who worsened saw Functional Medicine
    practitioner only during the study period


Integrator
: So, it looks like the ratio of worsened/improved for the 3 categories in this small sample was: combined (4/15), CAM practitioner only (4/12) and FM only (7/36). Be interesting to have a much larger sample.  Do you have any
comparative effectiveness and comparative cost information for “usual care”?

Dahlborg
: Unfortunately no. We have tried to share these data with
State of Maine organizations assessing impact of care models and they have
consistently refused to review our data as they say we are too different and
not a good comparison. We would love to compare and share best practices. For what it is worth, and merely anecdotally, when I have shared these
high-level data with politicians and even with leaders of the organizations
that do not want to review what we are doing in detail their words are that they are “blown away.”

Integrator: Were these findings in any way surprising? Have they in any way shifted practices? And have they had any use value for the Center other than “blowing away” a few outsiders?

Dahlborg
I initially expected a correlation between specific
integrative modalities and more positive outcomes. Knowing in my heart the importance of empathy, human
connection and authentic relationship was one thing but to see it play out as
it did in this pilot study was amazing. This pilot study has truly reinforced the
importance of not only integrative care with high-quality and credentialed
healers in a safe setting, but also ensuring a container that allows time for empathy,
human connection and authentic relationship to develop and flourish.

One of our practitioners termed this the love quotient.

To learn even more we followed up this pilot study with a
patient satisfaction outcomes scrutiny study leveraging the American College of
Physicians-Internal Medicine Patient Satisfaction tool
(modified by True
North to include Health Status Outcomes). This tool was sent to each of the 80
patients in the pilot MSQ depression study to further assess the impact of this
model of care. In this analysis we found, of the 20% who responded:


  • 88% of these respondents felt healthier
  • 86% of these respondents ate better
  • 69% of these respondents slept better


The survey also showed that:


  • 100% of these respondents categorized the care they
    received as Excellent (86%) or Very Good (14%) quality


   
      “Yes, both the tool and the study outcomes
have served to
help us look at and continuously
improve our model, our individual practices

and our overall integrative practice
.”

In fact, the American
College of Physicians
published an article on our modification and use of this tool to improve
practices and healthcare provision. 

So yes, both the tool and the study outcomes have served to
help us look at and continuously improve our model, our individual practices,
and our overall integrative practice as we strive to create a healthier model
of healthcare.

Of course
this article references much aggregate data and the real gems are in the
individual stories and journeys of each of these patients. We are in process of further gathering and
leveraging more patient stories as part of our next study design.

______________________________


Comment
As happens with such data, as many questions
seem to be raised as answers given. Still, credit Dahlborg and True North for giving us the useful pleasure
from looking inside the black box of the promises of an “integrative center.”
These practice improvement data are often scoffed at by members of the research community: What do we know, really? The sample is so small. The practitioner groupings and treatments so individualized and variable. Frankly, this feels to me a heck of a lot better than running data-naked. Besides, if the right person is “blown away,” more access may be created. Credit the True North team for doing the work, and sharing. Any others of you got anything to share?

Send your comments to
johnweeks@theintegratorblog.com

for inclusion in a future Your Comments Forum.
John Weeks Written by John Weeks

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