Calling the Question: Integrative Medicine Moves toward Implementation Research

A significant trend is appearing in major research organizations on integrative health and medicine. The timing is right: in the United States, major reports, meetings and guidelines now include non-pharmacologic, a.k.a. integrative approaches. But how do we move these into practice? Top acupuncture, integrative oncology and general integrative health conferences are featuring what is called “implementation science.” This study of methods to promote the integration of research findings seeks to propel changes in healthcare policy and practice. The integrative trend arises amidst a renewed push for health services research of all kinds. Action on these lines can straighten out some twisted karma relative to the 1998 US Congressional legislative mandate that established the globe’s most significant scientific investment in alternative, complementary and integrative medicine.

Here are the percolating signs. Two months ago, the Society of Integrative Oncology announced such interest in their conference title: “From Research to Practice Applications.” Organizers included a plenary session with a National Cancer Institute scientist who is driving implementation science (IS) there. For the May 2019 International Congress on Complementary Medicine Research in Brisbane, Australia, conference planners embedded a morning plenary on IS inside a program bricked with policy-related content.

A month later, in Burlington, Vermont, USA, the Society for Acupuncture Research (SAR) jumps with both feet into this translational terrain. Amidst acupuncture pilots popping up in Medicaid programs in Maine, Rhode Island, West Virginia, Oregon, Ohio, and elsewhere, SAR will feature insurers, hospital administrators, elected officials and analysis of these existing pilots. Their theme: “Acupuncture Research, Health Care Policy, and Community Health – Closing the Loop.”

One senses both impatience and concern, given the horrendous lag for adoption of new research. If it takes nearly 17 years for a shift in regular medicine, will the measurement increment be not in years but eons if what is sought are integrative care’s cultural changes: more time intensive, human-centric, interprofessional, hands-on care from outsider practitioners like acupuncturists, massage therapists, chiropractors and others? Serious investment will be necessary.

Issues endemic to the emerging integrative health fields won’t make the job any easier. Two organizers of the Australian ICCMR conference, Amie Steel, ND, PhD, MPH and Jon Adams, MA, PhD – with a co-author Karen Rapport, PhD – recently published a commentary in Advances in Integrative Medicine in which they spoke to these challenges: “The disparate nature of complementary health care professions (both within and across disciplines) … [mean] IS applications in complementary medicine require an innovative rethink.”

There is some good, aligned news here from the broader research field of health services research (of which IS is one field). The established and largely unquestioned value set of the US research world considers basic research far more important than looking at what interventions are actually creating healthy outcomes. Health services research (HSR) inhabits a squinched zone near the bottom of the investment pile. The field’s dole reflects the low esteem in which it is held.  Despite the evident catastrophe of US medicine’s $3.3-trillion per year pilot project, only 3% of research investment targets making outcomes better through such applications.

A cynic might say: if you have a boat-load of questionable interventions and outcomes, starve researchers of the HSR resources that would allow them to point that out – and perhaps suggest better ones.

Recently the most powerful set of government and foundation agencies that do prioritize such HSR issued a report that is trying to reverse that lower class status. In“The Future of Health Services Research: Advancing Health Systems Research and Practice in the United States,” HSR champions mount what is effectively a peasant revolt to demand respect for such common sense. They consider their moment a “a pivotal time in thinking about federal support for health services research … there is a policy window of opportunity that is opening.” Former American Hospital Association chair Jonathan Perlin, MD, PhD offers the strongest blow against the empire in this summation of the need:

Health services research should not be the fourth kind of research that is considered but the first … because medical research makes no sense if it isn’t disseminated in a way that reaches every American and helps with their health.

Ironically, in this context, the 1998 mandate of the US Congress to the National Institutes of Health to establish what is now the National Center for Complementary and Integrative Health (NCCIH) explicitly urged practical, health services, and implementation oriented priorities. At that moment, mainstream interest in “CAM” was arising amidst the boom. Employers and insurers were offering new CAM benefits. Hospitals were starting clinics. The new Center’s champions like then US Senator Tom Harkin responded to these constituent interests. The first directive of the mandate reads:

… the Director of the Center shall, as appropriate, study the integration of alternative treatment, diagnostic and prevention systems, modalities, and disciplines with the practice of conventional medicine as a complement to such medicine and into health care delivery systems in the United States.

In short, help these stakeholders’ decision processes in including CAM! Anyone questioning this interpretation of the mandate must only read further in the mandate. Congress charged NCCIH to examine the impact of licensed disciplines with which Congress was concerned – such as acupuncture, chiropractic, naturopathic medicine and massage therapy. This is precisely the terrain the integrative oncologists and acupuncturists and others are opening – and that the Medicaid and other pilots such as we are seeing in the Veterans Administration are entering.

As if the NIH needed not only to he drawn away from its basic science predilections to this water, and then taught to drink, Congress chose to provide the agency with a prioritized list of the types of research that it was urging: 1) outcomes research and investigations, 2) epidemiologic studies, 3) health services research; 4) basic science research, 5) clinical trials and 6) other appropriate research. To date – while there are signs of change – their residual ideology has dominated.

That the timing is right for implementation science and HSR to not merely be elevated but put front and center is evident in submissions to the philanthropically-backed JACM Special Issue on Multi-Modal Approaches in Integrative Health: Whole Persons, Whole Practices, Whole Systems to be published first quarter 2019. One paper features research on Oregon’s efforts to include non-pharmacological practitioners in pain treatment. Another examines the Veterans Administration’s massive campaign to transform to a “whole health” model. Research at San Francisco General’s safety net hospital offers process outcomes on creating an integrative pain center. An Alberta, Canada researcher explores efforts to integrate indigenous methods in that province’s delivery system. Implementation interest is humming. More funding would be good.

Credit the NCCIH for its contributions of clinical trials that up-regulated integrative practices and practitioners in policy documents. And credit as well the NCCIH’s more recent focus on pragmatic trials and real world collaborations with the VA, DoD and others. These trains of action – in the integrative health field, in the NAM call to action on HSR, and at the NCCIH – are powering up the same track. It’s time now for NCCIH to fully own its Congressionally-derived mission and enhance its role in elevating HSR to its necessarily first class status in an industry as broken as ours. Integrative models offer hope. Yet their implementation will require ongoing investment, from developing expertise in the research workforce forward. The recent and upcoming programs for scientific conferences in complementary and integrative health indicate that the field’s researchers will welcome such a sustained campaign.

Note: This article is based on an editorial prepared for the December 2018 issue of the JACM – Paradigm, Practice and Policy Advancing Integrative Health (The Journal of Alternative and Complementary Medicine).

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