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 True North: Clinical & Cost Outcomes in Depression Pilot in an Integrative Center  
 
The following is one in an ongoing series of columns entitled Integrator Blog by . View all columns in series
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
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 About The Author
Resumes are useful in employment decisions. I provide this background so that you may understand what informs the work which you may employ in your own. I have been involved as an organizer-writer in the emerging fields......moreJohn Weeks
 
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