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Jaded by Past NIH NCCAM Past Priorities? The 2011-2015 Strategic Plan Says Think Again PDF Print E-mail
Written by John Weeks   

Jaded by Past NIH NCCAM Priorities? For Clinicians, New Strategic Plan Worth 2nd Look

Summary: Strategic Objective #3 of the 2011-2015 plan from the NIH National Center for Complementary and Alternative Medicine reads: "Increase understanding of 'real world' patterns and outcomes of CAM use and its integration into health care and health promotion." Outcomes, integration and especially a health-focus are directions that many clinicians wish the agency had taken from the start. This new plan, which declares the critical importance of clinician input, is worth both a review, and a renewed commitment to closer participation in NCCAM's work. Note the fascinating decision, since the draft was issued in August, to increase from 1 to 36 the number of times the word "disciplines" is included as a unit of participation or inquiry. This is an important addition to the products and modalities focus in NCCAM's first years. 
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Maybe I am a bit of a Pollyanna here.

Agency publishes 3rd strategic plan
Still, there are exceptional reasons to believe that the February 2011
release by the National Center for Complementary and Alternative Medicine (NCCAM) if its 2011-2015 Strategic Plan will be remembered as a big day for integrative practitioners and for research on advancing quality integrative care. The Plan offers the first significant alignment of government-backed research with discovery of whether integrative practices can live up to their health-focused promise. 

Pull back the veils of jadedness and disbelief for a moment. The business of evidence-capturing may have just become vastly more meaningful to clinicians and healthcare disciplines.

What jumps out is Strategic Objective #3: "Increase understanding of 'real world' patterns and outcomes of CAM use and its integration into health care and health promotion."

New directions: outcomes, integration and health promotion

Consider, clinicians, the 3 elements of this objective: outcomes, integration, and health promotion.
Do your outcomes and those of your colleagues stand scrutiny? Is there value in public and private investment toward proactive integration of what you do into payment and delivery? Are you and your discipline measurably creating health in your patients?

Director Briggs: Plan follows long listening
These complex questions are now on NCCAM's table. Wrapped up in Strategic Objective #3, they mark a significant break from NCCAM's past. The potential engagement with the health-creating clinical outcomes that consumers and practitioners say are at the core of practice represents a sea-change for the NIH itself. 

Strategic Objective #3 finally and frontally announces NCCAM's responsiveness to Congress' real world charge when it set up the agency in 1998. Surveys were then startling stakeholders in mainstream medicine with revelations that patients were using these therapies, disciplines and practitioners.  Hospitals, community centers, insurers and employers were beginning to explore their value. US Senator Tom Harkin (D-Iowa) and his colleagues responded with this charge to NCCAM:
"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."  (Italics added.)
In a fit of micro-management borne perhaps out of awareness of the NIH's predilections toward basic research and efficacy trials, Congress explicitly mandated the research strategies NCCAM was to prioritize. They turned the NIH world on its head and charged the fledgling agency to focus on outcomes and health services research, such as costs and cost savings. For most of its first decade, NCCAM was both grossly negligent and utterly non-compliant with Congress' wishes. An estimated 1%-3% of NCCAM's $1.29 billion spent between 1999-2010 reflected Congress' priorities.

Alignment with Congress' real world intent

The 2011-2015 plan announces a course correction. Harkin and his colleagues should be pleased that their intent is finally being honored. So should the rest of the real world.

Credit NCCAM director Josie Briggs, MD and her deputy director Jack Killen, MD, who had the internal lead during the plan's elephantine gestation process, for this focus. Appointed in January 2008, Briggs was  utterly new to CAM and integrative medicine. Killen was similarly unpracticed. To Briggs' great credit, she immediately announced a plan to engage a period of great listening to NCCAM's multiple constituencies. The informal development of the 2011-2015 plan began at once.

Killen: Oversaw plan's development
Briggs attended and spoke at national and international meetings of medical doctors, chiropractic doctors, naturopathic doctors, research institutes, acupuncture and Oriental medicine practitioners, massage researchers, Yoga therapists, scientists from these fields and more.
She entered the homes of the infidels and invited into her office a cadre of polarizers academics determined to shut down NCCAM.

An NIH insider, Briggs also seems to have worked her relationships in that bastion of reductive, pharma-oriented, drug-and-device science. NIH is itself one of NCCAM's constituencies. Briggs became centrally involved in the NIH's new "real world" exploration called comparative effectiveness research (CER). The Strategic Plan's formal development included, in Briggs' words, "scientific workshops, symposia, think tanks, and extensive consultation with our highly diverse stakeholder community."

Credit NCCAM's listening

The depth of NCCAM's listening is evident in the responsiveness to comments made after the
draft plan was opened to public comment in August 2010.

First, the NIH's familiar drug-interest that dominated NCCAM's spending from 1999-2010 was once again promoted in the draft as the top priority. There it was: "Strategic Objective #1: Advance research on CAM pharmacological interventions
." In the final plan, this pursuit is demoted to Strategic Objective #2 and the language is intriguingly re-framed: "Advance research on CAM natural products."

The far more significant and exciting change is the pervasive reference throughout the final document on researching the impact of "disciplines." The draft plan continued the historic focus on products and therapies, such as needles. The term "discipline" was used but 5 times, with all but one referring to different research disciplines rather than practice disciplines, such as practitioners of acupuncture and Oriental medicine.

The exciting new focus on the impact of "disciplines"

In the plan released February 4, the word "disciplines" is used not 6 but, hold on, 42 times. All but a half dozen refer to the practice disciplines in the integrative care community: integrative medicine, naturopathic medicine, chiropractic medicine, holistic nursing and etc. An example: discussion of Strategic Objective #3 now speaks of exploring "the potential role of CAM interventions, practices, or disciplines in supporting healthy lifestyles and well-being." There is a focus on the whole practice here. Again: " ... observational, outcomes, health services, and effectiveness research offer a number of tools, methods, and pragmatic study designs for gathering useful evidence regarding CAM interventions and disciplines on a larger scale than typical clinical trials." (Italics added.)

A third example of the nearly 35 additions of this concept is in the description of Strategic Objective #1. The charge now states: "Advance research on mind and body interventions, practices, and disciplines."
(Italics added.)

With this change, NCCAM, in the 11th hour, re-incorporated the "disciplines" language that Harkin and Congress used not once but 7 times in the brief two pages of NCCAM's mandate. I think they were trying to get a message across. The message from this other of NCCAM's significant constituencies, Congress, appears to finally have found responsive listening.

But what of examining whole practices?

In comments on the framework for the plan late in 2009 and then on
the draft plan a year later, national practitioner  organizations from the integrative practice community unanimously called for research that examines the real world of the multi-modal, holistic, whole person and whole systems approaches that characterize their approaches to patients. Some may be frustrated that the 2011-2015 plan does not specifically use these terms. A search brings up nada, nothing, zilch.

But if NCCAM is to fulfill on its intention to research the impact of disciplines, whole person practices must be on the table for examination. "Disciplines" are the Trojan Horse through which these combined mind-and-body approaches are deeply embedded in the plan.

Fine examples of disciplines research are out there. For instance: positive side-effect outcomes in the multiple integrative environments; health promoting and cost benefits to an employer from this Seely-Herman report on a project that lowered CV risk via naturopathic care; this Medicaid pilot with costly chronic pain patients who had access to licensed acupuncturists and massage therapists; cost savings to insurers from covered LAcs, DCs, and NDs as noted this 2010 review; savings from integrative MD and DC primary care project in Illinois; and this new project with functional medicine MDs.

Imagine what we can learn if NCCAM attaches significant funding to Strategic Objective #3.

Don't leave research to the researchers

The devil will be in the details. This sea change toward the real world and measurlng health outcomes is especially devilish given the habits, skills sets and biases of the reviewers and program managers in the NIH and NCCAM cultures. For most, whole practice thinking is not first nature. Assuming an outcomes-orientation may be seen as requiring significant re-training.

A skeptic will say that it wasn't until the 11th hour that NCCAM cut down natural pharma a notch and included "disciplines." Is this but surface paint to curry favor with NCCAM's patrons? Is the real world
focus just lock-step with the uptrend in CER in the NIH?

What we know for sure is that this direction is newly-planted on fairly inhospitable ground and with gardeners who have something less than generations of green-thumbing real world research in their blood. They can stand some help. To their credit, Briggs, Killen and the other authors of the 2011-2015 Strategic Plan name what they need:
"CAM practitioners are the key holders of knowledge related to the potential application of CAM interventions and disciplines."

Clinicians: D
on't leave research to the researchers. Engage the members of NCCAM's Advisory Council and NCCAM staff with your constructive ideas for these new directions. Get your institution or professional organization to focus attention here, help shape the questions and get in the dialogue. Admit the challenges of forming the optimal studies. Consider this your business, not something someone else is handling. Have fun with it.

Pollyanna doesn't usually talk like this. But I believe I heard her say: Clinicians, it's time to show up or shut up.


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