Jaded by Past NIH NCCAM Past Priorities? The 2011-2015 Strategic Plan Says Think Again
Written by John Weeks
Tuesday, 15 February 2011
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.
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 unanimouslycalled
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.
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: Don'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.
