ACC and Acupuncture 2

The ACC has responded to my Official Information Act request that I mentioned in my last post on ACC and acupuncture. Here’s what I asked for in my request:

Dear Accident Compensation Corporation,

In response to an Official Information Act request from Kevin McCready in June (https://fyi.org.nz/request/1749-continue…), Mrs Koleti Vae’au wrote that:

In 2011, ACC’s research team conducted a literature review of the efficacy of acupuncture in the management of musculoskeletal pain. It found the most convincing evidence for the effectiveness of acupuncture related to the treatment of chronic neck pain and the improvement of pain and mobility in chronic shoulder pain. In terms of other injuries, evidence of the benefits of acupuncture was either inconclusive or insufficient.

I have been unable to find this particular review by searching on the ACC website, although I have found other reports such as the “Effectiveness of acupuncture in selected mental health conditions” brief report from earlier this year.

Also, if ACC has any guidelines for carrying out these reviews, could you please provide me with a copy of or link to these guidelines.

Sincerely,

Mark Hanna

Here’s a (direct PDF download) link to the mental health review that I mentioned in my request: Effectiveness of acupuncture in selected mental health conditions – Brief report [2014]

The brief conclusion of this report is:

There is limited good quality evidence to conclusively determine acupuncture’s efficacy in treatment of mental health conditions such as Major Depressive Disorder, Dysthymia, Anxiety Disorder, Borderline Personality Disorder and Post Traumatic Stress Disorder.

As I mentioned in my last post on this topic, ACC released their review of the evidence for acupuncture in the management of musculoskeletal pain in response to another OIA request. That review can be read in full here: The efficacy of acupuncture in the management of musculoskeletal pain

Here’s what ACC said in response to my OIA request yesterday:

There are only two ACC literature reviews on the efficacy of acupuncture. These are:

The efficacy of acupuncture in the management of musculoskeletal pain.

I understand from your email of 25 August 2014 that you have accessed a copy of this report and therefore do not require another copy.

Effectiveness of acupuncture in selected mental health conditions — Brief report 2014.

As you have identified, this is available on the ACC website.

In regard to ACC guidelines on literature reviews, ACC follows standard practice when undertaking literature reviews, and there are no ACC specific guidelines on this practice.

After my previous post on this topic, I was contacted by Ross Mason who told me about a similar OIA request he had made some years ago. One interesting thing I read in their response to him, which was written by the same person as their response to me, was this (bolded emphasis mine):

2. Evidence of the efficacy of the use of CAM treatments/programmes;

Schedule 1 Part 1 sections 1 & 2 of the [Accident Compensation] Act detail ACC’s liability to pay for the cost of treatment. These provisions in part include the requirement that the treatment is necessary and appropriate and of the quality required for the purpose. ACC has always required that new treatments for which payment is requested are supported by evidence of effectiveness. However it must be noted that there are many treatments that treatment providers utilise that do now have a well established evidence base.

Examples of the research that ACC does in considering new treatments can be found on the “For Providers” section of the ACC website – http://www.acc.co.nz/about-acc/research-sponsorship-and-projects/research-and-development/evidence-based-healthcare-reports/index.htm

If requested to fund CAM, ACC would require that evidence be provided for the treatments [sic] efficacy. ACC evaluation process of the evidence is detailed on the ACC website in the “For Providers, Clinical Best Practice” section – http://www.acc.co.nz/for-providers/clinical-best-practice/index.htm.

The first link, to the “Evidence based healthcare reports” page, seems to provide a little more detail on what was described as “standard practice” in response to my request:

Evidence based reviews

These reports assess the effectiveness and safety of health interventions. They are developed according to a robust methodology similar to that used by the Centre for Evidence Based Medicine (external link) and the Scottish Intercollegiate Guidelines Network (external link). This includes systematic searches of the literature, critical appraisal of existing research evidence and peer review by clinical experts.


ACC has funded acupuncture treatments for over a decade, spending over $24 million on it last year alone.

In August 2011, ACC reviewed the evidence regarding the efficacy of acupuncture for musculoskeletal pain and found that (emphasis mine):

The evidence for the effectiveness of acupuncture is most convincing for the treatment of chronic neck and shoulder pain. In terms of other injuries, the evidence is either inconclusive or insufficient.

In March 2014, ACC published a brief report on the effectiveness of acupuncture in selected mental health conditions didn’t find enough good quality evidence to provide any recommendation.

No other review of the evidence for acupuncture has been undertaken by ACC. Despite this, over the last year ACC spent significant amounts of public money on acupuncture treatments for other medical issues such as burns ($30,002), lacerations and puncture wounds ($309,458), and fractures and dislocations ($591,613).

In the past year, they spent $22,592,552 on acupuncture for soft tissue injuries. Unfortunately, their recent response to another OIA request shows that they haven’t been keeping track of which body parts were treated, so we’ve been unable to determine how much of this substantial amount of money was spent on treatments that ACC’s own findings say are not supported by evidence.

As far as I’ve been able to tell, ACC’s funding scheme for acupuncture simply isn’t consistent with the evidential requirements they claim to require, and is instead largely based on the pre-scientific notions (to quote the author of their 2011 review) detailed in their Acupuncture Treatment Profiles document. When these issues were raised with the previous ACC minister Nick Smith in 2009 he promised a review of their effectiveness would be undertaken, but in the 5 years since then no such review has taken place. This latest response of theirs has only made me feel even more strongly about my recommendations for change:

I think ACC needs to review its funding scheme for acupuncture. I think their approach to this should start with reviewing their Acupuncture Treatment Profiles document, ensuring that the only treatments contained within it are those supported by rigorous evidence, and purging pseudoscientific claims from it. If they find they need to undertake further reviews of the evidence for the use of acupuncture for particular indications, then they should do that before approving funding for it.

I think ACC should then only agree to pay for acupuncture treatments that are aligned with their Treatment Profiles document, which they should commit to reviewing at regular intervals to keep it in line with the latest evidence (I’m not sure what time interval would be most appropriate, and I understand that there is a cost involved in that work).

I’m not sure, but it’s possible some changes to legislation may be required before this becomes a reality, but if that’s the case those changes should happen. A government body should not be bound by law to fund healthcare that is not supported by evidence.

There’s one last thing I’d also like to see, although I really feel like this is a long shot. I think ACC should take an active role in discouraging healthcare practice based on the “pre-scientific notions” described in their 2011 review. I think they should do this by distancing themselves from those acupuncturists who promote it and who base their practice on it, by refusing to grant them status as registered ACC practitioners if they are found to rely on it.

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Green Party Health Policy

There was a thread recently in one of the Facebook groups I’m a member of in which, among other election-related things, the Green Party’s Health Policy was being discussed. It was mentioned that the Green Party had been essentially pro-CAM, at least in the past. As I’d been considering voting for the Greens, this was something I thought I should look into further.

Here’s a link to their Health Policy. My first impressions of this document were quite positive, especially seeing that one of their “Key Principles” seems to echo the mission statement of the Society for Science Based Healthcare where it states that:

Decisions about health services should be based on the strongest possible evidence.

However, I found myself worried that this might just be paying lip service to evidence-based policy. Particularly considering the comments I’d seen regarding past policy, and some other sections of the current Health Policy such as:

The Green Party will… Find ways to integrate complementary therapies that have a sound evidence base into health services.

The Green Party will … Increase resources for physical and mental rehabilitation in… complementary practices.

Of course, complementary therapies that have a sound evidence base should be “integrated” into real medicine. That’s exactly what medicine should be – therapies with a sound evidence base. However, as I said before, I felt worried this mention of evidence may just be lip service, or perhaps that the standard of evidence required might be low (as I’ve typically seen when it comes to the promotion of complementary therapies).

As you’ll have seen if you’ve clicked on the Health Policy link, Kevin Hague is listed as the spokesperson for this policy, as well as the person to contact. So that’s what I did. Below is the email I sent him, and the response I received (much faster than anticipated – within 2 hours):

Hello Mr Hague,

My name is Mark Hanna. I don’t think we’ve met, although we were both at the New Zealand Skeptics conference in Wellington last year. I’m currently considering giving my party vote to the Greens this election but I wanted to email you first to clarify something about one of the policy statements.

I spend a lot of my spare time working with regulatory systems to combat misinformation about health and healthcare in the public sphere. The vast majority of this misinformation comes from sources that promote “complementary therapies”.

To this end, I’ve made dozens of successful complaints to the Advertising Standards Authority and Medsafe, and have recently co-founded the Society for Science Based Healthcare as part of this continued effort. I’ve also written on some aspects of publicly funded healthcare in New Zealand that I find troubling and would very much like to see change, such as ACC’s stance on acupuncture (http://sciblogs.co.nz/honestuniverse/?p=41).

I’ve read the Green Party’s Health Policy (https://home.greens.org.nz/policy/health-policy); I’m glad to see an emphasis on evidence and I strongly support with [sic] party’s focus on equality in healthcare and making it as accessible as possible. However, I’m also wary that I don’t want my party vote to inadvertently support the kind of thing I spend so much of my time fighting against. Most particularly, I am worried about point 7 under the “Whole-of-System Healthcare” section:

“Find ways to integrate complementary therapies that have a sound evidence base into health services.”

As you may be aware, the majority of complementary therapies have a very poor evidence base. Even in cases where there is a large amount of research, in general it is of poor quality, and in very many cases the use of complementary therapies is simply not supported by sound evidence.

Other sections of the Health Policy add to my concern here, such as the 1st point under “9. Post-Acute Care” which says “The Green Party will… Increase resources for physical and mental rehabilitation in… complementary practices”. Before I commit my party vote, I’d appreciate it if you could assuage my fear that the reference to sound evidence may be no more than lip service.

In general terms, what would the Green Party consider the minimum standard of a sound evidence base in this context? Could you describe what the evidence for a treatment that does not meet this standard might look like?

As part of their commitment, will the Green Party also make an effort to prevent the integration of therapies (whether “complementary” or otherwise) into health services where there is not a sound evidence base?

I also note the party has pledged to:

“Support rongoa Māori (traditional Māori healing) practitioners and practices, and develop better linkages with other health services.”

I’m wary that when dealing traditional healing practices such as rongoa Māori and Traditional Chinese Medicine, the complex issues of science- and evidence-based healthcare and cultural sensitivity and inclusiveness can become entangled. Will the Green Party maintain their commitment to basing decisions about health services being based on the strongest possible evidence even when dealing with complex and often difficult issues such as these?

I’m under the impression that other people I know who are also considering giving their party vote to the Greens could also be swayed one way or the other depending on your response. I’d appreciate it if I could have your permission to publicly share any response you send me regarding this.

Sincerely
Mark Hanna

This is the response I received from Kevin Hague:

hi Mark,
I’m an admirer of your work. Thank you for it!

As you probably know, Green Party policy is developed by members, rather than MPs, and the Policy Committee strives for consensus if possible.

if you have compared the current Health policy with its predecessor (and my statements with those of my predecessor in the role) you will have noted substantial change that I think you would be pleased with.

The statement in the principles concerning complementary therapies, is a neat compromise I think (nobody can really argue for the use of public money on something that doesn’t work, but if it does work then it should be integrated), but does give rise to your question of what kind of evidence would be sufficient. In practice it would be me as spokesperson who would interpret the meaning of the policy (this is established practice in the Green Party). My first port of call would be Cochrane. If there is no guidance there, then it’s probably a no, but as someone who used to teach at postgrad level in research methods I would also be in a position to look at any papers that are proposed as providing evidence and make an assessment.

The obverse of this commitment does also apply ie if the state is currently funding therapies with poor or no evidence of effectiveness then it should stop doing so. This applies both to ‘complementary therapies, but also to mainstream treatments (my favourite instructive example being mammary arterial ligation as a treatment for coronary heart disease – it’s worse than ineffective).

In the case of rongoa I think matters actually are more complex. In addition to the cultural sensitivity matters to which you refer there are also Article II Treaty rights, so it’s not simply a matter of evidence. And when it comes to the evidence, far fewer studies have been undertaken. You probably know that there is significant evidence internationally that such indigenous treatment systems may be effective, even though their intervention logic and mechanism are quite different from traditional western approaches (eg Kleinmann in relation to mental illness in Taiwan). It could be that strongly held cultural beliefs may create a substantial placebo effect. Sometimes, even if we know the effect is just placebo, it could be worth having. So on this point I would interpret our policy as supporting the availability of rongoa, even though the evidence base for effectiveness may not be strong. I would also support further research to create a sound evidence base, where this doesn’t currently exist.

Hope that’s useful. Please feel free to share this if you want.

Best,

Kevin

Honestly, I’m quite happy to hear this answer. It sounds to me like the mentions of evidence are more than lip service, and hopefully indicative of a change in direction for the Greens in this area. The fact that Kevin Hague is their spokesperson on Health and ACC gives me hope as well. Especially comparing him to their past Health spokesperson Sue Kedgley, who has some ideas about healthcare that are rather wacky.

I would like to make one more comment regarding the issue of traditional medicine such as rongoa. First off, rongoa is not something I’ve looked into in much depth, I don’t know much about the state of the evidence and don’t mean to discuss it here. I would like to say though, that when I referred to issues like it being “complex and often difficult”, I meant to imply that it is not as simple as it may be in some other cases, where the only important question may be “what does the evidence say?”.

These traditions are often more than just for healing, they’re part of a wider culture and the people that use them are often already part of a disadvantaged group. If we care about what’s best for people, then we also need to care about the repercussions of discouraging or somehow diminishing such a part of their culture. As Kevin mentioned in his response, this is where things like the Treaty of Waitangi become important. There’s also an important distinction to be drawn between treatments for which there is negative evidence and those for which there is no evidence one way or the other.

I certainly wouldn’t claim to have all the answers when it comes to issues like this, and I think it’s a matter on which I would do better to listen than to speak. I do agree with Kevin that it’s not simply a matter of evidence, though, and I’d welcome a discussion on this particular issue if anyone else has anything to add.