ALTERNATIVE MEDICINE USE AMONG MEDICAL OUTPATIENTS. M. Herman 1 , L. Inouye 1 ; 1 Naval Medical Center Portsmouth, Portsmouth, VA PURPOSE: The use of complementary and/or alternative medicine (CAM) is increasing in popularity among patients in the United States. Hundreds of herbal products and homeopathic remedies are readily available to the consumer, but most of these have not been proven safe or effective. Potential side effects and interactions with traditional medications are often unknown. Studies suggest that between 30% and 50% of the adult population in industrialized nations use some form of CAM to prevent or treat a variety of health-related problems. The purpose of our study was to evaluate CAM use by Internal Medicine. The analysis would assess the proportion of patients in the clinic who are using alternative medicines, provide a description of the most common alternative medicines being used, and evaluate characteristics associated with alternative medicine use. METHODS: A convenience survey was completed by patients of the Internal Medicine clinic at Naval Medical Center, Portsmouth (NMCP) between 6DEC99 and 7JAN00. Information was gathered on the patients gender, age, race, medical problems and medications, educational background, military status, herbal and non-herbal usage to include confidence of efficacy and safety, and the source of information for herbal and non-herbal products. Chi-squared analysis was used to compare CAM use differences in gender and educational groups. RESULTS: There were 212 surveys completed. Of those responding, 15% were active duty or a dependent of an active duty member, and 60% were female. The mean age of respondents was 53 years. Complementary therapies had been used in 60% of the patients. The most common herbal products were garlic, ginseng, gingko biloba, and St. Johns wort. The most common non-herbal products were vitamins, chromium, glucosamine, and chondroitin sulfate. Sixty-five percent of females used CAM compared with 53% males, although this difference was not statistically significant (p = 0.125). The average age of CAM users was 53 years. Thirty percent of CAM users had a college degree, 15% were active duty, 35% were retired, and 50% were dependent. Sixty percent of CAM users had been using an alternative medicine for at least one year. Use of herbal CAM was associated with a higher educational background, although the difference was not statistically significant (p = 0.132). However, vitamin use was significantly correlated with a higher educational background. In those subjects with less education than a college degree, only 25% used vitamins. Among college graduates 54% used vitamins (p < 0.0001). Seventy-one percent of respondents felt that complementary therapy was safe and only 17% were very confident of its efficacy. CONCLUSION: CAM use among Internal Medicine patients at NMCP is higher than reported use in studies of civilian populations, which may reflect a difference in patient profile. Of interest is that a significant proportion of people using alternative medicines were not confident of its safety and only a few were very confident of its efficacy. This information may correlate with compliance issues pertaining to physician prescribed medications. While the social profile may reflect those most likely to use CAM, our data demonstrates widespread use of alternative medicine. This information has important implications for health care providers, who must consider safety, efficacy and possible interactions with standard therapies. Further analysis will include the results from over 400 respondents. METHODS: In 1995, 500 primary care patients presenting to a walk-in clinic with physical complaints were screened for mental disorders with the PRIME-MD. Five years later, patient surveys assessed symptom outcome, mental disorders (PRIME-MD), functional status (MOS SF-6) and whether they had been diagnosed or treated for a mental disorder. Vital status was assessed with the Social Security Index. RESULTS: Forty patients (8%) died. Among the remainder, 65% completed surveys, with follow up losses equal between patients with and without a mental disorders. The prevalence of mental disorders declined from 30% at baseline to 12%, though patients with a disorder at baseline were more likely to still have a disorder at 5 years (RR: 3.5, 95% CI: 2.0 ± 6.0). Only 32% of patients with a mental disorder at enrollment were diagnosed during the 5 years of follow up. The rate of diagnosis varied by disorder: 52% of patients with major depression, all patients with panic disorder and 66% of patients with generalized anxiety at baseline were diagnosed. For subthreshold disorders, diagnoses rates were lower: 32% for depression and 5% for anxiety. Patients with unrecognized depression (RR: 5.0, 95% CI: 1.2 ± 21.1) or anxiety (RR: 4.8, 95% CI: 1.1 ± 23.5) were more likely to still have their disorder 5 years later, compared to patients whose disorders were recognized. While most patients with minor depression or subthreshold anxiety (73 ± 83%) had their disorder at only one time point and no patient with subthreshold anxiety progressed to generalized anxiety or to panic disorder, 18% of those with minor depression progressed to major depression by 5 years. Patients whose mental disorder went undiagnosed over 5 years were more likely to have worsening of their initial symptom (RR: 3.6, 95%CI: 1.6 ± 8.4), greater stress (RR: 2.3, 95% CI: 1.9 ± 2.8), greater worry that their symptom represented a serious illness (RR: 2.9, 95% CI: 1.7 ± 4.9), a greater number of``other'' bothersome physical symptoms (p < 0.0001), and worse functional status (p < 0.0001). Outcomes among patients whose mental disorders were diagnosed during the intervening 5 years, were the same as among those without mental disorders. CONCLUSION: Patients with unrecognized major mental disorders were more likely to still be struggling with their disorder 5 years later, had less resolution of their presenting physical symptom and experienced worse health-related outcomes. METHODS: In 1995, 500 adults presenting with a physical complaint completed surveys that assessed symptom characteristics, functional status (MOS SF6) and mental disorders (PRIME-MD). Follow up surveys assessed symptom outcome, functional status and satisfaction at 2 weeks, 3 months and 5 years. RESULTS: Patients averaged 43 years in age (18 ± 92), were 52% female, 45% African American and 49% white. Patients presented with a myriad of complaints that we collapsed to 13 categories. Musculoskeletal symptoms were the most common category, present in a third and half had some sort pain complaint. Twenty ± one percent had experienced their symptom less than 3 days, 40% less than a week, 68% less than a month; 46% had seen a previous doctor for the same problem. Most patients experienced improvement, 70% at 2 weeks, 79% at 3 months and 75% at 5 years. There was no relationship between type of symptom and likelihood of improvement. However, there was good correlation between improvement in symptoms between each of the three time points. (Spearman's rho:0.40 ± 0.43). Among patients whose symptom had improved by 3months, most (83%) were still improved at 5 years. Conversely among those reporting no improvement, 52% were still not improved at 5 years. There was no relationship between likelihood of symptom improvement and age, sex, or baseline functional status. Patients without symptom improvement had worse functional status (p < 0.001), more illness worry (p < 0.001), a greater number of``other'' bothersome symptoms (p = 0.003) and were more likely to have an active mental disorder at 5 years (RR: 1.3, 95% CI:1.02 ± 1.7). Independent predictors of improvement included improvement at 3 months, symptom less than 3 days in duration at presentation and no patient worry that the illness could be potentially serious at presentation. CONCLUSION: Patients with symptoms present for more than 3 days at presentation,who are worried their symptom may be serious or who have not improved by 3 months are likely to still have problems with their symptom at 5 years. The 1994 AHRQ Low Back Pain Clinical Guidelines recommended treatment with tylenol in patients less than 55 years of age with no historical or physical examination findings suggestive of more serious causes. Nonsteroidal use was discouraged. Muscle relaxants, narcotics and routine radiographs were deemed inappropriate. Our purpose was to assess the impact of these guidelines on clinical practice. METHODS: Patients greater than 17 but less than 55 years in age, being seen in primary care settings (FP, IM, GP) with low back pain, without an inflammatory or secondary diagnosis to explain their back pain were abstracted from the National Ambulatory Medical Care Survey. Data from 1991 ± 1993 (prior to release of the 1994 AHRQ), were compared to data from 1995 ± 1997. RESULTS: A total of 11,854,653 encounters met criteria and were included in this analysis. The mean age of patients was 37 years, 57% were male and 34% of the visits were injury related. Prior to the guidelines, 0.33% of patients with back pain were treated with acetaminophen, 39% with a nonsteroidal, 27% with muscle relaxants and 4% with narcotics. Twenty-seven percent were referred for physiotherapy and 16% had an Xray associated with the visit. After the guideline release in 1994, acetaminophen use increased to 3%, muscle relaxant use declined to 17% and referrals to physiotherapy declined to 22%. Nonsteroidal (40%), muscle relaxants (20%), narcotic use (6%) and the rate that Xray's were obtained (19%) were unchanged. CONCLUSION: The AHRQ guidelines increased acetaminophen use, but only to 3%. Physicians were less likely to prescribe a muscle relaxant and were less likely to refer for physical therapy. There was no impact of the guidelines on clinician use of nonsteroidals, narcotics or radiographic evaluation. PURPOSE: Clinicians are often reluctant to recommend alcohol consumption among those with a history of stroke. We therefore sought to examine the relationship between alcohol intake and the risk of total and cardiovascular mortality in men with a previous history of stroke. METHODS: The study population consisted of the 104,353 physicians who comprised the enrollment cohort of the Physicians' Health Study. We focused our analyses on the 1,320 men who indicated a history of stroke at baseline and provided self-reported data on alcohol consumption. Cox proportional hazards was used to model the association between alcohol and mortality after adjustment for major lifestyle and clinical risk factors. Alcohol consumption was classified into four categories, with those reporting rarely/never used as the referent group. RESULTS: During a mean follow-up of 4.6 years, 369 men died, of whom 267 died from cardiovascular disease. Multivariate relative risks of total mortality were decreased in men with a history of stroke who consumed < 1drink per week, 1 ± 6 drinks per week, and at least 1 drink per day, at 0.88(0.60,1.28), 0.64(0.48,0.85) and 0.71(0.54,0.94) respectively (p, linear trend 0.028). Multivariate relative risks of cardiovascular mortality in men with a history of stroke were also decreased in men who consumed < 1 drink per week, 1 ± 6 drinks per week, and at least 1 drink per day, at 0.89(0.58,1.36), 0.56(0.40,0.79), and 0.64(0.46,0.88) respectively (p, linear trend 0.008). Adjustment for lifestyle and other clinical risk factors did not significantly change the risk estimates for total or cardiovascular mortality as compared with age-adjusted models. Because only fifty-five men died as a result of stroke, we were underpowered to examine this association, but the risk estimates were nonsignificantly lower among men consuming at least 1 drink per week.