National health statistics reports number 18, july 30, 2009

Number 18 n July 30, 2009 Costs of Complementary and Alternative Medicine
(CAM) and Frequency of Visits to CAM Practitioners:
United States, 2007
by Richard L. Nahin, Ph.D., M.P.H., National Institutes of Health; Patricia M. Barnes, M.A.; Barbara J. Stussman, B.A.; and Barbara Bloom, M.P.A., Division of Health Interview Statistics Abstract
use at 38.3% of adults (83 million persons) and 11.8% of children (8.5 Objective—This report presents selected estimates of costs of complementary million children under age 18 years) (2). and alternative medicine (CAM) use among U.S. adults, the frequency of visits The most recent national estimates of made to CAM providers, and the frequency of purchases of self-care CAM out-of-pocket expenditures for CAM therapies. Data from the 2007 National Health Interview Survey (NHIS), which therapies are now more than a decade is conducted by the Centers for Disease Control and Prevention's National Center old (3). In their 1997 telephone survey, for Health Statistics, are used in this report. Eisenberg et al (3) contacted a Methods—Estimates were derived from the Complementary and Alternative nationally representative sample of Medicine Supplement of the 2007 NHIS, sponsored by the National Center for 2,055 individuals aged 18 years or older, Complementary and Alternative Medicine, which is part of the National Institutes with a weighted response rate of 60%. of Health. Estimates were generated using the SUDAAN statistical package to At that time, the total out-of-pocket account for the NHIS complex sample design. expenditure for CAM use in adults was Results—In 2007, adults in the United States spent $33.9 billion out of estimated at $27.0 billion per year, with pocket on visits to CAM practitioners and purchases of CAM products, classes, $12.2 billion of the total going toward and materials. Nearly two-thirds of the total out-of-pocket costs that adults spent payment of CAM professionals such as on CAM were for self-care purchases of CAM products, classes, and materials acupuncturists, chiropractors, and during the past 12 months ($22.0 billion), compared with about one-third spent massage therapists. This report is based on a CAM practitioner visits ($11.9 billion). Despite this emphasis on self-care therapies, survey supplement administered as part 38.1 million adults made an estimated 354.2 million visits to practitioners of of the sample adult questionnaire of the CAM. About three-quarters of both visits to CAM practitioners and total 2007 National Health Interview Survey out-of-pocket costs spent on CAM practitioners were associated with (NHIS). The report focuses on the manipulative and body-based therapies. A total of 44% of all out-of-pocket costs out-of-pocket expenditures on CAM. for CAM, or about $14.8 billion, was spent on the purchase of nonvitamin, Estimates of total cost and cost per visit nonmineral, natural products. for all CAM therapies used, as well as Keywords: complementary and alternative medicine c National Health Interview
prevalence of use of individual CAM therapies and the associated per-visit costs to a CAM provider, are presented. The report also examines the number of products (1). Over the last decade, the U.S.
public has shown a steady and made to CAM providers in a Complementary and alternative use of complementary and period. A previous report medicine (CAM) comprises a diverse set medicine, with 2007 the prevalence of CAM use of healing philosophies, therapies, and placing overall prevalence of adults and children (2). U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics National Health Statistics Reports n Number 18 n July 30, 2009 management classes, support groups, episodes, access to medical care, and and religious (faith) healing are not health insurance coverage. Data source
included in the definition of CAM used The NHIS questions have several in this report, although questions on limitations: 1) The questions are The statistics shown in this report their use were included in the CAM dependent on respondents' memory and are based on data from the Adult supplement. Within the CAM their willingness to report use Complementary and Alternative supplement, one section asked about accurately. 2) The collection of survey Medicine supplement of the 2007 NHIS participants' use of ‘‘herbal data at a single point in time results in (4). NHIS, which is in the field supplements.'' This section queried an inability to produce consecutive continuously, is conducted by the participants on a list of 45 dietary annual prevalence estimates, and can Centers for Disease Control and supplements that went beyond the reduce the ability to produce reliable Prevention's National Center for Health category of ‘‘herbal supplements'' to prevalence estimates for small Statistics. It is a survey of a nationally include such items as androstenedione, population subgroups, as this could representative sample of the civilian, carnitine, creatine, DHEA, fish oils, require a larger sample and more than noninstitutionalized household glucosamine, lutein, lycopene, one year of data. 3) The total costs per population of the United States. In the family person for nonvitamin, nonmineral, section, basic health and omega fatty acids, prebiotics demographic information is collected on or probiotics, and SAM-e, but not natural products and homeopathy were all household members. All adult vitamins or minerals. Therefore, to more calculated by multiplying the amount members of the household who are correctly label this extensive set of spent at the most recent purchase by the home at the time of the interview are dietary supplements in this report, this number of purchases per year. Because invited to participate and respond for group of supplements is referred to as data were not available for the exact themselves, with proxy responses nonvitamin, nonmineral, natural cost at each purchase, and the most allowed for persons unavailable at the recent purchase may not have been time of the interview. Additional Inclusion and development of the typical of the respondent's usual information is collected on one 2007 CAM supplement was supported purchase of CAM products, the randomly selected adult aged 18 years by seven institutes, centers, or offices of estimates may contain errors. or over (sample adult) and one the National Institutes of Health: randomly selected child aged 0–17 years Statistical analysis
(sample child) in each family. + National Center for Complementary Information on the sample adult is and Alternative Medicine In 2007, NHIS interviews were self-reported except in rare cases when + National Heart, Lung and Blood completed in 29,266 households, which the sample adult is physically or yielded 75,764 persons in 29,915 mentally incapable of responding, and + National Institute of Allergy and families and a household response rate information on the sample child is Infectious Disease of 87.1%. This report is based on data collected from an adult who is + National Institute of Child Health and from 23,393 completed interviews with knowledgeable about the child's health, Human Development sample adults aged 18 years and over. usually a parent. + National Institute of Mental Health The final 2007 sample adult response The 2007 CAM supplement was + Office of Behavioral and Social rate was 67.8%. Procedures used in administered to sample adults and Science Research calculating response rates are detailed in respondents for sample children. It + Office of Dietary Supplements Appendix I of the Survey Description included questions on 36 types of CAM Document, NHIS data files (5). therapies used in the United States, Strengths and limitations of
All estimates and associated including 10 types of provider-based standard errors shown in this report CAM therapies (e.g., acupuncture, were generated using SUDAAN, a chiropractic and osteopathic A major strength of the NHIS CAM software package designed to account manipulation, traditional healers) and 26 data is that they were collected for a for a complex sample design such as other CAM therapies for which the nationally representative sample of U.S. that of NHIS (6). All estimates for services of a provider are not necessary adults, allowing estimation of CAM use adults were weighted, using the sample (e.g., nonvitamin, nonmineral, natural for a wide variety of population adult record weight, to represent the products; special diets; movement subgroups. The large sample size also U.S. civilian, noninstitutionalized therapies); see ‘‘Technical Notes,'' facilitates investigation of the population aged 18 years and over. ‘‘Definition of terms,'' for a list and association between CAM and a wide Estimates were calculated using descriptions of all 36 CAM therapies. range of other self-reported health recodes for the number of times the Following the taxonomy of characteristics included in the NHIS, respondent saw various CAM unconventional health care proposed by such as health behaviors, chronic health practitioners, the amount paid out of Kaptchuk and Eisenberg (1), stress conditions, injury and poisoning pocket for each CAM practitioner visit, National Health Statistics Reports n Number 18 n July 30, 2009 the number of times self-care therapies Total costs: $33.9 billion were purchased, and the amount paid out of pocket for the self-care therapy $14.8 billion (43.7%) (see ‘‘Technical Notes,'' ‘‘Calculation of estimates,'' for a detailed explanation of Yoga, tai chi, qigong classes the recodes and ‘‘Definition of terms'' $4.1 billion (12.0%) for definitions of CAM practitioner and self-care therapies). Persons with unknown CAM information have been Homeopathic medicine $2.9 billion (8.7%) excluded from the analysis. In tables shown in this report, Practitioner costs Relaxation techniques estimates with a relative standard error $0.2 billion (0.6%) of more than 30% but less than or equal to 50% are identified with an asterisk 1 Nonvitamin, nonmineral, natural products. (*), indicating that they are statistically NOTES: Percentage refer to the total out-of-pocket costs in 2007. Totaling individual self-care cost percentages is affected by rounding. Estimates are based on household interviews of a sample of the civilian, noninstitutionalized population. unstable due to small sample size. DATA SOURCE: CDC/NCHS, National Health Interview Survey, 2007. Estimates with a relative standard error of greater than 50% are indicated with a Figure. Out-of-pocket costs for complementary and alternative medicine among adults
(†) and are not shown. 18 years and over: United States, 2007
manipulative and body-based + Adults spent $2.9 billion out of pocket on the purchase of + On average, adults in the United homeopathic medicine in 2007 Out-of-pocket costs for CAM
States spent $121.92 per person for visits to CAM providers and paid + Across categories of self-care CAM $29.37 out of pocket per visit. Some products, most adults who purchased + In 2007, adults in the United States of the highest per-person, out-of­ the products spent less than $30 per spent $33.9 billion out of pocket on pocket costs are associated with visits purchase. However, about 5% of visits to CAM practitioners and to practitioners of naturopathy and individuals who bought nonvitamin, purchases of CAM products, classes, chelation therapy, while one of the nonmineral, natural products or who and materials (see figure). lowest per-person, out-of-pocket costs purchased self-help materials to learn + Nearly two-thirds of the total is associated with visits to relaxation techniques spent more than out-of-pocket costs that adults spent practitioners of chiropractic or $120 per purchase on CAM were for self-care purchases osteopathic manipulation therapy of CAM products, classes, and Discussion
materials during the past 12 months + For most types of CAM therapies, the ($22.0 billion) compared with about Using data from the 2007 NHIS, we majority of adults spent less than $50 one-third spent on practitioner visits estimate that U.S. adults spent about per visit to a practitioner. However, at ($11.9 billion) (see figure). $33.9 billion out of pocket on visits to least 20% of persons visiting CAM practitioners and on purchases of + A total of 44% of all out-of-pocket practitioners of acupuncture, CAM products, classes, and materials. costs for CAM was spent on the homeopathy, naturopathy, massage, This equates to 1.5% of total health-care purchase of nonvitamin, nonmineral, and hypnosis therapy paid $75 or expenditures in the United States and to natural products (see figure). 11.2% of out-of-pocket health-care expenditures (7). Almost two-thirds of practitioner therapies
CAM self-care therapies
CAM costs were associated with self-care therapies such as nonvitamin, + In 2007, 38.1 million adults made an nonmineral, natural products; estimated 354.2 million visits to + Nonvitamin, nonmineral, natural homeopathic products; and yoga. Of CAM practitioners, at an estimated products ($14.8 billion) accounted for this, the public spent $14.8 billion out out-of-pocket cost of $11.9 billion the majority of out-of-pocket dollars of pocket to purchase nonvitamin, spent on CAM self-care purchases nonmineral, natural products—about + About three-quarters of both visits to 31% of the amount that the public spent CAM practitioners and total out-of­ + Adults who made CAM self-care out of pocket to buy pharmaceutical pocket costs spent on CAM purchases spent a total of $4.1 billion drugs in 2007 ($47.6 billion) (7). The practitioners during the past 12 out of pocket on yoga, tai chi, or public also spent $12.4 billion out of months were associated with pocket on visits to CAM providers, or National Health Statistics Reports n Number 18 n July 30, 2009 25% of that spent out of pocket for implementation. However, these Underlying these declines in the number conventional physician services ($49.6 estimated expenditures are broadly of visits is a corresponding decrease in consistent with industry sales data that the numbers of persons who sought care It has been 10 years since the last also demonstrate a large increase in from practitioners. While 15.3% of national estimates on the cost of CAM expenditures for nonvitamin, persons who used relaxation techniques and on the number of visits to CAM nonmineral, natural products between sought care from a practitioner of providers were made by Eisenberg and 1997 and 2007 (8). Industry sales data, relaxation techniques in 1997 (3), the colleagues (3). That survey varied from however, suggest lower total proportion dropped to 9.0% in 2007. For the 2007 NHIS in several ways, expenditures for homeopathic medicine those who saw a practitioner, the including being a telephone survey and than the estimates derived here (9). number of visits per person in 2007 was collecting information differently on the Comparison of the two surveys about one-fifth of that observed in 1997: cost of CAM therapies. Nevertheless, suggests that the number of visits U.S. 3.5 visits per person compared with 20.9 comparisons between the two surveys adults make to CAM practitioners has visits per person (3), respectively. are of special interest given that they dropped by about 50% since Approximately twice as many collected information on an overlapping, 1997—628.8 million or 3,176 visits per individuals bought a self-help book or if not identical, set of CAM therapies 1,000 adults in 1997 (3) compared with other materials to learn relaxation and that both provide national estimates 354.2 million or 1,592 visits per 1,000 techniques in 2007 (6.4 million) as saw of costs and visits. adults in 2007. The Eisenberg et al. a practitioner (3.1 million), suggesting The greatest contrast between the estimate of visits to CAM providers (3) that relaxation techniques are used two surveys concerns the relative was even somewhat similar in size to primarily as self-care. Similarly, the amount of out-of-pocket dollars spent on the total number of office visits to percentage of the adult population who CAM providers compared with self-care physicians [M.D. and doctor of saw a practitioner of energy-healing CAM therapies such as homeopathic osteopathy (D.O.)] in 1997 (787.4 therapy declined by half in 2007 (0.5%) products, yoga, and nonvitamin, million) (10). However, the estimated compared with 1997 (1.0%), while the nonmineral, natural products. The number of office visits to CAM number of visits per person dropped by present observation that about two-thirds providers in the 2007 NHIS is almost 90%, from 20.2 visits per person of CAM costs were associated with substantially lower than the projected in 1997 to 2.3 visits per person in 2007 self-care therapies contrasts with the number of visits to physicians (M.D. findings of Eisenberg et al. (3), who and D.O.) for 2007 (more than 902.0 Despite the overall decrease in reported that the majority of CAM costs million visits) (11). While some of these visits to CAM providers in 2007 resulted from consultations with discrepancies may result from the compared with 1997, visits to health-care professionals offering CAM different methodologies used in the two acupuncturists, a progressively more services (3). While these differences surveys, as well as the different types of regulated and professionalized CAM may be partly attributed to variations in CAM therapies queried, the 2007 NHIS provider group, increased over this same survey methodology, they are consistent data suggest that a major factor in the time period, with 17.6 million visits with the hypothesis that the use of reduction in visits to CAM providers in estimated for 2007 (79.2 visits per 1,000 self-care therapies has increased and the 2007 compared with 1997 was a decline adults), or three times that observed in use of CAM health-care professionals in the number of adults who sought care 1997 (27.2 visits per 1,000 adults) (3). has decreased. For instance, using the from these practitioners and the The increase for acupuncture may in Consumer Price Index and expressing frequency of this care. part be due to the greater number of 1997 costs in 2007 dollars, the out-of­ The two practitioner groups that had states that license this practice and a pocket costs in 2007 for CAM the largest reduction in visits in 2007 corresponding increase in the number of practitioner services ($11.9 billion) fell compared with 1997 were practitioners licensed practitioners in 2007 compared outside the range calculated by of energy-healing therapies and the with 1997, as well as increased Eisenberg et al. ($15.8 billion–$25.3 various relaxation techniques. Together, insurance coverage for these therapies. billion) (3), while the NHIS cost the drop in visits to these two groups of Large numbers of articles in the lay estimate of nonvitamin, nonmineral, practitioners accounted for about half of press about the benefits of acupuncture natural products is more than twice that the total decrease in 2007 from 10 years were published during this period, estimated by Eisenberg et al. ($14.8 earlier. Visits to practitioners of increasing awareness in the general billion vs. $6.6 billion). Some of these relaxation techniques declined from population. Together, greater opportunity differences in estimated expenditures 103.2 million in 1997 (521.2 visits per and increased awareness may explain may be the result of differences in how 1,000 adults) (3) to 28.9 million in 2007 much of the observed increase in adult nonvitamin, nonmineral, natural (128.9 visits per 1,000 adults), while use of acupuncture. products were operationally defined in visits to energy healers decreased from In summary, NHIS data indicate the two surveys, or in how cost per 40.0 million in 1997 (201.9 visits per that the U.S. public makes more than purchase was determined, or other 1,000 adults) (3) to 7.2 million in 2007 300 million visits to CAM providers differences in survey design and (32.4 visits per 1,000 adults). each year and spends billions of dollars National Health Statistics Reports n Number 18 n July 30, 2009 for these services, as well as for p 31. San Diego, CA: Penton Media, self-care forms of CAM. These expenditures, although a small fraction 9. Nutrition Business Journal. of total health-care spending in the Supplement Business Report 2006. p 202. San Diego, CA: Penton Media, States, constitute a substantial part of out-of-pocket health-care costs 10. Woodwell DA. National Ambulatory and are comparable to out-of-pocket Medical Care Survey: 1997 costs for conventional physician services summary. Advance data from vital and prescription drug use. and health statistics; no 305. Hyattsville, MD: National Center for References
Health Statistics. 1999. 11. Cherry DK, Hing E, Woodwell DA, 1. Kaptchuk TJ, Eisenberg DM. Rechtsteiner EA. National Varieties of healing. 2: A taxonomy Ambulatory Medical Care Survey: of unconventional healing practices. 2006 summary. National health Ann Intern Med 135(3):196–204.9. statistics reports; no 3. Hyattsville, MD: National Center for Health 2. Barnes PM, Bloom B, Nahin RL. Statistics. 2008. Complementary and alternative 12. Willson S, Stussman B, Maitland A, medicine use among adults and Nahin RL. The role of self concept children: United States, 2007. in answering survey questions on National health statistics reports; no complementary and alternative 12. Hyattsville, MD: National Center medicine: Challenges to and for Health Statistics. 2008. strategies for improving data quality. 3. Eisenberg DM, Davis RB, Ettner SL, Submitted to a refereed journal. Appel S, Wilkey S, et al. Trends in alternative medicine use in the United States, 1990–1997: Results of a follow-up national survey. JAMA 280(18):1569–75. November 11, 1998. 4. National Center for Health Statistics. National Health Interview Survey (NHIS): 2007 data release [online]. 5. National Center for Health Statistics. National Health Interview Survey (NHIS): Public-use data release. NHIS survey description [online]. 6. Research Triangle Institute. SUDAAN (Release 9.0.1) [computer software]. Research Triangle Park, NC: Research Triangle Institute. 2005. 7. Center for Medicare & Medicaid Services. National Health Expenditure Projections 1960–2007 14, 2008. 8. Nutrition Business Journal. Supplement Business Report 2006. Table 1. Frequencies and percentages of persons aged 18 years and over who saw a practitioner for selected complementary and alternative medicine therapies during the past
12 months, total practitioner visits per year, and total out-of-pocket costs per year, by type of therapy: United States, 2007
Saw a practitioner Total out-of-pocket Total visits per year costs per year (dollars) Alternative medical systems. . . . . . . . . . Homeopathic treatment2 . . . . . . . . . . Traditional healers3. . . . . . . . . . . . Biologically based therapies. . . . . . . . . . Nonvitamin, nonmineral, and natural products2. . . Diet-based therapies2,4 . . . . . . . . . . Manipulative and body-based therapies . . . . . . Chiropractic or osteopathic manipulation2 . . . . . Relaxation techniques6 . . . . . . . . . . Energy-healing therapy2 . . . . . . . . . . . * Estimates preceded by an asterisk have a relative standard error of greater than 30% and less than or equal to 50% and do not meet the standards of reliability or precision. †Estimates with a relative standard error greater than 50% are indicated with a dagger, but are not shown. 1The totals of the numbers and percentages of the individual therapies are greater than the total number and 100% because respondents could choose more than one therapy. The totals of the numbers and percentages of the five therapy groups are greater than the total number and 100% because respondents could choose more than one therapy and would therefore be counted in more than one group. Estimates are based on the questions, ‘‘DURING THE PAST 12 MONTHS, how many times did you see a practitioner for {fill in therapy}?'' and ‘‘On average, how much did you pay out-of-pocket for each visit to a practitioner for {fill in therapy}?'' 3Traditional healers include Curandero, Espiritista, Hierbero or Yerbera, Shaman, Botanica, Native American Healer/Medicine Man, and Sobador. Estimates are based on the questions, ‘‘DURING THE PAST 12 MONTHS, how many times did you see a {fill in traditional healer}?'' and ‘‘On average, how much did you pay out-of-pocket for each visit to a {fill in traditional healer}?'' 4Diet-based therapies include vegetarian diet, macrobiotic diet, Atkins diet, Pritikin diet, Ornish diet, Zone diet, and South Beach diet. 5Movement therapies include Feldenkreis, Alexander technique, Pilates, and Trager Psychophysical Integration. Estimates are based on the questions, ‘‘DURING THE PAST 12 MONTHS, how many times did you see a practitioner or teacher for {fill in movement therapy}?'' and ‘‘On average, how much did you pay out-of-pocket for each visit to a practitioner or teacher for {fill in movement therapy}?'' Relaxation techniques include meditation, guided imagery, progressive relaxation, and deep-breathing exercises. Estimates are based on the questions, ‘‘DURING THE PAST 12 MONTHS, did you see a practitioner or take a class for {fill in relaxation technique}?'' and ‘‘On average, how much did you pay out-of-pocket for each visit to a practitioner or to take a class for {fill in relaxation technique}?'' NOTE: The denominators for statistics shown exclude persons with unknown complementary and alternative medicine information. Estimates are based on household interviews of a sample of the civilian, noninstitutionalized population. DATA SOURCE: CDC/NCHS, National Health Interview Survey, 2007. Table 2. Median (with 95% confidence intervals) number of visits per person, median out-of-pocket costs per person, and median out-of-pocket costs per visit for persons aged 18
years and over who saw a practitioner for selected complementary and alternative medicine therapies during the past 12 months, by type of therapy: United States, 2007 Saw a practitioner Number of visits costs per person Out-of-pocket cost per visit (dollars) Median (95% confidence interval) 3.86 (3.49–4.42) 121.92 (114.69–141.55) 29.37 (29.05–30.76) Alternative medical systems . . . . . . . . . . . 2.83 (2.65–3.01) 101.00 ( 86.91–136.03) 39.59 (33.56–48.40) 2.42 (2.10–2.75) 122.35 (100.10–171.31) 48.25 (38.40–49.50) Homeopathic treatment1 . . . . . . . . . . . 2.00 (1.47–2.52) *86.73 ( 36.38–155.81) 32.16 (12.18–39.81) 1.98 (1.48–2.42) 251.84 (102.11–333.99) 63.25 (45.23–91.69) *28.57 ( 7.37– 48.50) 19.00 ( 5.39–27.27) Biologically based therapies . . . . . . . . . . . 2.13 (1.53–2.74) 97.86 ( 65.32–178.40) 29.62 (23.81–45.30) 224.52 (133.12–315.80) Nonvitamin, nonmineral, natural products1 . . . . . . 2.32 (1.70–2.98) *102.16 ( 67.50–190.39) 32.90 (27.21–46.86) Diet-based therapies1,3. . . . . . . . . . . . and body-based therapies . . . . . . . 3.43 (3.33–3.69) 121.30 (114.38–142.77) 29.45 (29.13–29.77) Chiropractic or osteopathic manipulation . . . . . . 3.45 (3.28–3.89) 104.29 ( 88.15–119.45) 21.62 (19.73–24.30) 2.16 (2.01–2.31) 136.73 (107.17–144.60) 46.65 (45.46–47.82) 4.98 (3.46–6.57) *4.55 ( 0.36– 8.31) *3.22 (2.67–7.07) 2.38 (1.37–3.41) Relaxation techniques5 . . . . . . . . . . . . 3.47 (2.96–5.89) 44.06 (20.52–61.31) Energy-healing therapy1 . . . . . . . . . . . . 2.26 (1.69–2.88) *59.58 (36.22–131.22) 28.47 (14.43–43.72) § Based on the small amount and/or the distribution of the data, it was not possible to estimate confidence interval boundaries, and the median is not shown. * Estimates preceded by an asterisk have a relative standard error of greater than 30% and less than or equal to 50% and do not meet the standard of reliability or precision. †Estimates with a relative standard error greater than 50% are indicated with a dagger, but are not shown. 1Estimates are based on the questions, ‘‘DURING THE PAST 12 MONTHS, how many times did you see a practitioner for {fill in therapy}?'' and ‘‘On average, how much did you pay out-of-pocket for each visit to a practitioner for {fill in therapy}?'' 2Traditional healers include Curandero, Espiritista, Hierbero or Yerbera, Shaman, Botanica, Native American Healer/Medicine Man, and Sobador. Estimates are based on the questions, ‘‘DURING THE PAST 12 MONTHS, how many times did you see a {fill in traditional healer}?'' and ‘‘On average, how much did you pay out-of-pocket for each visit to a {fill in traditional healer}?'' 3Diet-based therapies include vegetarian diet, macrobiotic diet, Atkins diet, Pritikin diet, Ornish diet, Zone diet, and South Beach diet. 4Movement therapies include Feldenkreis, Alexander technique, Pilates, and Trager Psychophysical Integration. Estimates are based on the questions, ‘‘DURING THE PAST 12 MONTHS, how many times did you see a practitioner or teacher for {fill in movement therapy}?'' and ‘‘On average, how much did you pay out-of-pocket for each visit to a practitioner or teacher for {fill in movement therapy}?'' 5Relaxation techniques include meditation, guided imagery, progressive relaxation, and deep-breathing exercises. Estimates are based on the questions, ‘‘DURING THE PAST 12 MONTHS, did you see a practitioner or take a class for {fill in relaxation technique}?'' and ‘‘On average, how much did you pay out-of-pocket for each visit to a practitioner or to take a class for {fill in relaxation technique}?'' NOTES: The estimates shown exclude persons with unknown complementary and alternative medicine information. Estimates are based on household interviews of a sample of the civilian, noninstitutionalized population. DATA SOURCE: CDC/NCHS, National Health Interview Survey, 2007. Table 3. Percent distributions (with standard errors) of average out-of-pocket costs per visit to a practitioner for complementary and alternative medicine therapy, for persons
aged 18 years and over who saw a practitioner for that type of therapy during the past 12 months, by therapy: United States, 2007
Practitioner costs (dollars) Percent distribution (standard error) Alternative medical systems Homeopathic treatment1 . . . . . . . . . . . . Biologically based therapies Nonvitamin, nonmineral, natural products1 . . . . . . Diet-based therapies1,3 . . . . . . . . . . . . Manipulative and body-based therapies Chiropractic or osteopathic manipulation . . . . . . . Mind-body therapies Relaxation techniques5 . . . . . . . . . . . . Energy-healing therapy1 . . . . . . . . . . . . * Estimates preceded by an asterisk have a relative standard error of greater than 30% and less than or equal to 50% and do not meet the standards of reliability or precision. †Estimates with a relative standard error greater than 50% are indicated with a dagger, but are not shown. – Quantity zero. 1Estimates are based on the question, ‘‘On average, how much did you pay out-of-pocket for each visit to a practitioner for {fill in therapy}?'' 2Traditional healers include Curandero, Espiritista, Hierbero or Yerbera, Shaman, Botanica, Native American Healer/Medicine Man, and Sobador. Estimates are based on the question, ‘‘On average, how much did you pay out-of-pocket for each visit to a {fill in traditional healer}?'' 3Diet-based therapies include vegetarian diet, macrobiotic diet, Atkins diet, Pritikin diet, Ornish diet, Zone diet, and South Beach diet. Movement therapies include Feldenkreis, Alexander technique, Pilates, and Trager Psychophysical Integration. Estimates are based on the question, ‘‘On average, how much did you pay out-of-pocket for each visit to a practitioner or teacher for {fill in movement therapy}?'' 5Relaxation techniques include meditation, guided imagery, progressive relaxation, and deep-breathing exercises. Estimates are based on the question, ‘‘On average, how much did you pay out-of-pocket for each visit to a practitioner or to take a class for {fill in relaxation technique}?'' NOTES: The denominators for statistics shown exclude persons with unknown complementary and alternative medicine information. Estimates are based on household interviews of a sample of the civilian, noninstitutionalized population. DATA SOURCE: CDC/NCHS, National Health Interview Survey, 2007. Table 4. Frequencies of persons aged 18 years and over who purchased selected complementary and alternative medicine therapies or materials, total purchases per year, and
total out-of-pocket costs per year; and median (with 95% confidence interval) number of purchases per person, median out-of-pocket costs per person, and median out-of-pocket
cost per purchase, by type of therapy: United States, 2007
Purchases of a therapy or materials person (dollars) purchase (dollars) Number (in thousands) Median (95% confidence interval) Nonvitamin, nonmineral, natural products1 . . . . . . 5.41 ( 5.16– 5.65) 176.77 (150.52–185.09) 19.18 (18.12–20.27) 1.58 ( 1.20– 1.97) 37.99 ( 28.66– 53.08) 15.28 (14.30–18.92) 24.90 (16.94–31.39) *49.43 ( 16.22– 97.16) 4.37 ( 1.39– 5.64) Relaxation techniques4 . . . . . . . . . . . . 18.30 ( 14.89– 18.78) * Estimates preceded by an asterisk have a relative standard error of greater than 30% and less than or equal to 50% and do not meet the standards of reliability or precision. . .Category not applicable. 1Estimates are based on the questions, ‘‘About how often do you buy herbal supplements?'' and ‘‘About how much did you spend the last time you bought herbal supplements?'' 2Estimates are based on the questions, ‘‘About how often do you buy homeopathic medicine?'' and ‘‘About how much did you spend the last time you bought homeopathic medicine?'' 3Estimates are based on the questions, ‘‘DURING THE PAST 12 MONTHS, on average, how often did you take a class or in some way receive formal training for {fill in yoga, tai chi, or qi gong}?'' and ‘‘On average, how much did you pay out-of-pocket for each class or other formal training for {fill in yoga, tai chi, or qi gong}?'' 4Relaxation techniques include meditation, guided imagery, progressive relaxation, and deep-breathing exercises. Estimates are based on the questions, ‘‘Did you buy a self-help book or other materials to learn about {fill relaxation technique used most}?'' and ‘‘How much did you pay for these materials?'' The estimates shown exclude persons with unknown complementary and alternative medicine information. Estimates are based on household interviews of a sample of the civilian, noninstitutionalized population. DATA SOURCE: CDC/NCHS, National Health Interview Survey, 2007. Table 5. Percent distributions (with standard errors) of costs for therapy or materials, for persons aged 18 years and over who purchased that type of therapy or materials, by
therapy: United States, 2007
Purchased therapy costs (dollars) Percent distribution (standard error) Nonvitamin, nonmineral, natural products1 . . . . . . Relaxation techniques4 . . . . . . . . . . . . * Estimates preceded by an asterisk have a relative standard error of greater than 30% and less than or equal to 50% and do not meet the standards of reliability or precision. 1Estimates are based on the question, ‘‘About how much did you spend the last time you bought herbal supplements?'' 2Estimates are based on the question, ‘‘About how much did you spend the last time you bought homeopathic medicine?'' 3Estimates are based on the question, ‘‘On average, how much did you pay out-of-pocket for each class or other formal training for {fill in yoga, tai chi, or qi gong}?'' 4Relaxation techniques include meditation, guided imagery, progressive relaxation, and deep-breathing exercises. Estimates are based on the questions, ‘‘Did you buy a self-help book or other materials to learn about {fill relaxation technique used most}?'' and ‘‘How much did you pay for these materials?'' NOTES: The denominators for statistics shown exclude persons with unknown complementary and alternative medicine information. Estimates are based on household interviews of a sample of the civilian, noninstitutionalized population. DATA SOURCE: CDC/NCHS, National Health Interview Survey, 2007. National Health Statistics Reports n Number 18 n July 30, 2009 Technical Notes
Item nonresponse
times per week, and times per month were converted into times per year. For the 2007 complementary and Sample design
Based on prior cognitive testing results alternative medicine (CAM) items, of the Complementary and Alternative The National Health Interview nonresponse ranged from 0.0% to Medicine Supplement of the 2007 NHIS Survey (NHIS) is a cross-sectional 10.7%, with nonresponse for most items (12), few respondents report buying household interview survey of the U.S. being less than 5.0%. The denominators supplements as often as daily. Responses civilian, noninstitutionalized population. for statistics shown in tables exclude indicating purchases much more than Data are collected continuously persons with unknown CAM 365 times per year were therefore throughout the year in all 50 states and information for a given table. Among excluded from the analysis as presumed the District of Columbia. NHIS uses a the 23,393 interviewed sample adult errors. The question-and-response multistage, clustered sample design to respondents in the 2007 NHIS, 610 categories on which these recodes are collect data on a variety of health adults were missing data for all of the based can be found in the 2007 NHIS indicators. Information on basic health Sample Adult Complementary and topics is collected for all household Alternative Medicine Questionnaire at: members, if necessary by proxy from Calculation of estimates
one adult family member. Additional All estimates and associated information is collected from one standard errors shown in this report randomly selected adult and one were generated using SUDAAN, a unknown CAM information are randomly selected child in each family. software package designed to account excluded from the analysis. Self-response is required for the NHIS for a complex sample design such as Sample Adult Questionnaire except in that of NHIS (6). All estimates for Relative standard error
rare cases where sample adults are adults were weighted, using the sample physically or mentally incapable of Estimates with a relative standard adult record weight, to represent the responding for themselves. Interviews error of more than 30% but less than or U.S. civilian, noninstitutionalized are conducted in the home using equal to 50% are identified with an population aged 18 years and over. computer-assisted personal interviews, asterisk (*). Estimates with a relative For this analysis, the number of or CAPI, with telephone interviewing standard error of greater than 50% are visits to a CAM provider was calculated permitted for follow-up, if necessary. indicated with a dagger (†) and are not using the midpoint of the interval Starting in 2006, the sample design shown. The relative standard errors are containing the number of visits. These included Asian persons in the NHIS intervals were 2–5 times, 6–10 times, oversampling of minority populations; 11–15 times, and 16–20 times. For Relative standard error (as a previously, only households with black response categories of only ‘‘one time'' percentage) = (SE/Est) 100, and Hispanic persons were oversampled. and ‘‘more than 20 times,'' the values of The sample adult selection process was where SE is the standard error of the 1 and 21, respectively, were used. To also revised in 2006 so that when black, estimate and Est is the estimate. estimate the out-of-pocket costs per visit Hispanic, or Asian persons aged 65 and the costs for purchasing years or older were present, they had an Definition of terms
homeopathic medicine, relaxation increased chance of being selected as technique materials, and yoga, tai chi, These definitions were used in the the sample adult. and qigong classes, the continuous 2007 NHIS and may not reflect existing of $0–$499 were retained and evidence on safety, efficacy, or the response of ‘‘$500 or more'' was possible mechanisms of action. In 2007, NHIS interviews were treated as $500. To estimate how often Acupuncture—A family of completed in 29,266 households, which nonvitamin, nonmineral, natural procedures involving stimulation of yielded 75,764 persons in 29,915 products and homeopathic medicine anatomical points on the body by a families; the household response rate were purchased, the respondent's variety of techniques. American was 87.1%. The sample adult original answer of times per day, week, practices of acupuncture incorporate questionnaire was completed by 23,393 or month was converted into times per medical traditions from China, Japan, persons aged 18 years and over. The year. The number of times a person took Korea, and other countries. The final response rate (which takes into a yoga, tai chi, or qigong class was acupuncture technique that has been account household and family calculated by using the midpoint of the most studied scientifically involves nonresponse) for the 2007 sample adult interval containing the number of times penetrating the skin with thin, solid, file was 67.8%. Procedures used in the person took a class. These intervals metallic needles that are manipulated by calculating response rates are described were 2–11 times per year, 2–3 times per the hands or by electrical stimulation. in detail in Appendix I of the Survey month, 2–3 times per week, and 4–6 Alexander technique—A movement Description, NHIS data files (5). times per week. Responses of daily, therapy that uses guidance and National Health Statistics Reports n Number 18 n July 30, 2009 education on ways to improve posture injured muscles, control asthmatic complete exhalation for a similar count. and movement. The intent is to teach a attacks, and relieve pain. The process may be repeated 5 to 10 person how to use muscles more Botanica—A traditional healer who times, several times a day. efficiently to improve the overall supplies healing products, sometimes Energy-healing therapy—The functioning of the body. Examples of associated with spiritual interventions. channeling of healing energy through the Alexander technique as CAM are CAM practitioner—Someone the hands of a practitioner into the using it to treat low-back pain and the knowledgeable about a specific CAM client's body to restore a normal energy symptoms of Parkinson's disease. health therapy who provides care or balance and, therefore, health. Energy Alternative provider or gives advice about its use. healing therapy has been used to treat a therapy—A chemical wide variety of ailments and health process in which a substance is used to about a specific alternative health problems, and is often used in bind molecules, such as metals or practice who provides care or gives conjunction with other alternative and minerals, and hold them tightly so that advice about its use, and who usually conventional medical treatments. they can be removed from a system, receives payment for his or her services. Espiritista—A traditional healer such as the body. In medicine, chelation For some practices, the provider may who assesses a patient's condition and has been scientifically proven to rid the have received formalized training and of excess or toxic metals. For herbs and religious amulets have been certified by a licensing board example, a person who has lead to improve physical or mental health or or related professional association. For poisoning may be given chelation to help overcome a personal problem. example, a practitioner of biofeedback therapy to bind and remove excess lead Feldenkreis—A movement therapy (biofeedback therapist) usually has from the body before it can cause that uses a method of education in received training in psychology and physical coordination and movement. physiology, and may be certified by the Chiropractic manipulation—A form Practitioners use verbal guidance and Biofeedback Certification Institute of of health care that focuses on the light touch to teach the method through relationship between the body's one-on-one lessons and group classes. Atkins diet—A diet emphasizing a structure, primarily the spine, and its The intent is to help the person become drastic reduction in the daily intake of function. Doctors of chiropractic, who more aware of how the body moves carbohydrates (40 grams or less), are also called chiropractors or through space and to improve physical countered by an increase in protein and chiropractic physicians, use a type of hands-on therapy called manipulation Guided imagery—A series of Ayurveda—A system of medicine (or adjustment) as their core clinical relaxation techniques followed by the that originated in India several thousand visualization of detailed images, usually years ago. In the United States, Complementary and alternative calm and peaceful in nature. When used Ayurveda is considered a type of CAM medicine (CAM)—Therapies not usually in treatment, a person is taught to and a whole medical system. As with taught in U.S. medical schools or visualize his or her body free of the other such systems, it is based on generally available in U.S. hospitals. specific problem or condition. Sessions theories of health and illness and on CAM therapies include a broad range of are typically 20 to 30 minutes in length ways to prevent, manage, or treat health practices and beliefs such as and may be practiced several times a problems. Ayurveda aims to integrate acupuncture, chiropractic care, and balance the body, mind, and spirit; relaxation techniques, massage therapy, Hierbero—A traditional healer or some view it as ‘‘holistic.'' This balance and herbal remedies. They are defined practitioner with knowledge of the is believed to lead to contentment and by the National Center for medicinal qualities of plants. Also health and to help prevent illness. Complementary and Alternative known as a yerbera. However, Ayurveda also proposes Medicine as a group of diverse medical Homeopathy—A system of medical treatments for specific health problems, and health care systems, practices, and practices based on the theory that any both physical and mental. A chief aim products not presently considered to be substance that can produce symptoms of of Ayurvedic practices is to cleanse the part of conventional medicine. disease or illness in a healthy person body of substances that can cause Curandero—A type of traditional can cure those symptoms in a sick disease, in the belief that this helps to folk healer. Originally found in Latin person. For example, someone suffering re-establish harmony and balance. America, Curanderos specialize in from insomnia may be given a Biofeedback—A method that uses treating illness through the use of homeopathic dose of coffee. simple electronic devices to teach clients supernatural forces, herbal remedies, and Administered in diluted form, how to consciously regulate bodily other natural medicines. homeopathic remedies are derived from functions, such as breathing, heart rate, Deep-breathing exercises— many natural sources, including plants, and blood pressure, to improve overall Exercises involving slow and deep metals, and minerals. health. Biofeedback is used to reduce inhalation through the nose, usually to a Hypnosis—An altered state of stress, eliminate headaches, recondition count of 10, followed by slow and consciousness characterized by increased National Health Statistics Reports n Number 18 n July 30, 2009 responsiveness to suggestion. The include herbs or herbal medicine (as training is required. These techniques hypnotic state is attained by first single herbs or mixtures), other can be self-taught with the aid of books relaxing the body, then shifting attention botanical products such as soy or flax, or instructional videos, or learned from toward a narrow range of objects or and dietary substances such as enzymes an experienced practitioner. Once the ideas as suggested by the hypnotist or and glandular material. Among the most techniques are learned, a person requires hypnotherapist. The procedure is used to popular are echinacea, ginkgo biloba, no additional outside assistance unless effect positive changes and to treat ginseng, feverfew, garlic, kava kava, and improvement of skills is desired. numerous health conditions including saw palmetto. Garlic, for example, has Shaman—A traditional healer who ulcers, chronic pain, respiratory been used to treat fevers, sore throats, is said to act as a medium between the ailments, stress, and headaches. digestive ailments, hardening of the invisible spiritual world and the physical Macrobiotic diet—A diet low in fat, arteries, and other health problems and world. Most gain knowledge through emphasizing whole grains and contact with the spiritual world and use vegetables and restricting the intake of Ornish diet—A high-fiber, low-fat the information to perform tasks such as fluids. Of particular importance is the vegetarian diet that promotes weight divination, influencing natural events, consumption of fresh, nonprocessed loss and health by controlling what is and healing the sick or injured. eaten, not by restricting the intake of Sobador—A traditional healer who Massage—Therapy involving the calories. Fruits, beans, grains, and uses massage and rub techniques in manipulation of muscle and connective vegetables can be eaten at all meals, order to treat patients. tissue to enhance function of those while nonfat dairy products such as South Beach diet—A diet that tissues and promote relaxation and skim milk, nonfat cheeses, and egg distinguishes between ‘‘good'' and whites are to be consumed in ‘‘bad'' carbohydrates and fats. ‘‘Good'' Meditation—A group of techniques, moderation. Products such as oils, carbohydrates are those that are digested most of which started in Eastern avocados, nuts and seeds, and meats of relatively slowly, and ‘‘bad'' fats include religious or spiritual traditions, in which all kinds are avoided. saturated and trans fats. Although the a person learns to focus his or her Osteopathic manipulation—A program does not require a person to attention and suspend the stream of full-body system of hands-on techniques count calories or limit portions, dieters thoughts that normally occupy the mind. to alleviate pain, restore function, and are encouraged to eat whole-grain foods This practice is believed to result in a promote health and well-being. and an abundant amount of vegetables. state of greater physical relaxation, Pilates—A movement therapy that Tai chi—A mind-body practice that mental calmness, and psychological uses a method of physical exercise to originated in China as a martial art. A balance. Practicing meditation can strengthen and build control of muscles, person doing tai chi moves his or her change how a person relates to the flow especially those used for posture. body slowly and gently, while breathing of emotions and thoughts in the mind. Awareness of breathing and precise deeply and meditating; the practice is Native American Healer/Medicine control of movements are integral sometimes called ‘‘moving meditation.'' Man—A traditional healer who uses components of Pilates. Special Many practitioners believe that tai chi information from the ‘‘spirit world'' in equipment, if available, is often used. helps the flow throughout the body of a order to benefit the community. People Pritikin diet—A low-fat diet that proposed vital energy called ‘‘qi.'' A see Native American healers for a allows meat but emphasizes the person practicing tai chi moves his or variety of reasons, especially to find consumption of foods with a large her body in a slow, relaxed, and relief or a cure from illness or to find volume of fiber and water, including graceful series of movements. The spiritual guidance. many vegetables, fruits, beans, and movements, performed alone or in a Naturopathy—An alternative natural, unprocessed grains. Also known group, make up what are called forms, medical system that proposes that a as Pritikin Principle. healing power in the body establishes, Traditional healer—Someone who maintains, and restores health. used to relieve tension and stress by employs any one of a number of ancient Practitioners work with the patient with systematically tensing and relaxing medical practices that are based on a goal of supporting this power through successive muscle groups. indigenous theories, beliefs, and treatments such as nutrition and lifestyle Qigong—An ancient Chinese experiences handed down from counseling, dietary supplements, discipline combining the use of gentle generation to generation. The methods medicinal plants, exercise, homeopathy, physical movements, mental focus, and employed by each type of traditional and treatments from traditional Chinese deep breathing directed toward specific healer have evolved to reflect the parts of the body. Performed in different philosophical backgrounds and Nonvitamin, nonmineral, natural repetitions, the exercises are normally cultural origins of the healer. products—Products taken orally that performed two or more times a week for Trager Psychophysical contain a dietary ingredient intended to 30 minutes at a time. Integration—A movement therapy in supplement the diet with other than Self-care therapies—Forms of CAM which practitioners apply a series of vitamins and minerals. Examples that a person can perform alone, even if gentle, rhythmic rocking movements to National Health Statistics Reports n Number 18 n July 30, 2009 the joints. Practitioners also teach physical and mental self-care exercises to reinforce the proper movement of the body. The intent is to release physical tension and increase the body's range of motion. An example of Trager Psychophysical Integration as CAM is using it to treat chronic headaches. Vegetarian diets—Diets that are totally devoid of meat, red or white. However, numerous variations are followed on the nonmeat theme. For example, some vegetarian diets are restricted to plant products only, while others may include eggs and dairy products. Another variation limits consumption to raw fruit, sometimes supplemented with nuts and vegetables. Others prohibit alcohol, sugar, caffeine, or processed foods. Yerbera—See hierbero. Yoga—A practice that combines breathing exercises, physical postures, and meditation to calm the nervous system and balance body, mind, and spirit. Usually performed in classes, sessions are conducted once a week or more and roughly last 45 minutes. Zone diet—A diet in which each meal consists of a small amount of low-fat protein, fats, and fiber-rich fruits and vegetables. Its basic goal is to alter the body's metabolism by controlling the production of key hormones. National Health Statistics Reports n Number 18 n July 30, 2009 Suggested citation
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National Center for Health Statistics
Nahin RL, Barnes PM, Stussman BJ, Bloom All material appearing in this report is in the B. Costs of complementary and alternative public domain and may be reproduced or Edward J. Sondik, Ph.D. medicine (CAM) and frequency of visits to copied without permission; citation as to Acting Co-Deputy Directors CAM practitioners: United States, 2007. source, however, is appreciated. Jennifer H. Madans, Ph.D. National health statistics reports; no 18. Michael H. Sadagursky Hyattsville, MD: National Center for Health Statistics. 2009. U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Disease Control and Prevention POSTAGE & FEES PAID National Center for Health Statistics Hyattsville, MD 20782 OFFICIAL BUSINESS PENALTY FOR PRIVATE USE, $300 To receive this publication regularly, contact the National Center for Health Statistics by calling 1–800–232–4636 E-mail: cdcinfo@cdc.gov Internet: http://www.cdc.gov/nchs DHHS Publication No. (PHS) 2009–1250 CS204734-C T34740 (07/2009)

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Ronald: A Domain-Specific Language to study the interactions between malaria infections and drug T. Antao and I. Hastings Liverpool School of Tropical Medicine Department of Computer Science University of Liverpool University of Liverpool Abstract Malaria kills more than 1 million peo- domain, they are more expressive and easier to ple a year, mostly children in sub-Saharan Africa.

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