Herbal Remedies and HMO Patients

It has been estimated that up to 80% of the world's population routinely uses some form of herbal medicine. Although the popularity of such remedies is not as high in the United States, studies have shown that the use of herbal medicine in the U.S. in clearly on the rise. One well-known study found that herbal medicine usage in the United States increased 500% between 1990 and 1997; another reported estimated that one-third of the nation's adults routinely used herbal remedies.^1,2

While several studies have examined the use of alternative medicine in general, few have specifically examined the use of herbal remedies. As a result, little is know about the specific use of (and experience with) herbal medicine by the general population; even less is known about patients in managed care organizations.

To determine how managed care patients use herbal medicine, researchers conducted a survey of patients belonging to a health maintenance organization in Brazos County, Texas. A total of 159 patients completed the surveys, which were distributed at the offices of physicians who belonged to the HMO. Of those, 135 surveys were deemed "usable" and compiled into a study, the results of which appeared in a recent issue of the Journal of the American Pharmacological Association.³

Among the study's findings:

• More than a third of all managed care patients (37.8%) reported using herbal remedies. They used an average of 2.5 different remedies and consumed those remedies an average of 4.9 times in the past 12 months.
• Nearly half of those taking herbal remedies (48.9%) indicated they had sufficient knowledge of the safety, effectiveness and dosage of garlic. Other remedies with which herbal users appeared knowledgeable included aloe gel and cranberry (37.8% each) and echinacea (31.1%). Patients appeared least knowledgeable about feverfew and milk thistle (2.2% each).
• More than 60% of the respondents took herbal remedies in place of prescription or over-the-counter medications; another 19.1% used herbals in conjunction with those medications. Most (61.7%) used herbals to treat a health condition, but an almost equal percentage used them for general health maintenance.
• When asked what health conditions were treated with herbal remedies, the common cold was cited most frequently (51.0%). Almost one-fourth of patients said they took herbals to reduce stress anxiety; another 20.4% used them to lose weight.
• More than two-thirds (69.4%) of respondents believed herbal remedies were safe, even though a nearly equal amount of people indicated they didn't know whether commercial preparations were "dependable" in terms of strength and quality.
• Surprisingly, many people taking herbals didn't consider health professionals particularly helpful in providing information. The two most "useful" sources of information on herbal remedies, according to the respondents, were the popular media (39.0%) and friends/relatives (34.1%). Only 26.8% of herbal users regarded "other sources" (herbologists, the Internet, medical books and journals) as useful.
• An overwhelming percentage of users did not discuss the use of herbal therapies with either their physician or pharmacist (85.7% and 95.8%, respectively). Similarly, most herbal users (90%) supervised their own use of herbal remedies.
• Most patients (64.7%) spent less than $25 per month on herbal remedies. However, 15.8% spent at least $25 per month; 4% spent more than $50 on herbal remedies monthly.

Better Communication Needed on All Sides

Of all the trends that emerged from the study, perhaps the most disconcerting was the way herbal products were being used by patients without informing their health care provider. The fact that a majority of patients reported using herbal remedies instead of (or in conjunction with) prescription or over-the-counter medications, coupled with the fact that very few patients discussed the use of herbals with their health practitioner, revealed an increased risk of adverse events and unwanted drug-herb interactions that could otherwise be avoided if the level of communication were greater between patient and practitioner.

"It is apparent that those who used herbal remedies exclusively had made a conscious decision not to use prescription or OTC medications," the authors remarked. "· Moreover, although respondents were unsure of the quality of herbal remedies, they still felt that these products were safe and somewhat effective. Taken together, these findings signal a potentially dangerous situation."

The results of the study could also have great significance in the way acupuncturists and doctors of Oriental medicine interact with HMO patients. As more health plans and managed care groups begin incorporating acupuncture and Oriental medicine into their coverage, it follows that these practitioners will begin seeing more managed care patients, including those that belong to HMOs. Knowing how and why those patients use herbal medicines in advance, in addition to improving the lines of communication, could affect how herbal remedies are consumed and help reduce adverse events from occurring.

Given this information, the authors suggested that providers "should be routinely asking patients about their use of alternative therapies in order to obtain a valid and complete representation of each patient's therapies, to help patients make informed decisions about treatment, and to effectively monitor drug therapy outcomes."

References

1. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine in the United States, 1990-1997. JAMA 1998;280:1569-75.
2. Eliason BC, Kruger J, Mark D, et al. Dietary supplement users: demographics, product use, and medical system interaction. J Am Board Fam Prac 1997;10:265-271.
3. Bennett J, Brown CM. Use of herbal remedies by patients in a health maintenance organization. J Am Pharm Assoc 2000;40(3):353-358.