Super-Users at an Acupuncture and Oriental Medicine Teaching Clinic: Demographics and Unique Clinical Characteristics

Abstract

Objective:

The use of acupuncture in the United States has consistently grown over the last two decades, and the National Center for Complementary and Integrative Health has recently called for greater understanding of “real life outcomes and use” by complementary and alternative medicine users. This study assesses the demographics and utilization patterns of “super-users” treated at the Oregon College of Oriental Medicine intern clinic.

Methods:

This was a retrospective chart review at the Oregon College of Oriental Medicine (OCOM) intern clinic, a large acupuncture and oriental medicine (AOM) school in Portland, Oregon. Participants were patients who were treated 100+ times at the OCOM between August 6, 2002, and 2012. The outcome measures were demographic and treatment characteristics, including sex, age, chief complaint, income, medication use, and visit patterns.

Results:

The super-user cohort comprised approximately 1.5% of the total annual patient population and 8% of total visits at the OCOM in any given year, with an average treatment duration of 4 years from visit 1 to visit 100, and a visit frequency of 32 visits per year. Similar to other studies, the super-user cohort consisted predominantly of older, female patients seeking treatment primarily for pain (57.3%). Prescription medication use (45.2%) was also similar to other acupuncture cohorts. In contrast to typical AOM patients, OCOM super-users were older, with 64% being age ≥50 years when initiating treatment, and a majority reported low-income status (92%).

Conclusions:

Super-users represent a small yet real subset of AOM patients. They tend to be older, report lower income, and exhibit greater visit frequency than more typical AOM users. The factors motivating AOM super-user behavior may be different from those in other medical domains, notably emergency medicine, and likely include long-term management of chronic pain and other chronic conditions. Future studies into the long-term health outcomes of AOM super-users, as well as the economic impact on other health services, are warranted.

Introduction

In the National Center for Complementary and Alternative Medicine's Third Strategic Plan, 2011–2015, the National Center for Complementary and Integrative Health (NCCIH) prioritized the need to “increase understanding of ‘real world’ patterns of outcomes and complementary and alternative medicine (CAM) use, and its integration into health care and health promotion.”¹ Two of the specific aims it mentions are to “support survey and epidemiological research” and “develop research using observational, outcomes, health services and effectiveness research.”¹

Despite this, and given the dramatic increase in the use of acupuncture between 2002 and 2012 documented by the National Health Interview Survey (NHIS),^2

–6 there is a relative paucity of studies specifically describing patients who seek acupuncture.^{2,7

–14} Using data from the NHIS, Upchurch,^3,4 Burke,¹² and Yan Zhang² described some populations of Americans who use acupuncture, as well as the determinants and motivations that led people to seek treatment. Other studies have described the patient populations at acupuncture and oriental medicine (AOM) college clinics in Minnesota,⁸ Massachusettes,¹² and Oregon.¹⁴ Generally, these studies found that middle-aged, educated, and financially secure women were most likely to seek care with AOM, and that musculoskeletal conditions, particularly back pain, were the most common reasons for treatment.

There have been fewer studies comparing characteristics of distinct acupuncture-user cohorts.^9,10 Chao et al. compared populations of acupuncture users and described differences between those treated at community-style clinics and those from the 2007 National Institutes of Health sample.¹⁰ Their analysis found that almost half (48%) of “community acupuncture” users received ≥10 treatments in the past year. In contrast, less than one sixth (15%) of patients from the 2007 NHIS data had seen an acupuncturist >10 times in the previous year,⁵ a slight decrease from the 2002 NHIS data, which showed 17.8% receiving treatment at this frequency.¹² A pilot study by Lumiere et al.¹⁵ compared self-selected patients at three community acupuncture clinics in three different regions of the United States, and found similar patient demographics as the national data, with the exception of income level.

A 2011 study compared patients who received only one treatment in an AOM college teaching clinic within a single year to those received five or more treatments.⁹ The study found that female and older patients (M _age = 52 years) were more likely to return for at least five treatments, and the mean number of visits within a year for this cohort was 12.

Though most evidence suggests that the majority of acupuncture patients do not typically receive >10 visits a year,^7,10,13 anecdotal evidence suggests that a distinct cohort of acupuncture patients return with much greater frequency and for considerable stretches of time. Often termed “high-frequency users,” “super-utilizers,” or “super-users,” a literature review revealed only one study that reports on acupuncture super-users.¹⁶

The phenomenon of super-users has been explored in a number of medical domains, most frequently in emergency department care,^{17

–24} where the findings have initiated debate on whether super-users should be managed differently from the general population.^25,26 As a result, some healthcare systems are instituting changes to the way that emergency department care is delivered to this cohort.^27,28 The super-user phenomenon has also been studied in genito-urinary²⁹and psychiatric³⁰ domains, as well as drug rehabilitation.²²

In this study, characteristics for patients who received ≥100 treatments, “super-users,” at the teaching clinic of the Oregon College of Oriental Medicine (OCOM), an AOM college located in Portland, Oregon, are presented. Describing the differences and similarities between AOM super-users and typical users it is hoped that the treatment strategies that may be unique to this population, and the factors that may indicate why a patient returns for frequent extended acupuncture care, will be elucidated. Understanding these characteristics will assist practitioners, policy makers and healthcare institutions to improve treatment planning, policy, and marketing for the full spectrum of acupuncture patients, and ultimately improve health outcomes.

Materials and Methods

Clinic setting

A retrospective chart review was conducted at the OCOM intern clinic, a large AOM college located in Portland, Oregon. The clinic provides approximately 20,000 treatments and sees roughly 3400 patients annually. Slightly more than one-third of new patients report no experience with acupuncture prior to their first visit.¹⁴

Patient selection

Three methods were used to identify patients who received at least 100 treatments. First, a search query was performed in Medisoft, the electronic medical billing system utilized by the OCOM. Second, patient charts that consisted of multiple volumes were hand searched to determine the number of treatments the patients received. Finally, to capture archived patient visits, charts that had been removed for off-campus storage were retrieved and inspected.

Selected charts were reviewed and patients were included if they had received at least 100 treatments at the OCOM prior to August 6, 2012. Patients were excluded based on three criteria: (1) the patient was a student or staff of the college, (2) the patient had not received treatment since August 6, 2002, and (3) access to the complete chart was unavailable.

All patients included in analysis signed an informed consent that allowed their anonymized data to be used for research. Approval for the use of patient data for research was obtained from the OCOM Institutional Review Board.

Data collection and analysis

Three students in their final year of the OCOM master's program used a standardized template to abstract and enter data from the selected patient charts. Accuracy of the students' work was reviewed for the first three patients entered, and spot checked thereafter to assure data quality and consistency. The following variables were abstracted from the patients' charts: sex, age, chief complaint, income, frequency and duration of treatments, and medication use.

Results

A total of 188 charts were initially selected. Of these, 27 student/staff charts were excluded; 36 were excluded, as their last treatment was prior to August 6, 2002; 32 were excluded due to missing pages or volumes in the chart; and nine were excluded, as they did not meet the requisite 100-treatment threshold. A total of 84 charts were included in the final analysis (Fig. 1).

FIG. 1.

Exclusion criteria.

The cohort was predominantly female (79.8%; n = 67), with a mean age of 54.1 years (SD = 15.5 years; range 18–90 years). Roughly two-thirds (63%) were aged ≥50 years when initiating treatment, and the relative proportion of patients in each successive age bracket increased up to 60–69 years (Table 1). Musculoskeletal pain was reported as the chief complaint by 57.3% (n = 47) of super-users, followed by respiratory conditions (7.3%; n = 6), headaches or migraines (6.0%; n = 5), fatigue (4.9%; n = 4), and nervous system conditions (4.9%; n = 4). Thirty-eight super-users (45.2%) reported using medication for the chief complaint (Table 1). Of the 25 patients in the cohort who reported yearly income, the mean was $19,224 (SD = $9829; range $5100–$42,000; Table 1). The average treatment duration at visit 100 was 4.02 years (SD = 2.17), with a frequency of 32 (SD = 16.96) visits per year (Table 2). It is estimated that approximately 50 super-users were active in any given year, representing 1.5% of the total yearly patient population at the OCOM clinic and accounting for 8% of total yearly patient visits to the clinic.

Table 1.

Patient Characteristics of Super-Users at OCOM Teaching Clinic (n = 84)

Characteristic	n	%
Sex
Male	17	20.2
Female	67	79.8
Age, years
18–29	6	7.1
30–39	11	13.1
40–49	13	15.5
50–59	20	23.8
60–69	23	27.4
70+	11	13.1
M ± SD	54.1 (15.5)
Chief complaint^a
Musculoskeletal pain	47	57.3
Respiratory conditions	6	7.3
Headache or migraines	5	6.0
Fatigue	4	4.9
Nervous system conditions	4	4.9
Mental/emotional conditions	3	3.7
Gastrointestinal conditions	3	3.7
Women's health conditions	3	3.7
Other	3	3.7
Urologic conditions	2	2.4
Stress	1	1.2
Autoimmune	1	1.2
Medication for chief complaint
Yes	38	45.2
No	32	38.1
Unanswered/missing	14	16.7
Annual income^a
$0–9999	4	16.0
$10,000–19,999	12	48.0
$20,000–29,999	3	12.0
$30,000–39,999	5	20.0
$40,000–49,999	1	4.0
M ± SD	$19,224 ($9829)

Super-users are patients who return for ≥100 treatments.

Totals do not add up to 84 because of missing data.

OCOM, Oregon College of Oriental Medicine; SD, standard deviation.

Table 2.

Visit Characteristics of Super-Users at OCOM Teaching Clinic (n = 84)

Characteristic	n	%
Treatment duration at visit 100
0–1 year	1	1.2
1–2 years	9	10.7
2–3 years	22	26.2
3–4 years	19	22.6
4–5 years	10	11.9
5–6 years	9	10.7
6–7 years	5	6.0
7–8 years	4	4.8
>8 years	5	6.0
M ± SD	4.02 (2.17)
Yearly visit frequency
≥61 visits	3	3.6
49–60 visits	11	13.1
37–48 visits	15	17.9
25–36 visits	24	28.6
13–24 visits	26	30.1
0–12 visits	5	6.0
M ± SD	32 (16.96)

Super-users are patients who return for ≥100 treatments.

Discussion

The analysis presented here is the first to define acupuncture super-users and to describe comprehensively the unique clinical characteristics of this cohort. The study found that super-users comprised approximately 1.5% of the total annual patient population and 8% of total visits at the OCOM in any given year, with an average treatment duration of 4 years from visit 1 to visit 100, and a visit frequency of 32 visits per year. Similar to other studies reporting on more typical AOM patients, the super-user cohort consisted predominantly of female patients who sought treatment primarily for pain conditions.^7,8,10,13,14 Prescription drug use among super-users was also similar to those reported elsewhere.⁷ However, compared with acupuncture patients in other samples, the OCOM super-users were older: roughly 64% were aged >50 years when initiating treatment, while minorities were reported in more typical AOM patient samples.^7,13 Additionally, the average age of super-users was notably higher (54 years), while other samples report averages <50 years.^7,8,10,13,14 Also different from other studies, a vast majority of OCOM super-users (92%) reported an income <$35,000/year, while minorities reported a lower income in more typical acupuncture patient populations.^7,10

It is interesting to speculate as to why older patients are more likely to return for frequent, extended treatment in the context of AOM. Older patients typically suffer more chronic pain and other chronic health conditions,^31,32 and it is possible that these conditions are being self-managed with the incorporation of regular, long-term AOM. Furthermore, other studies suggest that a large majority of acupuncture patients typically receive no more than six visits.^2,7,13 However, many AOM treatment plans routinely call for considerably more treatments in order to be effective.^33,34 Future studies of AOM could analyze outcomes and completion rates by age group, and policy makers/administrators should consider that younger acupuncture patients may be less likely to complete extended treatment plans, minimizing positive outcomes.

It is also noteworthy that 64% reported incomes <$19,999, which is near the poverty line in Oregon for households of two to three people,³⁵ and nearly all (92%) of OCOM super-users reported an income <$35,000. Considering that AOM treatments in intern teaching clinics are low cost, it is not surprising that they would attract low-income patients in general, and likely explains why, by comparison, less than half of patients in the national sample reported a low income.⁷ The high percentage of low-income super-users suggests that for this subset of patients, the low cost of student AOM clinics represents a financially viable option for long-term management of chronic health challenges, particularly chronic pain.

The phenomenon of “super-users” has most frequently been studied in emergency departments (ED), where frequent use by patients for non-urgent care can increase costs and fragment treatment.¹⁷ In the ED setting, “super-users” (or high-frequency users) have been described as patients who return for 20+ ED visits in a 12-month period, while “frequent users” have been defined as four or more annual visits.^17,20,21 A 2013 study by LaCalle reported that high-frequency ED users accounted for 1.1% of all visits over a 12-month period, were most likely to be aged 30–59 years, were 52% female, and had at least one significant psychosocial cofactor.²⁰

Though some similarities can be drawn between ED and acupuncture super-users (i.e., age, sex, income status, and visit frequency), the overarching characterization of super-users between the two medical domains appears different and is worth highlighting. It has been suggested that ED super-users use a disproportionate amount of ED resources and increase costs.^21,33 In contrast, intern AOM teaching clinics are designed as low-cost health options, and support frequent, sustained care when appropriate. According to the OCOM clinic director, the low cost per treatment enables acupuncture super-users to pay out-of-pocket for long-term care and does not deplete clinic resources or increase overall costs (B. Alaskar, pers. commun., May 2016).

Another significant distinction between ED and AOM super-users involves the use of either treatment frequency or treatment volume to define the cohort. Unlike studies in the ED domain, which characterize super-users by annual visit frequency, the present study characterized AOM super-users by total treatment volume. While high-volume treatment in EDs may be problematic for a number of reasons,³³ adherence to prolonged and repeated AOM treatment is traditionally viewed as health promoting.^34,36,37

Acupuncture patients who return for care, not just frequently but for prolonged time periods, are potentially engaged in long-term management of chronic conditions and/or are seeking to improve or sustain overall wellness. Future research could explore whether super-user behavior in AOM and similar medical domains such as massage or PT is minimizing the drain on other healthcare resources in the community, including EDs.

Limitations

The limitations of this analysis include a variety of factors that may not reflect real-world situations, including a bias sample gathered at a single teaching institution. Additionally, due to limitations in the collection of patient data at the OCOM, a significant amount of demographic data was missing or unavailable for this retrospective review, including race/ethnicity, education, employment status, marital status, and health insurance, all of which may have had added depth to the final results.

Future directions

This study reveals that there is a small subset of patients who return for frequent, extended AOM treatment, often for many years. This finding suggests that AOM super-user behavior is potentially driven by a number of factors, including chronic condition management, wellness/QOL maintenance, and the low cost of AOM student health clinics. Given this, future research should explore a number of questions: What are the specific factors motivating AOM super-user behavior? Does AOM super-user behavior decrease usage, and the associated costs, of other health services, including emergency medicine? Are there measurable effects on chief complaints, well-being, or QOL in AOM super-users over time? Is super-user behavior present in settings outside of AOM college intern clinics, such as private practice?

Conclusion

Super-users, or those who return for 100+ treatments, represent a small yet real subset of AOM patients. They tend to be older, report lower income, and exhibit greater visit frequency than more typical AOM users do. The factors motivating AOM super-user behavior may be different from those in other medical domains, notably emergency medicine, and likely include long-term management of chronic pain and other chronic conditions. Further studies into the long-term health outcomes of AOM super-users, as well as the economic impact on other health services, are warranted.

Footnotes

Acknowledgments

The authors would like to thank Ronica Steel, Ramson Shabaz-Amasni, and Amara Narten for carefully abstracting data from patient charts, and Miranda Frear, MAcOM, LAc, for her many years of excellent data management as OCOM's clinic data coordinator.

Author Disclosure Statement

The authors declare that no competing interests exist.

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