Feasibility of Group Acupuncture Clinics at a Health Maintenance Organization

Abstract

Background:

Chronic pain remains a challenging clinical issue. The literature suggests that acupuncture may be effective for subsets of chronic pain patients. How to best integrate acupuncture into a conventional managed care program, however, remains a perplexing issue.

Objective:

The aim of this study was to evaluate patient satisfaction with acupuncture services provided on site at a health maintenance organization (HMO) in both individual and group settings.

Design, Setting, and Patients:

Retrospective telephone interviews were completed with 33 adult patients with chronic pain who received acupuncture in group or individual sessions.

Main Outcome Measures:

Participants were asked to rank their satisfaction with clinician, satisfaction with care received, level of overall clinical improvement, and advantages or disadvantages of the group setting. Quantitative analysis included descriptive statistics for fixed-choice and demographic data. Qualitative data analysis involved summarizing respondents' statements as well as identifying and summarizing themes for each open-ended question across all responders.

Results:

Chronic pain patients who received acupuncture were generally satisfied with the care they received. Patients reported improvements in quality of life and pain control.

Conclusions:

The findings suggest that there may be a potential role for group acupuncture clinics within conventional managed care networks.

Introduction

Chronic pain remains a challenging clinical issue for which conventional management is often inadequate.^1–3 The literature suggests that acupuncture may be effective for subsets of chronic pain patients.^4,5 How to best integrate acupuncture into a conventional managed care program, however, remains a perplexing issue. Referring acupuncture services to outside clinicians is a common practice, but this is associated with higher costs and raises concerns regarding clinical quality monitoring and inter-clinician communication.⁶ As such, managed care organizations (MCOs) may improve delivery of chronic pain care at less cost to patients and insurers by providing acupuncture as an internal service.

The benefits of providing acupuncture as an internal service can potentially be furthered by implementing acupuncture services within the context of a group clinic format.^7,8 Group acupuncture clinics are increasingly popular in the community, and other types of complementary and alternative medicine (CAM) services have previously been provided in the group setting within MCOs with documented success.⁹

The aim of this project was to evaluate patient satisfaction with acupuncture services provided on site at a health maintenance organization (HMO) in both individual and group settings.

Methods

Setting

Kaiser Permanente Northwest (KPNW) is an established HMO serving approximately 475,000 patients in the states of Oregon and Washington. Group acupuncture clinics were introduced at KPNW in 2007 on a trial basis to deliver efficient, high-quality care to chronic pain patients. In order to be eligible for acupuncture services, KPNW patients must show evidence of a chronic musculoskeletal pain syndrome for at least 3 months. In addition, there must be evidence in each patient's medical record that he or she has undergone an adequate trial of usual care prior to receiving approval for acupuncture coverage. Such usual care interventions will generally include medications (nonsteroidal anti-inflammatory drugs [NSAIDS], narcotics, muscle relaxants), physical therapy, and perhaps subspecialty referral.

Study Procedure

As many as 5 patients received treatment in the group setting. Patients did not disrobe and only distal acupoints were used. No curtains or dividers were used, offering patients the ability to interact with one another and learn self-care instructions provided to other patients. A total of 3 practitioners provided individual acupuncture services. One practitioner was a physician–acupuncturist and 2 were licensed acupuncturists (LAcs). One of the two LAcs provided the group acupuncture service.

Survey

Thirty-three telephone interviews were conducted with adult KPNW patients with back or neck pain who received acupuncture in group or individual sessions between April and December 2008. Approximately half (18/33) of the patients received acupuncture in a group setting. Demographic data (gender and age) and presenting diagnosis were extracted from the medical records. Participants were asked to rank their satisfaction on a scale of 1–4 (1 = lowest, 4 = highest). Open-ended survey questions included: satisfaction with clinician; satisfaction with care received; level of overall clinical improvement; and advantages or disadvantages of the group setting.

Potentially eligible participants were identified from clinic rosters through a chart review. The telephone questionnaire was administered after obtaining informed consent. Quantitative analysis included descriptive statistics for fixed-choice and demographic data. Qualitative data analysis involved summarizing respondents' statements as well as identifying and summarizing themes for each open-ended question across all responders.

The project and all study-related materials were approved by the KPNW institutional review board.

Results

Recruitment and Demographics

Originally, attempts were made to contact a total of 68 patients for this study. Of these patients, 36 were reached, and of that group, 33 agreed to participate. Table 1 describes the demographics of these study participants.

Table 1.

Demographics

	Appointment type (N = 33)
Variable	Group	Individual
	18	15
Gender
Female	13	7
Male	5	8
Age range
18–33	0	0
31–40	1	0
41–50	3	3
51–60	4	5
61–70	9	4
71+	1	3
Diagnosis
Low-back pain	10	7
Upper-back/neck/shoulder pain	8	7
Other	0	1 (knee pain)

Only 12 of these 33 patients had previous experience with acupuncture treatments prior to the index study visit.

Impressions Regarding On-Site Acupuncture at the HMO

All 33 interviewed participants liked having acupuncture available at KPNW. Patients reported that they found the service “convenient” and stated that they were pleased “because I didn't have to pay out of pocket for it.” In response to the question, “what did you like best about your visits?” the most frequent responses included improvements in a medical condition (n = 15) and time spent with the practitioner (n = 11). Overall satisfaction scores were mean 3.36/4 for care received, and 3.64/4 for satisfaction with clinician.

The majority of patients (25/33) stated their conditions improved with acupuncture treatment independent of treatment setting. The two most commonly reported improvements were decreased pain (n = 10) and increased quality of life (QoL; n = 7). One patient stated: “What I learned from acupuncture was how to manage the pain. It taught me how to let pain go.” Another shared that she had multiple sclerosis (MS) and that, prior to the acupuncture treatments, she needed assistance from her walker to walk and was in a great deal of pain. After her acupuncture treatments, she stated that she was able to walk without her walker. She said: “I was a person again. When I come in for acupuncture, I can be 10/10 for pain, but when I leave, I am 0/10 for 3 or 4 days.” Another patient said: “I'm more functional, I sleep better, everything is easier. Even driving is more comfortable.” Another patient who had been initially skeptical about acupuncture reported,“now I can lift my hands above my shoulders. I can wash my own hair again.”

More than half (n = 18) suggested that KPNW should expand availability of acupuncture.

Impressions Regarding Group Acupuncture

Among the 18 group acupuncture participants, 7 reported favorable impressions of the group setting, while 9 were neutral. Participants reported that the advantages of group acupuncture included increased clinical efficiency and flexible appointment length. One patient commented: “I didn't have to wait in the waiting room. I could just go right in,” while another noted that there “didn't seem like a time limit. … We could bring things to closure.” Participants also cited the company of other patients as another plus: “I kinda liked the company and not being so isolated,”one patient said. Another patient noted: “It was set up appropriately, so I did not notice the other people that much.”

Perceived disadvantages of group acupuncture included lack of privacy. One participant stated: “Partitions would feel better for privacy,” while another commented: “Because I had to undress, [it] might be OK depending upon what's going on.”Another patient concern focused on noise level. As one said: “Sometimes, the noise would be too much, it would interfere with relaxing.” Some participants expressed reservations about the demands placed on the practitioner, with one patient commenting that the acupuncturist “is spread thin and jumps back and forth.” Overall, patients receiving group acupuncture reported that they were generally satisfied with their care.

In contrast, patients who received acupuncture in an individual setting preferred to receive future care in an individual setting (12/15) and were uncomfortable with the group acupuncture concept. One patient expressed concerns about “exposing” herself, while another stated that she “doesn't see how it is possible” in a group setting. These patients thus seemed unable to envision the group acupuncture concept and expressed particular concerns about privacy issues.

Discussion

Chronic pain patients who received acupuncture at KPNW were generally satisfied with the care received and reported improvements in QoL and pain control. Those who received acupuncture in individual consultations expressed reservations about the group setting, perhaps because it was an unknown experience for them. Patients who actually received group acupuncture, however, were generally satisfied with their care. These results suggest good patient satisfaction with on-site acupuncture in the HMO setting.

Conclusions

This pilot study demonstrates that there may be a potential role for group acupuncture clinics within conventional managed care networks, although further evaluation and research are needed.

Footnotes

Acknowledgments

This work was funded by an Innovation Scholarship from Northwest Permanente.

Disclosure Statement

No competing financial interests exist.

This work was completed during graduate work at the Oregon College of Oriental Medicine, Portland, OR in collaboration with the team at Kaiser Permanente Northwest, Center for Health Research, Portland, OR.

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