Patient Attitudes Toward Acupuncture in the Perioperative Setting

Abstract

Introduction:

Acupuncture is a potential treatment option for pain, nausea, vomiting, anxiety, and agitation in the perioperative period. Patient preference for participating in acupuncture in the perioperative period is not well understood. The aim of this study was to quantify patient interest in perioperative acupuncture, explore the relationship between acupuncture interest, insurance coverage and patient cost, and identify clinical factors associated with patient interest in acupuncture.

Materials and Methods:

Adult patients evaluated in the Preoperative Evaluation Clinic at the Mayo Clinic in Phoenix, AZ, between June 2019 and July 2019, received a voluntary survey to assess their attitudes toward receiving acupuncture in the perioperative period. Patient interest in acupuncture to help treat pain, anxiety, and postoperative nausea and vomiting, as well as their willingness to pay for such services, were assessed. Demographic data, American Society of Anesthesiologists (ASA) physical class, scheduled procedure, and insurance coverage were extracted from the medical record. Univariate analysis was performed to estimate interest in acupuncture.

Results:

Three hundred and seven respondents were included in this study with a response rate of 60.4%. A total of 68.4% of study participants were interested in receiving perioperative acupuncture. Of those interested in acupuncture, 86.7% were interested if acupuncture was offered at no cost (either free or fully covered by insurance). A total of 47.1% of those patients interested in acupuncture would be interested if the cost of acupuncture was between 20 and 50 U.S. dollars. A total of 8.6% would be interested in acupuncture if patients were expected to pay the full cost of treatment (estimated 175 U.S. dollars). Age, sex, ASA status, type of surgery, risk of procedure, and Medicare/Medicaid coverage were not statistically associated with interest in acupuncture.

Conclusions:

When there is little to no direct cost to the patient, the majority of patients are interested in acupuncture in the perioperative period.

Introduction

Acupuncture is a traditional Chinese medicine modality involving the insertion of thin, solid bore needles into the skin at precise locations for the purpose of balancing energy to affect symptoms, including pain, nausea, and anxiety.¹ Acupuncture has been an effective management strategy for many types of pain² and has been suggested as a readily available, scientifically supported, and safe strategy for combating the opioid epidemic.³ In the perioperative setting, a 2016 systematic review demonstrated reduced opioid requirement and improved pain with the acute use of acupuncture and acupuncture-related therapies.⁴

Although acupuncture has been included in clinical guidelines for nonpharmacologic management of pain,⁵ the American Pain Society guidelines for management of postoperative pain found insufficient data to recommend for or against its use in this setting.⁶ Notably, adverse events (AEs) with acupuncture are rare, generally minor, and are reduced when performed by well-trained licensed acupuncturists.^7,8

Patient preference for participating in acupuncture in the perioperative period is not well understood and has mostly been explored in postoperative nausea and vomiting (PONV).^9,10 Although there is some evidence that patient expectations and preference for acupuncture in other settings can predict clinical response, associations have been inconsistent in the literature.^11,12 As acupuncture has not been routinely included in perioperative clinical pathways, it is important to assess patient interest in the perioperative setting as it may assist with predicting future acceptance and viability.

The understanding of patient preference for acupuncture may be even more important in relationship to cost of and coverage for acupuncture services. Better insurance coverage was associated with doubling of interest in acupuncture in more than 600 patients with cancer seen in a multisite cohort.¹³ On a system-wide scale, the coverage for acupuncture services is frequently changing, inconsistent, and quite variable,¹⁴ although Medicare has recently expanded its coverage for limited indications.¹⁵ Patients' willingness to pay for the therapy as part of their care will likely also contribute to institutions' interest in and feasibility of providing the service.

The aim of this study was to quantify patient interest in perioperative acupuncture. The authors also sought to explore the relationship between acupuncture interest, insurance coverage, and patient cost, as well as identify factors associated with patient interest in acupuncture.

Materials and Methods

This study was approved by the Mayo Clinic Institutional Review Board as exempt and an HIPPA authorization waiver was approved in accordance with applicable HIPAA regulations. In a convenience sampling, all patients who were evaluated in the Preoperative Evaluation Clinic at the Mayo Clinic in Phoenix, AZ, between June 2019 and July 2019, were eligible for this study. Inclusion criteria included age ≥18 years old and being English-speaking. These patients were provided a voluntary, cross-sectional, nonweb-based survey to assess their attitudes toward acupuncture in the perioperative period.

The survey consisted of two items to evaluate interest in acupuncture to help treat pain, anxiety, and PONV, and willingness to pay for such services (Supplementary Data S1). The survey was generated by a multidisciplinary team considering patient acceptance, and staff and clinic workflow, and ease of administration. The electronic medical record was used to extract demographic data, American Society of Anesthesiologists (ASA) physical status class, scheduled procedure, outpatient surgery status, and type of insurance coverage. Surgical procedure was categorized as low-, intermediate-, or high-risk procedures using the stratification outlined by Fleisher et al.¹⁶ Participants fully completed all surveys, and data entry was performed by a study assistant and confirmed by a second study assistant. Data were deidentified and stored in an encrypted database using REDCap. This study adheres to the Checklist for Reporting of Survey Studies (Supplementary Data S2).

Statistical analysis

Descriptive statistics summarized demographic and clinical characteristics of the cohort. Median (interquartile range) was calculated for continuous variables with the Kruskal–Wallis rank sum test for the comparison. Count and frequency were calculated for categoric variables, with chi-squared or Fisher's exact test being applied. Univariate logistic regression was used to investigate the association between the interest in acupuncture and patient demographics and clinical characteristics. The analysis was conducted by R studio 3.6.2. All tests were two sided, and a p-value <0.05 was considered statistically significant.

Results

During the study period, 307 patients agreed to participate in the study, out of a potential 508 patients who were seen in the clinic, with a response rate of 60.4%. The median (interquartile range) age of respondents was 64 years (54–71), with the majority identifying as Caucasian. A total of 78.2% of the patients were scheduled for intermediate-risk surgery and 34.5% were scheduled for ambulatory surgery. A total of 46.4% were insured by Medicare/Medicaid.

In this study, 68.4% of respondents were interested in acupuncture. There were no significant differences in demographic or procedure characteristics in those patients who were interested in acupuncture and those who were not (Table 1). There was also no significant difference in Medicare/Medicaid coverage in those who were interested in acupuncture compared with those who were not (45.0% vs. 49.5%, p = 0.54).

Table 1.

Descriptive Analysis of Patient Demographics and Clinical Characteristics by Interest in Acupuncture

	Not interested in acupuncture (N = 97)	Interested in acupuncture (N = 210)	Total (N = 307)	p
Age, years, median (IQR)	65.00 (56.00, 73.00)	63.50 (53.25, 70.00)	64.00 (54.00, 71.00)	0.17^a
Gender, n (%)				0.27^b
Female	45 (46.4)	112 (53.3)	157 (51.1)
Male	52 (53.6)	98 (46.7)	150 (48.9)
Race, n (%)				0.57^b
African American	2 (2.2)	3 (1.5)	5 (1.7)
American Indian/Alaskan Native	0 (0.0)	2 (1.0)	2 (0.7)
Asian	3 (3.2)	5 (2.5)	8 (2.7)
Hispanic or Latino	1 (1.1)	0 (0.0)	1 (0.3)
Caucasian	87 (93.5)	188 (94.9)	275 (94.5)
Ethnicity, n (%)				0.14^b
Hispanic or Latino	10 (10.4)	11 (5.3)	21 (7.0)
Not Hispanic or Latino	86 (89.6)	195 (94.7)	281 (93.0)
ASA physical status class, n (%)				0.38^b
1	5 (5.2)	11 (5.4)	16 (5.4)
2	50 (52.1)	121 (59.6)	171 (57.2)
3	38 (39.6)	69 (34.0)	107 (35.8)
4	3 (3.1)	2 (1.0)	5 (1.7)
Risk of procedure, n (%)				0.74^b
Low	21 (21.6)	38 (18.1)	59 (19.2)
Intermediate	74 (76.3)	166 (79.0)	240 (78.2)
High	2 (2.1)	6 (2.9)	8 (2.6)
Type of surgery, n (%)				0.46^c
Cardiac	0 (0.0)	1 (0.5)	1 (0.3)
Colonoscopy	1 (1.0)	0 (0.0%)	1 (0.3)
Otolaryngology	10 (10.3)	17 (8.1)	27 (8.8)
General	14 (14.4)	44 (21.0)	58 (18.9)
Gynecologic	2 (2.1)	8 (3.8)	10 (3.3)
Neurosurgery	9 (9.3)	10 (4.8)	19 (6.2)
Orthopedic	27 (27.8)	67 (31.9)	94 (30.6)
Spine	10 (10.3)	23 (11.0)	33 (10.7)
Urology	22 (22.7)	36 (17.1)	58 (18.9)
Vascular	2 (2.1)	4 (1.9)	6 (2.0)
Outpatient surgery, n (%)	39 (40.6)	63 (31.5)	102 (34.5)	0.15^b
Medicare/Medicaid visit coverage, n (%)	48 (49.5)	94 (45.0)	142 (46.4)	0.54^b

Kruskal–Wallis rank sum test.

Fisher's exact test.

Pearson's chi-squared test.

ASA, American Society of Anesthesiologists; IQR, interquartile range.

Of the patients who were interested in acupuncture, 86.7% would consider acupuncture if acupuncture was offered at no cost to the patient (either free or covered by their insurance). If the cost of acupuncture was between 20 and 50 U.S. dollars, 47.1% of the patients interested in acupuncture would consider acupuncture (Table 2). If full payment for the cost of acupuncture was required (estimated at 175 U.S. dollars), only 8.6% would be interested in receiving acupuncture.

Table 2.

Descriptive Analysis of Patient Financial Coverage by Interest in Acupuncture

	Interested in acupuncture (N = 210)	Total (N = 307)	p
Covered by insurance or free to patient, n (%)	182 (86.7)	182 (59.3)	<0.001^a
Cost between $20 and $50, n (%)	99 (47.1)	99 (32.2)	<0.001^a
100% out of pocket, n (%)	18 (8.6)	18 (5.9)	0.001^a

Fisher's exact test.

Univariate logistic regression was performed on the patients who were scheduled for general, orthopedic, otolaryngology, spine, and urology surgery, as these types of surgeries had the most frequent occurrence in the study population. For this subset of patients, the strength of association between interest in acupuncture and patient characteristics was measured (Table 3). None of the factors examined had significant effect on the interest in acupuncture (p-value >0.05).

Table 3.

Univariate Analysis of Interest in Acupuncture for Patients with General Surgery, Otolaryngology, Spine, Urology, and Orthopedic Surgery

	OR (95% CI)	Overall p-value
Age	0.98 (0.96–1.00)	0.09
Gender (male vs. female)	0.77 (0.46–1.30)	0.33
ASA physical class ≥3 vs. <3	0.80 (0.47–1.37)	0.41
Low risk of procedure (yes vs. no)	0.93 (0.49–1.80)	0.81
Type of surgery (orthopedic surgery is the reference group)
General surgery	1.27 (0.61–2.73)	0.51
Otolaryngology	0.69 (0.28–1.73)
Spine	0.93 (0.40–2.27)
Urology	0.66 (0.33–1.32)
Coverage Medicare/Medicaid (yes vs. no)	0.84 (0.50–1.41)	0.51

CI, confidence interval; OR, odds ratio.

Although men were less likely to have interest in acupuncture when compared with women, with an odds ratio (95% confidence interval) of 0.77 (0.46–1.29), this did not reach statistical significance (p-value = 0.33). Factors such as ASA physical status class, risk of procedure, type of surgery, and eligibility for Medicare/Medicaid coverage were not associated with the level of interest in receiving acupuncture (p > 0.05).

Discussion

Acupuncture is an attractive treatment option for pain, nausea, vomiting, anxiety, and agitation in the perioperative period, given its low cost, safety profile, and efficacy. While these postoperative issues are typically treated with pharmacologic approaches, these medications have limitations and unintended side effects. For example, the use of opioids for management of postoperative pain was associated with a 9.1% prevalence of AEs, associated with increased costs, extended length of hospitalizations, and higher risk of death.¹⁷ Even opioid-sparing pharmacologic techniques, such as perioperative gabapentin, can have undesired side effects such as sedation and respiratory depression.¹⁸ Antiemetics, such as promethazine, prochlorperazine, and haloperidol, can also be sedating and therefore, may be of limited utility in the postoperative period.

Furthermore, in the setting of an opioid epidemic, in which 6% of opioid-naive patients who receive opioids postoperatively will become chronic opioid users,¹⁹ there is an urgent need for safe, well-tolerated, opioid-sparing techniques and multimodal analgesia. Integration of acupuncture perioperatively may be a reasonable option in the cadre of clinical tools needed to address these issues.

Patient interest in acupuncture is poorly understood. One study of patients in cancer treatment demonstrated greater preference for acupuncture over analgesic medication pain management.²⁰ The patients in this study expressed a high interest in acupuncture as a treatment modality for pain, nausea, and anxiety in the perioperative period. To the authors' knowledge, this is the first time that patient interest has been quantified in surgical patients and identifies a potential area for the inclusion of integrative medicine in the perioperative period. Furthermore, this high interest existed even without an explanation of the potential benefits or mechanisms of perioperative acupuncture.

Not surprisingly, patient interest in acupuncture correlated with cost to patient, with the highest interest if acupuncture was covered by insurance or free to the patient. In addition, 8.6% of the patients in this study who were interested in acupuncture were willing to pay the full charge out of pocket (175 U.S. dollars). While this is the minority of surveyed patients, this percentage extrapolated across more than 48 million surgical procedures performed each year in the United States^21,22 could represent a large number of patients (>4 million) interested in and willing to fully pay for acupuncture treatments. Participation and payment for acupuncture by 8–9% of patients who are willing to bear the full cost have the potential to make offering acupuncture financially viable.

In this study, there was no difference in acupuncture interest based on whether the patient was undergoing a high- or low-risk procedure, nor was there a difference in those having a procedure that would require inpatient hospitalization compared with outpatient procedures. Although the authors postulated that patients undergoing high-risk procedures would likely have more comorbidities and therefore would be more open to treatments with fewer side effects such as acupuncture, this was not supported by this study. Patient preference for acupuncture may be related more to previous experience with acupuncture and other integrative medicine treatments, as well as a desire to avoid opioids and other medications, rather than the risk of the procedure.

Furthermore, the risk assessment used in this study was based on cardiac risk. As the risk of surgery does not necessarily predict postoperative pain or need for pain medication, this may explain why it was not associated with acupuncture interest. Patients who have had negative side effects from opioids or other medications may be more interested in acupuncture as an alternative or adjunct treatment, and future studies should explore this issue. The authors also postulated that a surgery requiring hospitalization may be more painful than an outpatient procedure; however, that may not be true.

Furthermore, patients who require hospitalization will have greater access to opioids and acute pain management, including the option of intravenous opioids if needed, whereas those with outpatient procedures will have more limited access and options. Providers might consider increasing access to acupuncture in both inpatient and outpatient settings. Those in the hospital might have expanded access for repeated treatments by an acupuncturist. Both inpatients and outpatients could use acupuncture to limit medication use and the potential AE from medications. While these data do not specifically tease apart what types of surgical patients would most prefer acupuncture, they highlight important directions for future studies to explore.

Limitations

A limitation of this study is that participation was voluntary and performed as a survey without clear expectation for intervention. Patients who have a higher interest in acupuncture and nonpharmacologic treatments may have elected to participate in the study. The generalizability of this study may be limited as the study participants tended to be older, were predominantly Caucasian, and were seen at a single institution. Another limitation is that the survey provided participants with a range of payments to choose from and they were not able to assign their own monetary value to the service.

Thus, the authors are unable to determine an exact value for acupuncture from the patient perspective. Participants who were not interested in acupuncture were not probed further to understand why they were not interested—if it was a concern of cost, efficacy, side effects, previous negative experience with acupuncture, or lack of knowledge about acupuncture. Furthermore, they were not able to elucidate if uninterested respondents would be interested if they could learn more information about the potential benefits of acupuncture in this setting.

Conclusions

This study suggests that a majority of patients may be interested in acupuncture in the perioperative setting. This interest is higher when there is little to no cost to the patient and decreases as the cost to the patient increases. Future studies are needed to explore what patient barriers exist regarding acupuncture as an adjunct in the perioperative setting.

Footnotes

Authors' Contributions

M.W.H. and D.M.M. were involved in the study conception, study design, data analysis, and article writing. L.N.B. was involved in data collection, article review, and editing. L.M. and J.Q. were involved in formal data and article writing. All authors were involved in editing and approval of the article before submission.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Data S1

Supplementary Data S2

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