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Acupuncture referrals in rural primary healthcare: a survey of general practitioners in rural and regional New South Wales, Australia
  1. Jonathan Lee Wardle1,2,
  2. David Sibbritt1,2,
  3. Jon Adams1,2
  1. 1Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
  2. 2Network of Researchers in the Public Health of Complementary and Alternative Medicine (NORPHCAM), Ultimo, New South Wales, Australia
  1. Correspondence to Dr Jonathan Lee Wardle, Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, 235–253 Jones Street, Ultimo, New South Wales 2007, Australia; jon.wardle{at}uts.edu.au

Abstract

Background Acupuncture services form a significant part of the Australian healthcare setting, with national registration of acupuncture practitioners, public subsidies for acupuncture services and high use of acupuncture by the Australian public. Despite these circumstances, there has been little exploration of the interface between acupuncture providers and conventional primary healthcare practitioners in rural and regional Australia.

Methods A 27-item questionnaire was sent by post in the second half of 2010 to all 1486 general practitioners (GPs) currently practising in rural and regional Divisions of General Practice in New South Wales, Australia to explore their practices and attitudes to a variety of complementary and alternative medicine (CAM) practices. Their responses on other therapies have been published previously; this report covers acupuncture.

Results A total of 585 GPs completed the questionnaire; 49 were returned as ‘no longer at this address’, resulting in an adjusted response rate of 40.7%. Two-thirds of GPs (68.3%) referred patients to an acupuncturist at least a few times per year, while only 8.4% stated that they would not refer patients to an acupuncturist under any circumstances. GPs being older (OR=6.08), GPs being women (OR=2.94), GPs practising in a rural rather than remote area (OR=6.25), GPs having higher levels of self-reported knowledge of acupuncture (OR=5.54), the use of complementary medicine (CAM) by a GP for their personal health (OR=2.37), previous prescription of CAM to other patients (OR=2.99), lack of other treatment options (OR=4.31) and GPs using CAM practitioners as the major source of their CAM information (OR=3.05) were all predictive of increased referral to acupuncture among rural GPs.

Conclusions There is a significant interface between acupuncture and Australian rural and regional general practice, with generally high levels of support for acupuncture.

  • ACUPUNCTURE
  • PRIMARY CARE
  • PUBLIC HEALTH
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Background

Complementary and alternative medicine (CAM) treatments—a diverse group of healthcare practices not considered part of conventional medicine1—are used in some form by the majority of Australians, with some studies suggesting visits to CAM practitioners account for up to half of all health consultations and that Australians have more out-of-pocket expenditure on CAM than conventional medicine.2 Acupuncture is a significant CAM discipline within the Australian healthcare setting, with high prevalence of public use when performed by medical and non-medical acupuncture providers.3 ,4 The acupuncture profession also forms an increasingly significant part of the Australian CAM practitioner sector. Acupuncturists are the third largest CAM profession in Australia after naturopaths and chiropractors, and the acupuncture profession is one of the fastest growing as well.5 ,6 This is perhaps largely unsurprising, given that Chinese medicine has a long history in Australia relative to other Western nations.7 However, acupuncture has remained a distinct discipline (separate from Chinese medicine), largely due to its popularisation by non-Chinese medicine trained professionals (such as chiropractors, naturopaths and medical practitioners) from the late 1960s onwards.8 Together, acupuncturists and Chinese medicine practitioners constitute 11% of the ‘primary-care capable’ non-medical CAM practitioner workforce in rural and regional Australia.5

In addition to their significant presence in terms of practitioner numbers, acupuncturists are being increasingly integrated into healthcare delivery in Australia, with non-medical acupuncturists recently being included in the Australian national registration scheme for health practitioners (as standalone acupuncture practitioners and Chinese medicine practitioners).9 Furthermore, acupuncture consultations—when performed by a medical practitioner—have been eligible for public subsidies (Medicare) since 1984.10 In this sense acupuncture is unique among CAM therapies in Australia in that it has significant levels of use by non-medical CAM practitioners as well as medical providers. The non-medical practise of acupuncture in Australia is not limited to those trained in Chinese medicine, and there is also significant acupuncture practise among other practitioner groups not traditionally associated with the practise in Australia, including chiropractors, naturopaths, osteopaths and physiotherapists.11

General practice is one branch of medicine where CAM is making an impact, with data from Australian studies demonstrating significant levels of referral from general practitioners (GPs) to CAM practitioners.12–14 The results of these surveys indicate a preference among GPs for referral to other GPs practising CAM therapies, rather than referral to non-medically trained CAM providers.14 There is also evidence of closer working relationships developing between CAM practitioners and GPs.12 ,15 However, support for CAM is not even, as different CAM therapies and practitioners attract varying levels of support from GPs.12 ,16

Prevalence rates of acupuncture use by the Australian public have been estimated to be between 4.2% and 9.2%.2–4 There also appear to be relatively high levels of support for acupuncture among the Australian GP community (at least in relation to other CAM therapies), with 84% of GPs rating acupuncture moderately or highly effective in a national survey, and 93% viewing it as an appropriate treatment for medical practitioners to use in practice.12 ,13 Such support appears to have translated into high referral levels to acupuncture practitioners—with a national surveys indicating 76% to 78% of GPs refer to an acupuncturist at least a few times per year12 ,13—as well as high levels of acupuncture practice by GPs, with national surveys indicating that 18% to 21% of GPs use the treatment in their clinical practice. Such support does not appear, however, to translate to high levels of referral to non-medical Chinese medicine practitioners.17 Additionally, despite high levels of support for acupuncture among the Australian GP population and rising acupuncture use among the Australian population, publicly reimbursed acupuncture services by GPs have steadily declined over the previous two decades.10

Recent research has also uncovered increased use of CAM by rural populations when compared to urban populations, in Australia and internationally.18 The presence of geographical variations in acupuncture use are less clear, with the previous Australian analyses not identifying significant difference in acupuncture use among middle-aged women from rural or urban areas.3 ,4 ,19 In one Australian study, prevalence of lifetime acupuncture use in an isolated rural region was found to be significantly lower than the national average, though still above 20%.20

These conflicting results may be due to variation in service providers in small communities. Analysis of Australian health insurance reimbursement data has also suggested that medical practitioners in rural areas are less likely to provide reimbursed acupuncture services than medical practitioners in urban areas, though pockets of high rural service provision do exist.10 Similarly, non-medical acupuncturists make up a significant part of the CAM primary care workforce in rural and regional New South Wales, though there was significant variation between areas, with acupuncturists ranging from between 4% and 42% of total CAM providers in individual rural Divisions of General Practice.5

The high level of integration of acupuncture in the Australian healthcare sector, relative to other CAM professions and therapies, has significant implications for general practice and healthcare delivery in rural and regional Australia, especially when viewed in the context of high use of these therapies in non-urban areas.21 However, despite the extensive presence of acupuncture and acupuncturists in these areas, and the significant interactions that appear to occur between acupuncture and conventional medical providers, there has been little research to date exploring the level of integration or the factors that underlie any integration of acupuncture in rural and regional general practice in Australia. This paper provides a first step in addressing this research gap by exploring practise and referral patterns of GPs in relation to acupuncture in rural and regional areas of Australia's largest state (New South Wales).

Methods

A 27-item questionnaire was mailed by post to all 1486 GPs registered as practising in rural and regional General Practice Divisions of NSW, with a reminder card sent after 2 months in the second half of 2010. The questionnaire was adapted for rural and regional use from previous Australian surveys of GP attitudes, use and practices of a variety of CAM practises.12 ,13 The survey was piloted at the Department of General Practice, School of Medicine and Public Health, University of Newcastle, with modifications made based on feedback to ensure the instrument was clinically relevant. GPs were asked about their knowledge, attitudes and practice, referral patterns to acupuncturists and about CAM use in their areas more generally.

The final survey questionnaire contained 27 items, which included multiple choice and multiple response close-ended questions. This paper reports referral to acupuncture; analyses of referral to other CAM professions have been reported previously.17 ,22 ,23 The survey had five general areas: the GPs’ assumptions on acupuncture use by patients in their area (eg, what proportion of patients GPs thought used acupuncture and the factors behind this use), the GPs’ personal use and knowledge of acupuncture, the GPs’ professional relationship with acupuncture practice and practitioners, the GPs’ information-seeking behaviours on acupuncture and the GPs’ specific opinions on acupuncture. GPs were also asked for demographic and practice information such as gender, age, number of years in practice, location of practice, number of patients seen per week and country of graduation. Acupuncture was specifically differentiated from Chinese medicine in the survey, with Chinese medicine defined as a system of medicine with acupuncture being defined as a specific therapeutic treatment (with definitions provided to GPs). Ethical approval for the study was obtained from the School of Population Health Research Ethics Committee of the University of Queensland (JW130508) and the Human Research Ethics Committee of the University of Newcastle (H-2008-0344).

Rural and regional areas were defined by their classification in the Rural, Remote and Metropolitan Area (RRMA) classifications.24 The RRMA classification categorises areas based on population and remoteness as large or small metropolitan (1, 2), large, small and other rural centres (3–5); and remote or other remote (6, 7). To minimise the effects of local variation, every rural and regional GP in Australia's largest state (New South Wales) was surveyed.

Questionnaire data was analysed using descriptive statistics via frequency distributions and crosstabulations. Demographic and practice characteristics of GPs who referred for acupuncture treatment often (at least monthly) and seldom or never were compared using χ2 tests. Logistic regression modelling, that included all practitioner and practice characteristics variables, was conducted using a backwards stepwise method of elimination using a likelihood ratio test, to parsimoniously predict referral to acupuncture treatment. Statistical significance was set at the α=0.05 level. Data were analysed using the software program STATA V.11.

Results

A total of 585 questionnaires were returned completed, with 49 questionnaires returned uncompleted as ‘no longer at this address’, giving a response rate of 40.7%. Respondents had an average age between 45 and 54 years and 53.5% were men. Over three-quarters of respondents (77.8%, n=456) had completed their medical training at an Australian university. Aside from a slight over-representation of women, the respondent profile was broadly representative of the GP community in the study area in relation to average age and training location.25

Referral rates of rural and regional GPs to acupuncturists are shown in table 1. Nearly one-quarter (22.7%, n=133) of GPs referred patients to an acupuncturist at least once per month, with a further 45.6% (n=267) referring patients a few times per year. Most GPs were either actively referring to acupuncturists, or would consider referring in certain circumstances, with only 8.4% (n=49) stating that they would not refer their patients to an acupuncturist under any circumstances. Most GPs were aware of practitioners who practised acupuncture in their local area, with only 2.6% (n=15) of respondents unable to identify acupuncturists to refer their patients to.

Table 1

Referral rates of patients by rural general practitioners to acupuncture in the past 12 months (n=585)

Some GPs also perform acupuncture services themselves, with 16.1% (n=94) stating that they had practised acupuncture on a patient during the past 12 months (data not shown). Approximately one in six (16.9%; n=99) GPs had a personal professional relationship with a specific individual acupuncturist to whom they referred their patients.

Table 2 shows a comparison between GPs who referred to an acupuncturist often (at least weekly or at least monthly) and seldom (less than a few times per year or never) by demographic characteristics. Significant differences in GP referral to acupuncturists was found in differing age groups, with the youngest and oldest GP age groups less likely to refer. Significant differences were also found in RRMA groups, with GPs from the least rural and most rural classifications less likely to refer to an acupuncturist. GPs with a lower or higher patient load were less likely to refer to an acupuncturist than those with average patient loads. Female GPs were more likely to refer at least monthly for acupuncture than male GPs. There was no significant association between country of graduation from medical school or initially being from a rural area and referral to acupuncture.

Table 2

Demographic and practice characteristics associated with referral to acupuncture by rural and regional GPs in New South Wales, Australia (n=585)

Table 3 shows a comparison between GPs who referred to an acupuncturist often (at least weekly or at least monthly) and seldom (less than a few times per year or never) by other factors. Referral to acupuncture was significantly associated with level of knowledge about acupuncture, the number of patients asking about CAM, personal CAM use by the GP, not having other options available, having had positive results with acupuncture previously, using CAM practitioners as a major source for CAM information, belief in the efficacy of acupuncture, having prescribed CAM previously to patients and being comfortable with referral to acupuncture.

Table 3

Other factors associated with referral to acupuncture by rural and regional GPs in New South Wales, Australia (n=585)

Predictive factors

The result of multiple logistic regression modelling to determine predictive factors for referring to acupuncture is shown in table 4. There was a trend for older GPs to be more likely to refer often to acupuncture, with GPs over 55 years being 6.08 (95% CI 3.01 to 12.29) times more likely to refer at least once per month to an acupuncturist than GPs aged between 25 and 44 years. Male GPs were only one-third as likely (OR=0.34; 95% 0.19 to 0.62) to refer at least once per month as female GPs. GPs practising in a remote area were 6.25 (95% CI 1.88 to 20.00) times more likely to refer to acupuncture at least once per month than those who practised in a rural area. GPs with increased knowledge of acupuncture were more likely to refer for acupuncture at least once per month, with GPs reporting good or very good knowledge of acupuncture being 5.54 (95% CI 2.96 to 10.38) times more likely to refer to an acupuncturist than those who reported poor or very poor knowledge of the discipline. GPs who used CAM for their own health were also more likely to refer, with GPs using CAM regularly or often being 2.37 (95% CI 1.31 to 4.31) times more likely to refer to an acupuncturist at least once per month than those who did not use CAM at all. GPs who had previously prescribed CAM to their patients were 2.99 (95% CI 1.76 to 5.07) times more likely to refer to acupuncture than those who had not. GPs were 4.31 (95% CI 1.80 to 10.34) more likely to refer to acupuncture at least once per month if they perceived there were no other options available. Information sources also affected referral, with GPs CAM practitioners as a major source of CAM information being 3.05 (95% CI 1.53 to 6.07) times more likely to refer to acupuncture at least once per month than those who did not.

Table 4

Predictive factors for referral of patients by GPs to acupuncture at least once per month by rural and regional GPs in New South Wales, Australia (n=573)

Discussion

This is the first focused examination of conventional medical practitioner referral to acupuncture in rural and regional Australia, and complements analyses performed in other professions such as chiropractic and homoeopathy.22 ,23 Our study findings show that a significant level of interaction exists between acupuncture (and acupuncturists) and GPs in this area. The high prevalence of personal professional relationships and referral between GPs and acupuncturists could be indicative of high presence of non-medical acupuncture practitioners in the study area, as previous research has identified these practitioners are present in 10% of the GP numbers in rural and regional New South Wales.5

However, the high level of professional relationships and referral with acupuncturists among GPs may also be related to longstanding (since 1984) and formal referral and reimbursement arrangements that exist for acupuncture services in the Australian public healthcare system, when performed by medical practitioners.10 The established nature of acupuncture in Australian general practice may also explain why this treatment has high levels of support, relative to other CAM professions, among the general practice community in this study. However, given the longstanding decline in the number of medical practitioners performing acupuncture in Australian general practice,10 and the rise of the emergent Chinese medicine and acupuncture professions in Australia,26 it is also likely that there is also a significant interface between general practice and non-medical acupuncturists. Although our study results suggest that acupuncture was largely accepted by the majority of the Australian rural and regional GP community, nearly 1/10th of GPs in this study maintained that they would never refer patients to acupuncture under any circumstances. Given the recent high-profile attacks on non-medical acupuncturists in the Australian medical media,27 further examination of differences in perception and attitudes of GPs to medical and non-medical practice of CAM may offer valuable insights into how these therapies are integrated in primary healthcare.

It is also possible that the very presence of formal and subsidised methods to offer acupuncture treatment to patients may affect referral by rural and regional GPs to acupuncturists. Analysis of GP referrals to other CAM practitioners subsidised under the Australian national health insurance scheme (chiropractic and osteopathy), also suggested that the convenience of formal and subsidised referral pathways may be an influential factor in driving referral to these therapies.22 Previous Australian research on CAM professions not eligible for subsidies, such as naturopathy, has also highlighted that a lack of subsidies for certain CAM therapies may adversely affect referral to those therapies, as patients are unable or unwilling to pay the full out-of-pocket costs for non-subsidised CAM treatment.28

In this study, formalised arrangements enabling publicly subsidised acupuncture treatment for patients may provide a cost-effective method for GPs to recommend CAM treatment to patients. This may partly explain why factors that suggest GP support of CAM more generally (previous use of CAM for their own health, previous prescription of CAM to patients and using CAM providers as a major source of CAM information) were all independently predictive of greater referral to acupuncture by GPs. This may also partly explain why lack of other options for treatment independently predicts acupuncture referral, as acupuncture may be the most convenient non-conventional treatment to refer to. Such subsidies may not be restricted to acupuncture performed by medical practitioners—and therefore not limited by the presence or lack thereof of medical practitioners who perform acupuncture—with other professions subsidised by the Australian health system, including chiropractors, osteopaths and physiotherapists, also potentially offering their patients acupuncture services, albeit often surreptitiously under the terms such as ‘dry needling’.11 This may partly explain why high referral patterns exist in rural and regional New South Wales, even though the distribution of medical10 and non-medical5 acupuncturists is not high in this area. Workforce issues may also partly explain why although level of rurality did independently predict acupuncture referral, no other factors associated with rurality did, and lower referral in remote areas may simply be related to lower presence of practitioners in these areas.

However, the issue of how government reimbursements or formalised referral arrangements affects referral patterns between conventional and specific CAM providers has not been explored in depth. Similarly, the issue of whether CAM services are provided by conventional or ‘alternative’ professions has not been examined critically. Acupuncture in the Australian setting is unique among other CAM in that it has been integrated into conventional medical practice for over 30 years. However, there does appear to be growing levels of integration of non-medical practice of acupuncture in the Australian primary healthcare setting as well. The finding from this study that GPs who rely on CAM providers as major sources of CAM information may indicate higher levels of interaction with CAM providers among referrers than non-referrers, and may also suggest that GPs are willing to communicate and refer to a broad variety of CAM practitioners beyond acupuncturists. Whether positive support among these GPs is for CAM more broadly, or only for specific modalities and disciplines is an area that requires further examination.

The high prevalence of professional relationships with individual practitioners may also be partly related to the rural and regional nature of the sample in this study, as smaller communities may facilitate increased interaction between CAM and conventional providers.18 ,19 ,29 This may facilitate an increased level of referrals by rural and regional GPs to CAM providers as compared to their urban counterparts. However, high levels of professional relationships with individual acupuncture practitioners could also be related to the significant number of medical practitioners who purport to provide acupuncture services to patients, as previous Australian studies have shown that GPs may prefer to refer to medical rather than non-medical practitioners for CAM services.14 This may explain why acupuncture referral was relatively high among GPs in this study while referrals specifically to Chinese medicine practitioners among rural and regional Australian GPs are relatively low.17 The percentages of GPs practising acupuncture in this study are broadly similar to those found in studies of urban or national GP populations.12 ,13 Further investigation of referral patterns in the broader GP population, or comparative work with urban GPs, will assist in further ascertaining what role, if any, geographic factors such as the level of rurality have on the interface between CAM and general practice. It should also be noted that the proportion of GPs who claim to provide acupuncture services in this and in previous studies12 ,13 is significantly higher than the proportion of GPs who claim reimbursement for these services.10 Reasons behind this longstanding differential between practise and reimbursement also warrant further investigation.

Though limited to one state (New South Wales), the large and varied study area was chosen to be broadly representative of Australian rural and regional general practice demographics. Nevertheless, the demographics of the GPs in this study compared to national statistics (being as they are drawn from rural and regional areas and exhibiting a higher proportion of women25) should be considered when generalising the study's results to the broader Australian general practice population.

Other limitations of the study, which are common among other questionnaire studies, include the use of self-reported data and possible recall bias inherent in retrospective collection of data over a 12-month period, as well as self-selection that may have resulted in response bias. Note that the response rate is typical for large-scale GP surveys on CAM conducted in Australia over the past decade, which have reported response rates of between 29% and 58%,12 ,16 ,30 as well as with general surveys of Australian GPs, which routinely have difficulty receiving response rates of over 30%.31

Conclusions

Our study reveals a high level of interaction (via referrals as well as the development of professional relationships) between acupuncture and the GP community in rural and regional Australia. High use of acupuncture in the Australian community, combined with a high level of integration into conventional medical practice does highlight the important need for more research in this area, to ascertain the impact upon patient care delivery. A need for further research is also supported by the complexity and variability of acupuncture provision, which is provided by conventional and non-medical practitioners.

The significant presence, high use and interface of acupuncture in rural primary healthcare should serve as an impetus for increased research into acupuncture practice, policy and regulation in rural and regional health.

Summary points

  • A total of 585 (41%) general practitioners in New South Wales, Australia, responded to a survey about complementary medicine

  • Two-thirds of GPs refer patients for acupuncture more than once a year

  • Referrers are more likely to have certain features including being older, a woman and in rural practice.

Acknowledgments

We also thank the National Health and Medical Research Council for funding JA via a NHMRC Career Development Fellowship.

References

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Footnotes

  • Contributors JLW, DS and JA designed the study; performed the data analysis; and wrote the manuscript. All authors read and approved the final manuscript.

  • Funding This study was funded by the University of Queensland Foundation Research Excellence Award and National Health and Medical Research Council.

  • Competing interests JLW's involvement in this project was directly supported by a National Health and Medical Research Council Postgraduate Public Health Research Scholarship (grant number: 569782).

  • Ethics approval University of Queensland; University of Newcastle.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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