INTEGRATIVE MEDICINE AS A TOOL
TO REDUCE HEALTH DISPARITIES
Benjamin Kligler, MD, MPH
Vice Chair
Beth Israel Department of Integrative Medicine
Albert Einstein College of Medicine
bkligler@chpnet.org
OBJECTIVES
Discuss four examples of programs for
underserved populations using differing
successful strategies
 Provide examples of tools that an
individual practitioner working in an
underserved setting can used effectively
with patients

◦ Mind/body techniques
◦ Acupressure
◦ Herbal medicine
FOUR EXAMPLES
 Lawrence Family Health Center
Group Programs (Massachusetts)
 Venice Health Center (California)
 NYC-RING Albert Einstein Practicebased Research Network (New York)
 Wellness in the Schools (New York)

Thanks to Jeff Geller (Lawrence), Myles Spar (Venice),
and Nancy Easton (WITS), and to all of their funders!
EXAMPLE #1: GREATER LAWRENCE
FAMILY HEALTH CENTER
GROUP VISITS: EMPOWERING THE
PATIENT WHILE REDUCING COSTS
Lawrence, MA
◦ Poorest city in state
◦ Predominantly Latino (est. 70%)

Greater Lawrence Family Health Center
◦ Lawrence Family Practice Residency / HIP
fellowship
 38 weekly group visits: 9 providers, 1-3 fellows
 In addition to obesity: prenatal, chronic pain,
smoking cessation, asthma, buprenorphone,
diabetes, heart disease, homeless clinic,
acupuncture….
 Focus on support / loneliness and stress reduction
The Setting

2 types of group visit models

Open ended Models
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No end date
Rolling admission
No predetermined specific goals
Predetermined population / illness
Open access appointments
Enclosed Models
◦ Specific curriculum
◦ Certain number of meetings or classes
◦ Often specific predetermined goals / population /
illness
◦ More scheduled appointments, known participants.
2 types of group visit models
•
Open ended Models
– Cardiac disease: HTN, High Cholesterol, DM
– Weight loss
– Smoking cessation
– Stress related illness
– Chronic pain
– Developmental delay
– Pediatric Obesity
14
6
4
1
1
3
2
• 3 Family, 1 Toddler, 9 Children 8-12yo, 1 children 13-18yo
•
Enclosed Models
– Acupuncture (6 spaces)
– Prenatal
– Suboxone
2
– Diabetes self management and education 2
1
2
“The exercises aren’t just great for losing weight, but they
also relax the mind; the program helps me make new friends
…and we treat each other like family. When someone doesn’t
come on a particular day, we are already missing each other!
These exercise groups are a complete therapy.”
EXAMPLE #2: VENICE FAMILY
CLINIC/ALBERT EINSTEIN PRACTICE-BASED
RESEARCH NETWORK
INCREASING ACCESS BY BRINGING
COMPLEMENTARY/ALTERNATIVE
MEDICINE TRAINEES TO THE
COMMUNITY SETTING
Venice Family Clinic

Provides primary care & selected specialty care to
24,413 patients in 9 locations over west side of
Los Angeles

Over 106,000 visits per year

Mainly minority patients (81%) & without health
insurance (78%)

Racially mixed clientele but predominantly
Hispanic (63%)
Multidisciplinary
Chronic Pain Program

Conditions

Modalities

◦ All chronic, painful M/S conditions w & w/o injuries
◦ Especially back, neck and shoulder conditions
◦ Not soliciting referrals for neuropathy & other treatment
resistant conditions initially
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Conventional medicine
Traditional Chinese Medicine (Acupuncture)
Osteopathy
Chiropractic
Massage
Physical Therapy
Social Work/ Mental Health
Education of Staff, Providers & Patients
Program to Date

Started March 1, 2006

2,911 patients have been
seen (as of June 30, 2011)

Currently there is a waitlist
for all modalities

Patient Demographics
◦ Average age 49 (22-73)
◦ Gender: M 36%; F 64%

Education:
◦ 4% Graduate or professional
degree
◦ 17% College degree
◦ 25% Education beyond high
school
◦ 25% High School or equiv
◦ 29% no h.s diploma

Household Income
◦ 10% $20,000-$50,000
◦ 89% less than $20,000

Insurance Status
◦ 4% Medi-Cal
◦ 5% Medicare
◦ 91% no insurance
Outcomes tables

Brief Pain Inventory- Severity Scale
mean comment
score
Pre-treatment
BPI
Post-Treatment
BPI
23.94
19.74
Significant improvement in
severity of pain from pre-treatment
to post-treatment at P<0.05.
Follow-up BPI
17.79
Significant improvement in
severity of pain continued to be
reported at follow-up at P<0.05 (for
the difference from pre-treatment to
follow-up).
ADDOPT: ACUPUNCTURE TO
DECREASE DISPARITIES IN PAIN
TREATMENT

NIH/NCCAM-funded trial, testing acupuncture as an
adjunct to usual treatment for chronic pain in four
urban health centers.

These health centers belong to New York City
Research and Improvement Networking Group
(NYC RING), a practice-based research network
dedicated to decreasing health disparities through
primary care research and quality improvement in
the urban safety net setting.
METHODS

Population: primary care patients (>18 years) with
chronic pain due to osteoarthritis, neck or back pain
at four hospital owned safety net community health
centers in the Bronx NY. The patient population was
ethnically diverse and low income in a medically
underserved area of the Bronx.

Intervention: weekly acupuncture treatments for
up to 14 weeks. The acupuncture team was free to
adapt and change the treatment approach from week
to week based on the condition of the patient and
response to treatment.
RESULTS
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226 patients completed the trial
Average age was 54; 60% were Medicaid insured and
38% on disability; high baseline levels of pain (mean
BPI pain severity 6.8; mean days with pain, 12.3 of 14
days ).
Mean number of treatments was 8.0 (SD 4.7).
Reduction in pain severity between baseline and
treatment phase was significant (p <.001).
Improvements in physical well-being were significant
at 12 and 24 weeks post-baseline (p <.001).
30.3% experienced a 30% or greater improvement in
pain—the generally accepted threshold for clinically
significant change.
EXAMPLE #3: WELLNESS IN THE
SCHOOLS
BRINGING NEW KNOWLEDGE AND
SKILLS FOR GREATER HEALTH INTO
THE SCHOOLS!
WELLNESS IN THE SCHOOLS
$167 billion per year on obesity-related
illness
 43% of children in NY are obese
 30,000 kids in 36 under-resourced schools
 Cook for Kids: uses culinary interns to
bring fresh and health food to schools
 Coach for Kids: stations coaches in recess
yards to encourage physical activity
 Green for Kids: environmentally safe
cleaning products for schools

ACUPRESSURE FOR NAUSEA:
The Evidence

randomized, placebo-controlled, pilot study of acupressure at
the Neiguan point (P6) for NVP involving 60 women.

RESULTS: It is possible to reduce NVP significantly with
acupressure at P6 as compared to acupressure at a placebo
point or no treatment at all in healthy women with normal
pregnancies. Relief from nausea appeared one day after
starting treatment in both the P6 and placebo groups but
lasted for only six days in the placebo group. The P6 group,
however, experienced significantly less nausea after 14 days
as compared to the other two groups.

Werntoft, E. Dykes, A K Effect of acupressure on nausea and vomiting during
pregnancy. A randomized, placebo-controlled, pilot study.Journal of Reproductive
Medicine. 46(9):835-9, 2001
ACUPRESSURE FOR LOW BACK PAIN: The
Evidence

Randomized controlled trial of 129 patients with chronic low back pain.
Acupressure or physical therapy for one month.

RESULTS: The mean total Roland and Morris disability questionnaire score
after treatment was significantly lower in the acupressure group than in
the physical therapy group regardless of the difference in absolute score (3.8, 95% confidence interval - 5.7 to - 1.9) or mean change from the
baseline (- 4.64, - 6.39 to - 2.89). Acupressure conferred an 89% (95%
confidence interval 61% to 97%) reduction in significant disability
compared with physical therapy. The improvement in disability score in
the acupressure group compared with the physical group remained at six
month follow-up. Statistically significant differences also occurred
between the two groups for all six domains of the core outcome, pain
visual scale, and modified Oswestry disability questionnaire after
treatment and at six month follow-up.

Hsieh LL. Kuo CH. Lee LH. Yen AM. Chien KL. Chen TH.Treatment of low
back pain by acupressure and physical therapy: randomised controlled
trial.BMJ. 332(7543):696-700, 2006
Techniques Which Can Elicit the Relaxation
Response
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Diaphragmatic
Breathing
Meditation
Body Scan
Mindfulness
Repetitive exercise
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Repetitive prayer
Progressive muscle
relaxation
Yoga Stretching
Imagery
(Music)
What can you teach in a 15-minute office visit?
Exercise vs. SSRI for Depression
Observed mean depression scores before and after treatment
Blumenthal, J. A. et al. Arch Intern Med 1999;159:2349-2356.
Copyright restrictions may apply.
HERBAL MEDICINES
Pros and cons of using infusions/teas vs.
standardized extracts
 Specific conditions and applications

◦ Irritable bowel syndrome
◦ Upper respiratory infection
◦ insomnia
Organic Licorice Root, Organic Cardamom Seed, Organic
Fennel Seed, Organic Coriander Seed, Organic Barley Malt,
Organic Peppermint Leaf, Organic Ginger Root, Organic Black
Pepper.
RESOURCES:TEACHING MATERIALS
http://uwhealth.org/alternativemedicine/breathing-exercises/30408
 http://fammed.wisc.edu/integrative/mod
ules
 Integrative Medicine for the Underserved
http://im4us.org/HomePage
 Clinicians’ and Educators’ Desk Reference
on the Licensed Complementary and
Alternative Healthcare Professions
http://accahc.org/cedr

RESOURCES: ORGANIZATIONS
Consortium of Academic Health Centers
for Integrative Medicine
http://imconsort.org
 Academic Consortium of Complementary
and Alternative Healthcare (ACCAHC)
http://accahc.org
 Center Institute for Research and
Education in Integrative Medicine
http://healthandhealingny.org/Institute

Clinicians’ and Educators’ Desk
Reference on the Licensed
Complementary and Alternative
Healthcare Professions
Focus on the 5 licensed
integrative health and medicine
disciplines
◦
Chiropractic, acupuncture and Oriental
Medicine, naturopathic medicine, massage
therapy, direct entry midwifery
◦
All with US Department of Educationrecognized accrediting agencies
◦
Plus, 6 related fields
All
◦
to a template with 18 fields
Accreditation, licensing, scope, research,
integration, etc.
More
Info: accahc.org/cedr
David Eisenberg, MD
Harvard School of Public Health
“This information will be very useful to
patients, healthcare professionals,
educators, students and those responsible
for future clinical research and healthcare
policy.”