Bruce Barrett

Background . It is generally agreed that randomized controlled trials should be powered to detect small but clinically significant treatment effects. Toward these ends, minimal important difference (MID) was proposed as a benchmark for designing trials and for interpreting health-related quality-of-life instrument scores. MID was defined in 1989 as “the smallest difference in score in the domain of interest which patients perceive as beneficial and which would mandate, in the absence of troubling side effects and excessive cost, a change in the patient’s management.” Objective. 1) To expand the idea of minimal clinically important difference so as to take into account harms as well as benefits. 2) To propose concepts and methods with which to do so. Summary . The authors define sufficiently important difference (SID) as the smallest amount of patient-valued benefit that an intervention would require to justify associated costs, risks, and other harms. As a means toward estimation of SID, the authors propose benefit-harm tradeoff methods, in which domains of benefit and harm are systematically traded off against each other and assessed in relation to the global decision of whether a treatment choice is worthwhile. Specific SID estimates can be used to power and interpret clinical trials or to inform health services research and/or public health policy. This article briefly describes the evolution of the important difference concept and outlines similarities and differences between MID and SID.

BACKGROUND We wanted to explore the beliefs and practices of complementary and alternative medicine (CAM) practitioners.

Complementary and alternative medicine (CAM) has been defined largely in relation to conventional biomedicine. CAM therapies that are used instead of conventional medicine are termed "alternative." CAM therapies used alongside conventional medicine are said to be "complementary." "Integrative medicine" results from the thoughtful incorporation of concepts, values, and practices from alternative, complementary, and conventional medicines. The evolving process of integration between CAM and conventional medicine evokes new conceptual frameworks, as well as new terminology. Interview-based qualitative research at the University of Wisconsin-Madison seeks to probe and develop this theoretical structure. Interviews with users and practitioners of CAM therapies have revealed four primary themes: holism, empowerment, access, and legitimacy (HEAL). These themes characterize CAM and contrast it with conventional medicine. CAM is said to be more holistic and empowering yet less legitimate than conventional medicine. CAM is more intuitive; conventional is more deductive. While CAM is perhaps more psychologically accessible to many patients in that it better reflects commonly held values, it is often less financially and institutionally accessible, at least for those with conventional health insurance and limited income. Substantive barriers—including economic, organizational and scientific differences, as well as an apparent widespread lack of understanding— continue to thwart attempts at integration. More and better evidence is needed if CAM therapies are to be accepted by mainstream medicine. State-of-the-art research methods developed by conventional science will be needed to test CAM therapies. Conventional medicine, however, has much to learn from CAM. By incorporating a more holistic, empowering and accessible therapeutic approach, conventional medicine could build on its present legitimacy, and thereby enhance its power to "HEAL."

In attempts to improve their health and/or combat illness, approximately 4 in 10 Americans will use a complementary and alternative medicine (CAM) therapy this year. CAM therapies vary widely, with acupuncture, chiropractic, herbal medicine, and homeopathy among the more prominent modalities. CAM therapies are used in addition to and/or instead of the more conventional forms of medical care available in U.S. hospitals or licensed physicians' offices. A rapidly increasing interest in CAM has led to a nascent movement aimed at integrating various CAM therapies with the conventional health care system. In Washington State, for example, health insurance coverage for CAM therapies has been mandated, and a number of "integrated" delivery systems have been born. Although the political and economic forces leading to adoption and integration of CAM therapies vary widely by geographic locale, it is likely that some degree of integration will occur throughout much of the United States. Similar processes are occurring in Canada, Europe, and Australia, and indeed within middle and upper level socioeconomic strata worldwide. This paper identifies potential barriers and facilitators to potential integration, of medical disciplines and argues for an accessible, multidisciplinary and evidence-based, yet humanistic and patient-oriented approach.

A number of health-related interventions--from widespread therapies such as acupuncture, herbal medicine, homeopathy and yoga, to less well-known modalities such as Feldenkrais, iridology, reflexology and reiki--have increasingly come under the general heading of complementary and alternative medicine (CAM). A few, such as biofeedback, chiropractic and physical therapy, are considered conventional by some, alternative by others. Several national surveys estimate that around 40% of the US populace uses a CAM therapy in a given year. While a few people use CAM therapies instead of conventional medicine, the vast majority of CAM users continue to access the official health care system. Many, however, do not discuss their CAM use with their physician. Medical doctors, for their part, are sharply divided on their attitudes toward CAM, with strong advocates and vehement opponents writing and speaking about this issue. CAM therapists are even more diverse, spanning the spectrum from conventional-appearing registered and certified practitioners to iconoclasts promoting anomalous therapies in the place of conventional treatment. The majority, however, both respect and want to work with conventional medicine, as do their patients. Nearly everyone is calling for more and better evidence, and an ever-increasing number of randomized controlled trials and meta-analyses are now appearing in the literature. Over the past few years, a number of calls for "integrated medicine" have been made, and a few attempts at integrating CAM and conventional medicine have been launched. This article reviews these issues, citing our own interview-based work and the relevant literature. Whether the CAM phenomenon represents a short-lived social movement or the beginnings of a radical transformation of medicine has yet to be determined.

The use of various forms of complementary and alternative medicine (CAM) has become widespread. We investigated this use in Madison, Wisconsin. We conducted semistructured indepth interviews focused on the knowledge, attitudes, and behaviors of a random sample of 17 patients who had used both CAM and conventional therapies during the past year. Participants were recruited using telephone listings. Twenty alternative practitioners were selected to represent the major modalities. The topics discussed included healing philosophy, choices of therapeutic methods, and ideas concerning concurrent use of differing therapeutic modalities. An 8-member multidisciplinary team analyzed the transcripts individually and in group meetings. Four major themes emerged from the interview data: (1) holism, (2) empowerment, (3) access, and (4) legitimization. Both patients and providers distinguished between the socially legitimized and widely accessible but disempowering and mechanistic attributes of conventional medicine and the holistic and empowering but relatively less accessible and less legitimate nature of alternative healing. There was a strong call for integrating the best aspects of both. Practitioners and users of alternative therapies in the Madison area confirmed both the alternative and complementary natures of unconventional health care, called for more integrated and accessible health care, and provided insights that could be useful in bridging the gap between conventional and alternative medicine.

To review the evidence regarding the effectiveness of orally ingested Echinacea extracts in reducing the incidence, severity, or duration of acute upper respiratory infections (URIs). Information from a wide range of sources was used as background material. More than 100 articles, books, and book chapters were reviewed for content and further references. Database searches, bibliographic reviews, and conversations with experts were carried out iteratively from January 1997 to February 1999. Published or unpublished reports of all blinded placebo-controlled randomized trials of any Echinacea formulation used as a treatment or for the prevention of URIs. Review considerations included randomization, blinding, power, validity and clinical relevance of outcome measurements, inclusion and exclusion criteria, indistinguishability of treatment and placebo, and appropriateness of conclusions for the data presented. MAIN RESULTS. Nine treatment trials and 4 prevention trials fitting the selection criteria were found. Eight of the treatment trials reported generally positive results, and 3 of the prevention trials reported marginal benefit. Methodologic quality of the majority of the trials was modest. Evidence from published trials suggests that Echinacea may be beneficial for the early treatment of acute URIs. The influence of publication bias on those results is unknown. Echinacea preparations vary widely in composition, and are often found in combination with other potentially active constituents, making specific dose recommendations problematic. There is very little evidence supporting the prolonged use of Echinacea for the prevention of URIs.