Abstract
Introduction:
The authors compared the availability of integrative medicine therapies in National Cancer Institute-Designated Comprehensive Cancer Centers and community hospitals.
Methods:
The authors reviewed 51 Comprehensive Cancer Center and 100 community hospital websites and collected race and median household income data for community hospital populations.
Results:
Availability of acupuncture (56% vs. 76.5%, p = 0.01), meditation (63% vs. 82.4%, p = 0.02), and music therapy (55% vs. 74.5%, p = 0.02) was significantly lower at community hospitals compared with Comprehensive Cancer Centers. Integrative medicine availability was also significantly lower in community hospitals serving lower-income populations.
Conclusion:
Equitable access to evidence-based integrative medicine in community hospitals is needed.
Keywords: availability of integrative medicine, integrative oncology, community hospitals, supportive cancer care
Introduction
Integrative medicine is increasingly used by cancer patients1 and has a growing evidence base for cancer symptom management.2 Known as integrative oncology in the cancer setting, this field combines evidence-based complementary therapies with conventional cancer care to address symptoms associated with cancer and its treatment.3
Guidelines from the Society for Integrative Oncology (SIO)4 and the American Society of Clinical Oncology (ASCO)2 recommend evidence-based integrative medicine for cancer patients to help reduce symptoms and improve quality of life. The majority of U.S. National Cancer Institute (NCI)-Designated Comprehensive Cancer Centers evaluated in 2016 offered integrative medicine information to patients on their websites as well as various integrative therapies, such as acupuncture, massage, meditation, and yoga.5 However, the availability of integrative medicine therapies in U.S. community hospitals is unknown.
Community hospitals serve as the primary site for health care in most communities and ∼85% of cancer patients in the U.S. receive care in these settings.6,7 Hence, it is critical to understand whether community hospitals provide integrative medicine to their patients and include integrative medicine modalities in supportive cancer care. To fill this research gap, in this study, the authors compared the availability of integrative medicine therapies in community hospitals versus NCI-Designated Comprehensive Cancer Centers. The authors also evaluated whether the integrative medicine therapies offered by community hospitals differed by population income and racial composition.
Materials and Methods
The authors systematically reviewed the websites of NCI-Designated Comprehensive Cancer Centers and community hospitals. They identified Comprehensive Cancer Centers from the NCI website (https://www.cancer.gov/research/infrastructure/cancer-centers/find). The lead researcher (K.D.) selected a convenience sample of community hospitals from the interactive map on the American Hospital Association website in a 2:1 ratio relative to the number of Comprehensive Cancer Centers in each state. Community hospitals were selected if they were (1) members of the American Hospital Association, (2) had a cancer accreditation, and (3) were on the Association of Community Cancer Centers' website.
The authors entered the following key words into Comprehensive Cancer Center and community hospital website search engines to determine the availability of specific integrative medicine therapies: “acupuncture,” “massage,” “meditation,” “music,” “yoga,” “fitness,” and “tai chi.” They also manually browsed website descriptions of services, such as palliative or supportive care, pain management, and rehabilitation, to look for integrative medicine therapy offerings. They created a data collection form to enter data collected from the websites. A “no” signified websites that did not mention an integrative medicine modality, whereas a “yes” signified websites with any mention of an integrative medicine therapy available within the health systems of the community hospitals or Comprehensive Cancer Centers.
The authors used Data USA (https://datausa.io/) to collect data on race and median household income for the population served by the community hospitals; these data were based on the town or city where the hospitals are located. Median household income was categorized as lower tier (<$39,999) and middle tier ($40,000–$122,000). The authors categorized race by white, black, Asian, more than one race, and other. Researchers (K.L., K.D., and C.S.) independently evaluated websites for integrative medicine modalities and discussed any discrepancies until they reached a consensus. The Institutional Review Board of Memorial Sloan Kettering Cancer Center designated this study as exempt.
Using chi-square tests, the authors analyzed (1) the frequency of integrative medicine modality mentions on the websites and availability of therapies between community hospitals and Comprehensive Cancer Centers and (2) integrative medicine modalities offered at community hospitals by race and household income tier. All analyses were performed using STATA 15.0 (STATA Corp., TX), with a two-sided significance level of 0.05 indicating statistical significance.
Results
Between July and August 2020, the authors analyzed 100 community hospitals and 51 Comprehensive Cancer Centers. They were unable to fulfill the 2:1 community hospital to Comprehensive Cancer Center ratio for two states, Arizona and Utah; therefore, they evaluated 100 community hospitals rather than 102.
Overall, community hospitals offered fewer integrative medicine therapies as compared with Comprehensive Cancer Centers. Availability of acupuncture (56% vs. 76.5%, p = 0.01), meditation (63% vs. 82.4%, p = 0.02), and music therapy (55% vs. 74.5%, p = 0.02) was significantly lower at community hospitals compared with Comprehensive Cancer Centers. For massage (80% vs. 84.3%, p = 0.52), yoga (79% vs. 84.3%, p = 0.43), fitness (72.6% vs. 85%, p = 0.07), and Tai Chi (45% vs. 51%, p = 0.49), there was no significant difference between community hospitals and Comprehensive Cancer Centers (Table 1).
Table 1.
Availability of Integrative Medicine Therapies at Community Hospitals and National Cancer Institute-Designated Comprehensive Cancer Centers
| NCI-CCCs (n = 51) |
CHs (n = 100) |
p | |
|---|---|---|---|
| Yes, n (%) | Yes, n (%) | ||
| Acupuncture | 39 (76.5) | 56 (56) | 0.01 |
| Massage | 43 (84.3) | 80 (80) | 0.52 |
| Meditation | 42 (82.4) | 63 (63) | 0.02 |
| Music | 38 (74.5) | 55 (55) | 0.02 |
| Yoga | 43 (84.3) | 79 (79) | 0.43 |
| Fitness | 37 (72.6) | 85 (85) | 0.07 |
| Tai Chi | 26 (51) | 45 (45) | 0.49 |
CCC, Comprehensive Cancer Center; CH, community hospital; NCI, National Cancer Institute.
Among 100 community hospitals, 21 were in regions with lower-income populations, whereas 74 were in middle-income areas. Availability of acupuncture (23.8% vs. 64.6%, p = 0.001), meditation (38.1% vs. 69.6%, p = 0.01), yoga (52.4% vs. 86.1%, p = 0.001), and Tai Chi (14.3% vs. 53.2%, p = 0.001) was significantly lower in community hospitals serving lower-income populations compared with community hospitals serving middle-income populations. No significant difference was found in the availability of massage (66.7% vs. 83.5%, p = 0.12), music therapy (47.6% vs. 57%, p = 0.44), and fitness (81% vs. 86.1%, p = 0.51) (Table 2).
Table 2.
Availability of Integrative Medicine Therapies by Household Income Tier at Community Hospitals
| Lower income tier (n = 21) |
Middle income tier (n = 79) |
p | |
|---|---|---|---|
| Yes |
Yes |
||
| n (%) | n (%) | ||
| Acupuncture | 5 (23.8) | 51 (64.6) | 0.001 |
| Massage | 14 (66.7) | 66 (83.5) | 0.12 |
| Meditation | 8 (38.1) | 55 (69.6) | 0.01 |
| Music | 10 (47.6) | 45 (57) | 0.44 |
| Yoga | 11 (52.4) | 68 (86.1) | 0.001 |
| Fitness | 17 (81) | 68 (86.1) | 0.51 |
| Tai Chi | 3 (14.3) | 42 (53.2) | 0.001 |
The availability of integrative medicine therapies at community hospitals did not differ by racial characteristics.
Discussion
This study found that community hospitals offered fewer integrative medicine therapies than NCI-Designated Comprehensive Cancer Centers. In particular, community hospitals serving low-income populations offered fewer types of integrative medicine therapies compared with community hospitals serving middle-income populations. Studies have shown that the use of integrative medicine is lower among minority, less educated, and poor individuals,8,9 creating significant health care inequalities.
One of the key reasons identified for reduced use among these population is lack of availability of such therapies.10 For example, yoga studios and acupuncture and massage clinics tend to be concentrated in upper-income neighborhoods.10 Given that the majority of cancer patients receive their care in community settings,6 the findings highlight the need for equitable access to evidence-based integrative medicine therapies in communities without Comprehensive Cancer Centers.
This study has limitations. First, integrative medicine therapies may not be listed on public-facing websites. Hence, the results may underestimate the availability of integrative medicine at community hospitals and Comprehensive Cancer Centers. Second, socioeconomic and demographic data were based on the town or city where the hospital was located and thus may not reflect the actual patient population served by the hospital. Third, the analysis did not adjust for multiple comparisons; the authors were more interested in the absolute differences in the availability of integrative medicine therapies between Comprehensive Cancer Centers and community hospitals, as well as in community hospitals with varied sociodemographic backgrounds.
Conclusion
This study sheds light on the reduced availability of integrative medicine at community hospitals, especially among those serving low-income populations. The findings suggest that collaborations between NCI-Designated Comprehensive Cancer Centers and community hospitals may represent a feasible solution to facilitate resource sharing and the establishment of scalable and sustainable integrative medicine programs at a community level. Furthermore, using innovative virtual delivery models may help overcome some of the barriers to in-person participation, such as travel burden, time constraints, and cost.11 However, implementation of online programs must be informed by the unique challenges faced by low-socioeconomic groups, such as limited access to the internet or equipment needed for virtual sessions.
Evaluating and overcoming the challenges faced by community hospitals are important to expand equitable access to integrative medicine therapies among diverse cancer populations.
Authors' Contributions
Conceptualization, investigation, methodology, data curation, formal analysis, writing—original draft, and writing—review and editing by K.D. and C.S. Conceptualization, investigation, writing—original draft, and writing—review and editing by Ke.L. Data curation, methodology, formal analysis, writing—original draft, and writing—review and editing by Ka.L. Conceptualization, visualization, data curation, funding acquisition, investigation, methodology, writing—original draft, and writing—review and editing by J.J.M.
Author Disclosure Statement
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J.J.M. reports grants from Tibet CheeZheng Tibetan Medicine Co. Ltd. and from Zhongke Health International LLC outside the submitted study. All other authors declare no potential conflicts of interest.
Funding Information
This study was supported in part by grants from the National Institutes of Health/National Cancer Institute Cancer Center (P30 CA008748) and the Translational and Integrative Medicine Research Fund at Memorial Sloan Kettering Cancer Center.
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