The Aurum Project

PRIORITIES FOR AUSTRALIAN HOMEOPATHIC MEDICINE RESEARCH

The coming year holds some exciting new possibilities for homeopathy in Australia in the areas of education and research, as well as building on effective relationships with health authorities. We have achieved something in Australia that is almost unique in the West, and that is general internal harmony within the profession and, as a direct consequence, a constructive and productive relationship with government.”

Summary

In Australia, the use of homeopathy is growing both through practitioner consultations and through use of over-the-counter products. In clear consensus, practitioners and the general public agree that serious side effects do not occur and that the direct safety of homeopathy is high [1].

Homeopathy is a highly cost effective form of medicine with the majority of general practitioners in various European countries agreeing that homeopathy deserves a place in mainstream medicine though some dispute exists. This dispute is only one of the reasons that it is recognised that more research is needed [2].

Along with the need for research come many questions, including: Which conditions are frequently treated by homeopaths in Australia and what is the outcome of the treatment? These questions make basic high-quality data collection in daily practice imperative in order to accurately reflect the clinical homeopathic results being achieved in Australia. Since research subjects are a recent addition to the curriculum in homeopathy colleges, the majority of practitioners would benefit from upskilling [3].

Therefore, in Australia, a building-blocks approach to fostering research in the homeopathic community is recommended starting with capacity building regarding data collection and retrospective research, through to prospective outcome studies. The need for research consequently creates a need for sourcing funding.

In Australia, the conditions most frequently treated would include, for example: eczema, asthma, anxiety, and depression. One of the main priorities is not only to research effectiveness of treating these conditions but to improve on clinical effectiveness by transferring this knowledge from research into daily practice. It follows that educational research may also be a prime concern.

To summarise, our Australian homeopathic medicine research priorities include:

• research capacity and research funding
• utilisation and effectiveness
• safety and cost effectiveness
• education

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Introduction

This document, Priorities for Australian Homeopathic Medicine Research, has been developed through exchange of ideas with relevant researchers and practitioners in the homeopathic profession following the two Advisory Committee meetings of The Aurum Project for homeopathic medicine research in Australia, in 2007 and 2008.

Homeopathy has a research tradition with 200 years of carefully documented clinical work reported in journals, and while there is actually more contemporary research on homeopathy than is realised by the general public [4]  a call for an increase in up-to-the-minute homeopathic research comes from all corners of the globe.

With the call for more research about the use of homeopathy, certain questions arise which need answering:

• What is the capacity of the Australian homeopathic profession for research?
• What conditions are being treated by homeopaths in Australia and what conditions does the profession treat effectively?
• Do we need specifically Australian practitioner surveys?
• Is it important to align with the mainstream medicine National Research Priority: the ‘burden of disease?’
• How important is research about methodologies used by practitioners?
• How important is the inclusion of safety and cost effectiveness questions in trial design?
• How important is research into the education of homeopaths?

Building-blocks approach

While the call for research has been heard in Australia, there is a requirement for more homeopaths to increase their academic research skills to carry it out. In homeopathic education, research subjects are a recent addition to the curriculum and the majority of practitioners would profit from upskilling [5].

Individual homeopathic practitioners would benefit from a certain amount of research knowledge even when they have made a personal decision of ‘no interest in conducting research’. Gaining a general overview of past and current homeopathic research efforts is of benefit to daily practice and would also enable them to participate in some smaller way in national and international multi-centre studies [6].

Therefore, in Australia, a building-blocks approach to fostering research in the homeopathic community is recommended starting with capacity building regarding data collection and retrospective research aimed at collection and analysis of clinical cases through to prospective outcome studies and randomized clinical trials. In Canada, a step-by-step approach has also been recommended with a call for research capacity building workshops. [7]

Workshops could be run on the ‘Train the Trainer’ model and could include auditing. This may be the subject of an Australian Homeopathic Association (AHA) continuing-education programme [8].  Marketing of workshops to practitioners needs to include the benefits of basic data collecting in their own practice.

Examples are a good way of demonstrating the worthiness of research. For instance a data collection study in the UK, across all five NHS homeopathic hospitals, was reported in 2008. In this pilot study it was discovered that a high proportion of patients often representing ‘effectiveness gaps’ for conventional medical treatment, showed improvement in health after using homeopathic medicine — 73.3% of menopausal women reported significant improvement [9].  These findings are being used to develop standard setting for homeopathic care in the hospital outpatient context.

Conditions being effectively treated

In Australia, conditions frequently treated would include, for example: eczema, asthma, anxiety, and depression. Conditions being effectively treated by homeopaths include the ongoing chronic diseases where patients haven’t found solutions along the conventional medical path or ‘effectiveness gaps’ and importance should possibly be given to these conditions. One clear goal of research is to identify areas where homeopathy offers particularly effective treatment.

Health issues that effect children and their behaviour are of prime concern to the Aurum Project. The spectrum covers asthma, allergies, depression, ADHD, ADD, IBS and Autism according to the MINDD [10] definition. There is a need to collect data on how frequently homeopaths treat these paediatric conditions [11] and not just the variety of ailments being treated. These figures can then be presented to the relevant funding bodies [12].

There is a similar focus in mainstream medicine, with the four key areas for concern in children’s health including behavioural and learning disorders, asthma and allergies, diabetes and physical inactivity, and diet and nutritional status [13].

In paediatric homeopathic research, alongside the conditions being effectively treated, other important concerns are: issues of adherence to treatment recommendations since homeopaths often report that this is a positive part of homeopathic treatment; impact on quality of parents’ life and sleep; parental stress levels; and sense of self-efficacy [14].

What is happening in daily practice?

How can you measure what is happening in daily practice? The development of the Glasgow Homeopathic Hospital Outcome Scale (GHHOS) is one method of measuring outcomes and facilitates auditing. It attempts to mirror the dialogue between practitioner and patient when they are considering if the treatment has been successful. Measures include: satisfaction with care, the most frequently prescribed remedies, the outcome in different conditions, and patient characteristics. GHHOS has been used in many studies [15, 16, 17].

As a first step it is recommended that daily registration in homeopathic practice occur which encourages retrospective research aimed at collection of cases. When this work is collated from a large number of homeopaths showing different diseases and/ or remedies followed over a period of time it yields invaluable information [18].

In 1999, in Europe it was recommended that a first humble step in the direction of research would be a survey using the 10-item data set below:

1. Patient identification [initials//date of birth//sex]

2. Chief complaints [severity of complaint/s//onset of chief complaints]

3. Clinical diagnosis [acute//chronic//since when?]

4. General wellbeing [how was your general wellbeing during the last month?]

5. Health state [how is your health state today? 0 = worst imaginable health state, 100 = best imaginable health state]

6. Treatment prescribed [homeopathic (medication//potency) other treatments// no treatment, why?]

7. Total length of consultation time [minutes//hours]

8. Outcome of treatment

9. Adverse events [no//yes, observed adverse event//start date//end date or ongoing//relationship with treatment, probable//possible//improbable//unable to evaluate//initial aggravation]

10. Date of patient contact/consultation

The information on length of consultation can be linked with the average cost of consultation to give an idea of cost of homeopathic treatment and later compared with the cost of mainstream medical treatment. However, the important point to realise is that the more documentation there is by practitioners in a consistent way the higher amounts of valid data is available about the use of homeopathy[19].

The RADAR homeopathic repertory system in one computer programme which includes a patient data collection system called WINCHIP.

Case reports

Although publication of case reports may not be a relevant form of research they remain instructional for educating students.

“Despite its long history, Homeopathy has remained alive and open to completely new methods [and in order to communicate this, there is] nothing better than case reports. Our memory best remembers stories…. one cannot use homeopathy like a cookbook.”[20] If homeopathy is to continue its rich history of using the case report, one of the key concerns … must be using strict standards and extensive documentation of successfully treated cases considered incurable by mainstream medicine[21].

There is an argument that we also need to better document unsuccessful cases in order to generate a pool of knowledge and statistics that genuinely reflects the reality of practice.

Education

One of the goals of education is to constantly improve on the transfer of knowledge from research into clinical education and into daily practice. It follows that research about the effectiveness of educational methods may also be a prime concern in homeopathic research [22]. “It is very exciting to talk about research in Australia but no matter how much research is gathered and how effective it is seen to be, the key … is knowledge transfer. Does it end up being used in practice?”[23]

Cost effectiveness

Cost effectiveness of treatment, is seen by some to be the number one priority in research or should at least be included in every research effort even when questions about patient satisfaction or why the patient chose homeopathy are being addressed [24].

For example, important factors came to light when publications between 2000 and 2004, were reviewed. Validated Quality of Life Questionnaires were used and there were 6915 patients who presented with clinically significant improvement which was approximately 70% of cases but more in children. Homeopathy reduced costs and there was a reduction in lost work-days compared with conventional medicine. Many interesting questions not even asked should be prioritised, such as the potential of homeopathy to avoid invasive procedures in children and the long term effect of homeopathy in preventing chronic complaints [25].

Research funding

A practical research priority is sourcing research funding. This priority is beginning to be addressed by the Aurum Project for homeopathic medicine research which is an Australian institution with charity status able to give tax deductible receipts for donations. An aim of the Aurum Project is to promote and develop research in the homeopathic profession and enable a pathway for homeopathic researchers. By acting as a research partner for grant applications it aims to encourage collaboration between homeopathic practitioners and medical researchers.

Patient practitioner relationship

The importance of research into the patient practitioner relationship was already outlined more than ten years ago in Europe [26].

Various homeopathic phenomena

The importance of research into various homeopathic phenomena such as aggravations was outlined more than ten years ago in Europe [27], and has been reiterated in 2007 to include research concerning antidotes, posology and clinical management [28].

Research approaches

Research approaches including Evidence Based Medicine and the Randomised Controlled Trial (RCT) are seen as the ‘golden standard’ within various scientific circles. They are also well known concepts in wide parts of society and the media, and are believed to be better than other research approaches. However, they may not necessarily be accurate especially in homeopathic medicine research [29]. In the RCT it is often difficult to prove superiority to placebo, which has been called ‘the efficacy paradox’ by Walach [30].

To allow a balanced and reasoned ‘scientific’ response to allopathic trials of homeopathy (including meta analyses etc) a major research priority would have to include critical analysis of these allopathic efforts [31].

Problems encountered in some homeopathic medicine research in the past have arisen from the use of methodologies which may not have been entirely suitable — because research methodologies suitable for mainstream medicine about specific diseases or drugs may not adequately test homeopathic medicine. This is because homeopathy as a medicine takes into account the totality of the patient and is individually chosen. The RCT may be only partially appropriate for research into the effectiveness of homeopathy [32] or needs very careful design.

Collaboration

Sharing of expertise, cooperation and collaboration may be seen as a priority in homeopathic research. The question of “Where is the expertise?” may be answered by referring to the website of the Aurum Project under the heading of research where there is a list of people interested in various research topics. The list also includes their current undertakings. The Aurum Project encourages networking and collaboration in the planning, organising or carrying out of research.

Collaboration is to be encouraged with others outside the field of homeopathy as well as within eg: agriculture industry, universities (medical and veterinary schools) and overseas research institutions [33].

Conclusion

Many research methods are available and have been used in homeopathic research, from simple surveys to thoroughly planned prospective observational studies. The quality and validity of the data relies on the appropriateness of the method chosen for the topic of study. Highly sophisticated research methods are not the only necessary research method and all methods are appropriate for different topics. Each method yields data at a specific level, though it is wise to be aware that each method has its drawbacks. Any research project may require an extraordinary extra amount of time and effort from already busy practitioners so careful notice has to be taken to ensure that the project is also practically feasible [34] and the capacity to achieve the aims exists in the study team. This makes a building blocks approach to homeopathic medicine research of major importance in Australia.

September 2008

The Aurum Project for Australian Homeopathic Medicine Research.

110/20 Dale  st,

Brookvale  NSW 2100

Australia

Tel:  02)9905 9405   Fax: 02) 99059416

Correspondence:

info@aurumproject.org.au

www.aurumproject.org.au

1. Dr Wiegant F, Dr Koster D, Dr Nicolai T (1997) A strategy for research  in homoeopathy: Assessing the value of homeopathy for health care in Europe. European Committee for Homeopathy: Netherlands. p.1.
2. ibid
3. (2008) The second Advisory Committee meeting of The Aurum Project.
4. Ullman D Homeopathic Educational Services www.homeopathic.com accessed
5. (2008) The second Advisory Committee meeting of The Aurum Project.
6. (2007) ECCH Policy in the area of Homeopathy Research, Second Edition.
7. (2005) Natural Health Products Research Program Research Priority Setting Consultation on Homeopathic Medicines in Canada; An Invitational Roundtable.                                         www.hc-sc.gc.ca/sr-sr/pubs/nhp/hom_fin-eng.php accessed 5/7/2008
8. Hookham M (2008) The second Advisory Committee meeting of the Aurum Project.
9. Thompson E, Mathie R, Baitson E (2008) Towards standard setting for patient-reported outcomes in the NHS homeopathic hospitals. Homeopathy. 97(3):114-21.
10. Metabolic, Immunological, Neurological, Digestive Disorders (MINDD) Foundation.      www.mindd.org accessed 10. 9. 08
11. (2007) The first Advisory Committee meeting of The Aurum Project.
12. (2007) The first Advisory Committee meeting of The Aurum Project.
13. Senator Lundy K (2007) Children’s Health, Adjournment Speech.
14. Kemper K, Cassileth B, Ferris T. (1999) Holistic Pediatrics: A Research Agenda. Pediatrics. 103(4) Supplement to Pediatrics, Part 2 of 2: 902-909.
15. Neville-Smith R (1999) Community hospital clinic: Audit of the first 12 months activity. British Homeopathic Journal.
16. Riley D, et al (2001) Homeopathy and conventional medicine: An outcomes study comparing effectiveness in a primary care setting. The Journal of Alternative and Complementary Medicine.
17. Sevar R (2000) Audit of outcome in 829 consecutive patients treated with homeopathic medicine. British Homeopathic Journal. 89(4): 178-187.
18. Dr Wiegant F, Dr Koster D, Dr Nicolai T (1997) A strategy for research in homoeopathy: Assessing the value of homeopathy for health care in Europe. European Committee for Homeopathy: Netherlands. p.10.
19. (1999) Data collection in Homeopathic practice: A proposal for an international standard, European Committee for Homeopathy (ECH).
20. Dr Carstens V (2007) International Hahnemann Congress.
21. Dr Nestor Campora C (2007) International Hahnemann Congress.
22. Simpson L (2004) Lost in translation? Reflections on the role of research in improving health care for children. Health Affairs: The Policy Journal of the Health Sphere. 23(5):125-130.
23. Hermiston N (2008) The second Advisory Committee meeting of The Aurum Project.
24. Dr Ives G. (2004) European Committee for Homeopathy (ECH) Assembly XVII Symposium, scientific Report.
25. Dr Walach H (2004) European Committee for Homeopathy (ECH) Assembly, University of Freiburg, this symposium represents 33 homeopathic Doctors associations in 24 European countries.
26. (1997) Strategy for research in homeopathy, European Committee for homeopathy.
27. ibid
28. (2007) ECCH Policy in the area of homeopathy research, Second Edition.
29. ibid
30. Walach H (2001) The efficacy paradox in randomized controlled trials of CAM and elsewhere: Beware of the placebo trap. J Altern Complement Med. 7(3):213-218.
31. (2008) Dr Isaac Golden, feedback on the draft document, September.
32. (2007) ECCH Policy in the area of homeopathy research, Second Edition.
33. (2008) Sandra Venables, feedback on the draft document, September.
34. (1999) Data collection in Homeopathic practice: A proposal for an international standard. European Committee for Homeopathy. p.21.