ARTHRITIS CARE & RESEARCH 45:398 403, 2001

ORIGINAL ARTICLE

Use of Complementary and Alternative Medicine by Older Patients With Arthritis: A Population-Based Study
PETER J. KABOLI, BRADLEY N. DOEBBELING, KENNETH G. SAAG,
AND

GARY E. ROSENTHAL

Objective. To determine the prevalence of complementary and alternative medicine (CAM) use and to identify factors associated with its use in older patients with arthritis. Methods. A population-based telephone survey of 480 elderly patients with arthritis was conducted to determine demographics, comorbidities, health status, arthritis symptoms, and the use of CAM and traditional providers and treatments for arthritis. Results. CAM provider use was reported by 28% of respondents, and 66% reported using one or more CAM treatments. Factors independently related to CAM provider use (P < 0.05) included podiatrist or orthotist use, physician visits for arthritis, and fair or poor self-reported health. For CAM treatments, independent associations were found with physical or occupational therapist use, physician visits for arthritis, chronic obstructive pulmonary disease, and alcohol abstinence. Rural residence, age, income, education, and health insurance type were unrelated to CAM use. Conclusion. Many older patients with arthritis reported seeing CAM providers, and most used CAM treatments. The use of CAM for arthritis was most common among those with poorer self-assessed health and higher use of traditional health care resources. KEY WORDS. Alternative medicine; Arthritis; Chiropractor; Geriatrics; Health-related quality of life.

INTRODUCTION
Arthritis and related disorders affect more than 42 million people in the United States, of whom 8 million are older

Presented in part at the Society of General Internal Medicine 22nd Annual Meeting, San Francisco, CA, April 1999, and at the Midwest Society of General Internal Medicine, Chicago, IL, September 1999. Supported in part by grant AG09682 from the National Institute of Aging Center for Research on Older Rural Populations. Dr. Kabolis work was supported in part by a Quality Scholars Fellowship, Department of Veterans Affairs. Dr. Rosenthal is a Senior Quality Scholar, Department of Veterans Affairs. Peter J. Kaboli, MD, Bradley N. Doebbeling, MD, MSc, Gary E. Rosenthal, MD (current address: University of Iowa College of Medicine, Division of General Internal Medicine, Iowa City), and Kenneth G. Saag, MD, MSc (current address: Department of Internal Medicine, University of Alabama, Birmingham), Iowa City Veterans Administration Medical Center, Iowa City, Iowa. Address correspondence to Peter J. Kaboli, MD, University of Iowa College of Medicine, Division of General Internal Medicine, SE-615GH, 200 Hawkins Drive, Iowa City, IA 52242. Submitted for publication June 18, 2000; accepted in revised form February 24, 2001.

adults (1). These disorders result in the highest frequency of daily symptoms and activity limitations of all chronic diseases in the older adult population (2). The estimated prevalence of chronic joint symptoms in American adults ranges from 12.3% to 22.7% and varies from state to state (3). Complementary and alternative medicine (CAM) use is generally highest among people with chronic syndromes, including musculoskeletal disorders such as back and neck problems and arthritis. A 1997 national survey in the United States found that 42% of the general population had used CAM therapies, and 46% visited a CAM provider in the previous year (4). Several earlier studies suggest that use of CAM is very common among patients with arthritis. In 2 clinic-based samples, 40% and 62% of patients with arthritis, respectively, reported seeing CAM providers (5,6). In a single North Carolina county, 92% of patients with arthritis who were referred for a survey interview reported the use of prayer (7). In a clinic population of patients with rheumatoid arthritis in Australia, 82% reported using CAM treatments (8). In a recent survey of rheumatology clinic patients, two thirds reported the use of a CAM treatment or provider on at least one occasion (9). The objective of the current study was to further examine the use of CAM in older patients with arthritis. In
2001, American College of Rheumatology Published by Wiley-Liss, Inc.

398

Arthritis Care & Research addition, we sought to identify sociodemographic, clinical, and health care access factors that were related to the use of both CAM providers and CAM treatments. To our knowledge, this investigation is the rst large populationbased study to address this question and the rst population-based study of CAM use limited to older patients. In examining these questions, we recognize that CAM encompasses a wide range of providers and a broad spectrum of treatments that have different levels of empirical evidence supporting their efcacy and that are associated with widely varying costs. For the purpose of the current study, we classied providers or treatments as complementary or alternative using prior published taxonomies (4,10). We also recognize that, as new data emerge, some CAM treatments may become more mainstream. For example, in the rst large population-based survey of CAM use in the United States in 1993, exercise was considered a CAM treatment (10). Since then, however, studies have supported the benet of exercise therapy for arthritis patients. For this reason, we elected not to include exercise as a CAM treatment. Our classication of CAM treatments included prayer, relaxation or biofeedback, topical treatments, diet or enzyme therapy, jewelry, meditation or imagery, spa therapy, herbs, mail-order products, and energy healing. We recognize that some treatments (e.g., topical creams) may be prescribed by traditional providers, and others may be generally recommended (e.g., balanced diet) but not widely advocated as a primary treatment of arthritis. Our classication of CAM providers included practitioners of chiropractic, acupuncture, massage, hypnosis, faith healing, iridology, astrology, and homeopathy, as is consistent with prior studies (4 6,10).

Use of CAM by Older Patients With Arthritis 399 at the University of Iowa College of Medicine approved administration of the survey. The survey instrument was administered by trained interviewers using a computerassisted telephone interview system (Sawtooth Software, Evanston, IL) from May through August of 1995. Details of survey design and implementation have been published previously (11,13). Subjects with a self-reported physician diagnosis of arthritis were identied by asking subjects, Did a doctor or health care provider ever tell you that you now or in the past have had arthritis or rheumatism? Subjects who responded in the afrmative were then queried about their current arthritis symptoms, sociodemographic factors, access to health care, behavioral risk factors, self-assessed health status, use of CAM and traditional providers and treatments for arthritis, and overall health care satisfaction. Arthritis symptoms included morning joint stiffness, morning stiffness lasting more than 1 hour, swelling of any joints (specically ngers, wrists, elbows, knees, ankles, and feet), bilateral joint swelling, rheumatoid nodules, crepitus, hip pain, pain in thumbs while grasping, and enlargement of the knuckles. Health care access factors that were examined included urban versus rural residence, self-reported distance from an arthritis care provider, private health insurance coverage supplemental to Medicare, and availability of a regular source of medical care. Traditional providers included the following types of practitioners: general practitioners, family practitioners, internal medicine specialists, rheumatologists, orthopedists, surgeons, neurosurgeons, and other physicians. CAM providers included the following: chiropractors, homeopathists, massage therapists, acupuncturists, acupressurists, hypnotists, faith healers, iridologists, astrologists, and other reported alternative providers. CAM treatments included prayer, relaxation techniques or biofeedback, arthritis diets or enzyme therapy, arthritis jewelry, spa treatments, energy healing, rub-on or topical treatments, mailorder arthritis products or products produced in other countries, and other reported alternative treatments. In assessing CAM use, subjects were asked about prior use of these providers and treatments during the past year and ever. All data management and statistical analysis were performed using SAS for Windows, version 7.0 (SAS Institute, Cary, NC). Associations between the use of CAM providers and treatments and potential risk factors were examined using the chi-square test for categorical factors and the t-test or Wilcoxon signed rank test for ordinal variables, depending on the normality of distribution of the variable. In these analyses, ordinal and interval variables (e.g., age, health status) were examined as both continuous and categorical data. Variable classications that maximized the strength of the bivariate association and were theoretically based were retained. Factors associated with the use of CAM providers or CAM treatments at any time in the past (P 0.05) were then entered into logistic regression analyses to identify those factors that were independently associated (P 0.05) with either CAM treatment or provider use. Separate analyses were performed using stepwise, backward, and forward variable selection criteria. The 3 criteria con-

PATIENTS AND METHODS

The current survey was part of a larger population-based survey of community-dwelling adults 65 years of age or older who reported one or more of the following physician-diagnosed chronic diseases: arthritis, hypertension, diabetes mellitus, cardiac disease, peptic ulcer, and chronic obstructive pulmonary disease (COPD) (11). The study sample was drawn from a population-based random sample of all telephone-containing households in 10 urban and 12 rural counties in Iowa. Classication of counties was based on United States Department of Agriculture urbanrural continuum codes (12). To increase the power to examine potential urbanrural differences, stratied sampling was conducted to maintain a one-to-one urban rural mix of subjects throughout the survey. Because rates of the primary outcome variables (i.e., CAM provider and treatment use) were comparable in the urban and rural counties, study ndings were not formally adjusted for the stratied sample. Fewer than 5% of households in the counties of interest were without telephones. To minimize responder bias, a potential respondent was chosen by a random selection method among eligible adults in the household. Respondents were at least 65 years old, had at least one of the indicator conditions, and were required to be able to complete a telephone survey. The Institutional Review Board

400 Kaboli et al verged on the same model. We also examined rst-order interactions (e.g., sex medication use) between variables in the 2 models and tested each of the potential interaction terms for statistical signicance.

Vol. 45, No. 4, August 2001

Table 1. Use of complementary and alternative medicine (CAM) providers and treatments at any time in the past and during the past year by 480 older respondents with a self-reported physician diagnosis of arthritis Any time n (%) Any CAM provider* Use of 1 CAM provider Use of 2 CAM providers Chiropractor Acupuncturist/massage therapist Hypnotist, faith healer, iridologist, or astrologist Homeopathist One or more CAM treatments* Use of 1 CAM treatment Use of 2 CAM treatments Prayer Topical treatments Relaxation/biofeedback Diet or enzyme therapy Jewelry Meditation or imagery Spa Herbs Mail-order products Energy healing 133 (28) 122 (25) 11 (2) 126 (26) 16 (3.3) 2 (0.4) 1 (0.2) 318 (66) 160 (33) 158 (33) 203 (42) 180 (38) 47 (10) 34 (7.1) 24 (5.0) 22 (4.6) 21 (4.4) 20 (4.2) 10 (2.1) 3 (0.6) Past year n (%) 79 (16) 74 (15) 5 (1) 73 (15) 10 (2.1) 2 (0.4) 1 (0.2) 273 (57) 155 (32) 118 (25) 189 (39) 128 (27) 39 (8.1) 27 (5.6) 7 (1.5) 16 (3.3) 12 (2.5) 18 (3.8) 8 (1.7) 2 (0.4)

RESULTS
A total of 4,582 calls were placed to identify 1,381 potentially eligible subjects with one or more of the target chronic conditions. Of these subjects, 119 (8.6%) were excluded because they were either too ill or unable to fully participate in the interview. Of the 1,262 eligible subjects, 861 (68%) initiated interviews and 787 (62%) completed the entire survey. The completion rate for interviews initiated was 91%. Thirty-two percent (401) did not agree to participate. Of the 787 subjects who completed surveys, 480 (61%) had a self-reported physician diagnosis of arthritis. One fourth of subjects (27%; n 129) reported osteoarthritis or degenerative arthritis, and 20% (n 95) reported rheumatoid arthritis. The remaining 53% did not know the type of arthritis they had. The mean age ( SD) of the 480 respondents was 75.0 6.5 years (range 6595); 25% were age 80 years or older. Seventy-three percent of the sample were women, 96% were white, and 53% lived in a rural county. More than two thirds (69%; n 330) reported seeing a traditional physician (general or family practitioner, internist, rheumatologist, or surgeon) specically for the care of arthritis or rheumatism at any time in the past, and 45% (n 215) had seen a traditional physician for arthritis in the past year. Twenty-nine percent (n 137) reported taking prescription medication for arthritis in the past month, 31% (n 148) had taken an over-the-counter medication in the past month, and 47% (n 224) took nonsteroidal antiinammatory medications for arthritis. The mean number of arthritis symptoms was 3.7 (range 0 15); 34% of subjects reported having 4 or more symptoms. Twenty-eight percent of respondents (n 133) had used a CAM provider at any time for arthritis, and 16% (n 79) reported such use in the past year (Table 1). More than 90% of respondents who saw a CAM provider ever or in the prior year had visited chiropractors. Other CAM providers, including acupuncturists, massage therapists, hypnotists, faith healers, iridologists, astrologists, or homeopathists, were seen less often (14%). Of the respondents using a chiropractor at any time for arthritis, 9% had also seen another type of CAM provider. Many more subjects used CAM treatments at any time, or in the past year, than actually visited CAM providers during the same intervals. Two thirds of respondents (66%; n 318) had used one or more of the treatments (Table 1) at any time, and more than half (57%; n 273) had used at least one of the treatments in the past year. In bivariate analyses, CAM provider use at any time in the past was higher (P 0.05) among respondents with poorer self-assessed health, those with higher numbers of arthritis symptoms, those who had seen a physician for arthritis care, those using a podiatrist or orthotist, and those seeing a physical or occupational therapist (Table 2). CAM treatment use at any time in the past was higher (P

* Use of provider or treatment specically for arthritis.

0.05) in patients with more arthritis symptoms, in those who had seen a physician for arthritis care, and in those using a podiatrist or orthotist or a physical or occupational therapist. In addition, CAM treatment use was signicantly associated with COPD, female sex, alcohol abstinence, and the use of prescription or over-the-counter arthritis medications in the past month. Other demographic and clinical factors including age, marital status, education, other comorbidities, insurance type, employment status, rural residence, prior joint surgery, and tobacco use were not associated with using CAM providers or treatments (P 0.1). In addition, urban and rural residents reported similar use of CAM providers (26% and 29%, respectively) and CAM treatments (75% and 74%, respectively) at any time in the past. There was no difference in CAM provider or treatment use by educational level among the 334 subjects (70%) for whom information about education was available (P 0.5). Rates of CAM provider use were 20% in subjects with less than a high school education, 27% in those with some high school education, and 26% in subjects with greater than high school education. Rates of CAM treatment use were 68% in subjects with less than a high school education, 76% with some high school education, and 76% with greater than high school education. In a stepwise logistic regression model, CAM provider use was independently associated (P 0.05) with fair or poor self-reported health compared with good, very good, or excellent health, use of a podiatrist or orthotist, and having seen any type of physician for arthritis care (Table

Arthritis Care & Research

Use of CAM by Older Patients With Arthritis 401

Table 2. Bivariate association of factors with complementary and alternative medicine (CAM) provider and treatment use at any time in the past among 480 older respondents with arthritis CAM provider use Self-assessed health Fair/poor Good Very good/excellent P value Arthritis symptom score 0 symptoms 13 symptoms 4 symptoms P value Prior use of a physician for arthritis Yes No P value Prior use of podiatrist or orthotist for arthritis Yes No P value Prior use of physical or occupational therapist for arthritis Yes No P value Chronic obstructive pulmonary disease Yes No P value Sex Female Male P value Alcohol abstinence Yes No P value Use of prescription arthritis medications Yes No P value Use of over-the-counter arthritis medications Yes No P value CAM treatment use

Table 3. Independent predictors of complementary and alternative medicine provider use (P < 0.05) as identied using stepwise logistic regression Odds ratio Podiatrist/orthotist use Any physician visits (arthritis care) Fair/poor self-reported health 95% CI* P value

2.1 1.14.0 0.02 1.8 1.23.0 0.01 1.6 1.032.6 0.04

36% 28% 22% 0.04 14% 26% 34% 0.002

66% 69% 64% 0.65 43% 67% 72% 0.001

* CI condence interval. Compared to respondents with excellent, very good, or good selfreported health.

32% 19% 0.004

74% 48% 0.001

47% 26% 0.003

80% 65% 0.04

cating excellent model calibration. The overall P value for the logistic regression model was 0.001. Independent risk factors for CAM treatment included use of a physical or occupational therapist, use of a physician for arthritis care, a comorbid diagnosis of COPD, and alcohol abstinence (Table 4). A signicant interaction effect was identied between over-the-counter (OTC) medication use and sex. Thus, the 2 variables were expressed as a series of 4 stratied variables. Results indicated that the increased use of CAM treatments in patients using OTC medications was greater in men than in women (Table 4). The Hosmer-Lemeshow statistic for the model was not signicant (chi-square 3.97, 8 df, P 0.78), again demonstrating excellent model calibration. The overall P value for the logistic regression model was 0.001.

38% 25% 0.01

82% 62% 0.001

DISCUSSION
This study is the rst population-based study of complementary and alternative medicine use specically conducted in older patients with arthritis. We found the incidence of CAM treatment use to be higher than that in some (4) but not all studies (9,14). This divergence between CAM treatment use (66%) and CAM provider use (28%) in patients with arthritis suggests that people with arthritis may be more willing to try complementary therapies but
Table 4. Independent predictors of complementary and alternative medicine treatment use (P < 0.05) as identied using stepwise logistic regression* Odds ratio Physical/occupational therapy use Any physician visits (arthritis care) Chronic obstructive pulmonary disease Alcohol abstinence OTC use and sex Men not taking OTCs Men taking OTCs Women taking OTCs Women not taking OTCs
* CI condence interval; OTC ication.

24% 28% 0.52 27% 30% 0.45 28% 27% 0.86

81% 64% 0.01 71% 55% 0.001 70% 58% 0.01

28% 27% 0.80

73% 64% 0.04

95% CI 1.13.4 1.94.6 1.57.2 1.33.2

P value 0.03 0.001 0.003 0.004

1.9 3.0 3.3 1.98 1.0 3.8 2.2 1.9

32% 26% 0.11

74% 63% 0.02

3). Interaction between the independent variables was tested, and no signicant interactions were identied. All variables identied in bivariate analysis (P 0.05) were considered for inclusion in the model. The Hosmer-Lemeshow statistic for the model was not signicant (chisquare 0.12, 8 degrees of freedom [df], P 0.99), indi-

1.310.8 1.23.9 1.13.2

0.01 0.01 0.01

over-the-counter arthritis med-

402 Kaboli et al less willing to see complementary providers for care of their arthritis. One of the principal ndings of this study is that respondents who used conventional physicians and other allied health services were also more likely to use CAM treatments and providers. This may represent the high utilizer effect described in a prior analysis of the high association between use of unconventional and conventional medical therapies (14). Our bivariate analyses suggested that a greater number of arthritis symptoms were associated with CAM treatment and provider use, but this was not supported in a logistic regression analysis. Poorer self-assessed health was associated with CAM provider use, and this is consistent with a prior study (15). Factors positively associated with CAM treatment and provider use may be surrogate measures of self-perceived severity of illness and symptom burden. Higher use of prescription and OTC arthritis medications was found to be highly correlated with CAM treatment use in bivariate analysis. In the logistic regression model, the effect of OTC arthritis medication use was dependent upon sex, which was shown by the signicant interaction terms. Men who took OTC arthritis medications were 3.8 times more likely to use CAM treatments compared with men who did not take OTC medications. Women were found to be signicantly more likely than men to use CAM treatments when controlling for OTC arthritis medication use. These increases in arthritis medication use are likely surrogate measures of increased symptom burden as well. Sex has been inconsistently associated with CAM use. It was associated with CAM use in one study (4) but was not found to be signicant in others (9,15). Additional factors associated with CAM treatment use included COPD and alcohol abstinence. Of the 5 common comorbid conditions specically evaluated in the overall study (hypertension, diabetes mellitus, cardiac disease, peptic ulcer, and COPD), COPD was the only comorbidity associated with increased CAM treatment use. It is possible that this association may be spurious or may be due to confounding by unmeasured covariates related to arthritis severity. There are no prior reports of increased use of CAM in older or younger COPD patients; however, our analysis is limited to only those with arthritis as well, so any conclusions should be made with caution. Similarly, the association with alcohol abstinence may be related to other unmeasured factors reecting health status or health behaviors. Alcohol use has not previously been reported in other population-based surveys of CAM use in older or younger populations. Interestingly, measures of access to care and several sociodemographic measures, including rural residence, were unrelated to either CAM provider or treatment use. In addition, although prior population-based surveys have found higher CAM treatment use in respondents with more education (4,9), we found that CAM use was not associated with educational level. Prior studies have also reported that subjects did not use CAM because of dissatisfaction with conventional medicine but rather because they found these health alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life (15). Although not specically

Vol. 45, No. 4, August 2001 examined, the higher use of CAM among those who have used traditional providers for arthritis appears consistent with the earlier ndings. There are some potential limitations of this study. The observational design of our study does not permit identication of cause-and-effect relationships. Thus, the degree to which factors associated with CAM use actually led to the use of CAM is uncertain. As in any study evaluating associations with multiple independent variables, some of the associations found to be of statistical signicance may represent chance or spurious relationships. The urban rural distinction in our sample was somewhat arbitrary. Geographic residence is best modeled along a continuum. To maximize contrasts, the Iowa counties that were selected were as disparate as possible with respect to rural versus urban classication. Our ndings are therefore representative of only these 22 Iowa counties. This survey was conducted in only one state, and it may not be generalizable to older patients in other regions of the country. Previous studies have shown higher use of CAM in western states than elsewhere in the United States (4). Our study also relied on patient self-reported data, which is an inherent limitation in most population-based surveys examining chronic illness and health care utilization. Although our cohort self-reported a physician diagnosis of arthritis, 31% denied ever seeing a traditional medical provider specically for arthritis care. It is unclear whether this group had in fact been told that they had arthritis but had never been specically seen for arthritis, or whether this was a self-diagnosis of arthritis. Moreover, a larger proportion reported a diagnosis of rheumatoid arthritis than would have been expected on the basis of epidemiologic data, and this may reect difculties by patients in differentiating rheumatoid arthritis from rheumatism. Nevertheless, our analysis was not predicated on precise clinical differentiation. In addition, the study population was predominantly elderly women (73%) who are white (96%), which may limit generalizability. Similarly, the study was conducted as a telephone survey and was limited to individuals who were able to complete the interview, spoke English, and had a telephone. The generalizability of our ndings to patients with arthritis who did not complete our interview is also uncertain. In households with more than one eligible person, the respondent was chosen by a random selection method. This method facilitates an unbiased sampling of the household unit but may bias the overall sample if age and sex distributions vary in households with more than one eligible person. Finally, the overall response rate to the telephone survey for eligible subjects was only 62%, which may also limit generalizability. Because of these sampling limitations, our study sample may not represent the overall universe of older arthritis patients in Iowa. The denition of CAM is subject to some variation across studies and to change over time as new empirical data about the efcacy of CAM modalities begin to accumulate. Such differences in denitions of CAM may lead to differences in prevalence. Moreover, although chiropractic care is generally classied as an alternative modality, it may become increasingly mainstream in the treatment of musculoskeletal disorders. Indeed, chiropractic

Arthritis Care & Research care is included as an acceptable treatment modality for acute low back pain in national guidelines (16) and is reimbursed by Medicare and other insurers. As more CAM modalities are studied or become part of mainstream medical practice, it is likely that denitions of CAM will change. Nevertheless, our taxonomy of CAM providers and treatments has been used in other studies (4,15). In addition, this survey was completed in 1995, and higher rates of CAM use have been reported over time (4). Patients may also be receiving more information on CAM modalities, such as increased advertising of nutritional supplements. Thus, our ndings may underestimate the current use of CAM. Finally, the relatively small sample size of our study may have limited the power to detect statistically signicant relationships with some risk factors, particularly low-prevalence factors. In conclusion, this study adds to the growing body of knowledge on the widespread use of complementary and alternative medicine in older patients. It underscores the relatively high utilization rates in older adults with chronic illness and stresses the importance of taking a complete medication history on use of all types of treatments for arthritis. The particularly high use of CAM treatments may indicate the inability of traditional medicine to adequately treat the perceived needs of this group of patients. The association between CAM use and the use of a physician and other allied health professionals may further identify high utilizers of medical care. Further studies are indicated to better understand the needs of older patients with arthritis and how those needs can best be met.

Use of CAM by Older Patients With Arthritis 403

3. Prevalence and impact of chronic joint symptomsseven states, 1996. MMWR 1998;47:34551. 4. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, van Rompay M, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998;280:1569 75. 5. Boisset M, Fitzcharles MA. Alternative medicine use by rheumatology patients in a universal health care setting. J Rheumatol 1994;21:148 52. 6. Vecchio PC. Attitudes to alternative medicine by rheumatology outpatient attenders. J Rheumatol 1994;21:1457. 7. Arcury TA, Bernard SL, Jordan JM, Cook HL. Gender and ethnic differences in alternative and conventional arthritis remedy use among community-dwelling rural adults with arthritis. Arthritis Care Res 1996;9:384 90. 8. Kestin M, Miller L, Littlejohn G, Wahlqvist M. The use of unproven remedies for rheumatoid arthritis in Australia. Med J Aust 1985;143:516 8. 9. Rao JK, Mihaliak K, Kroenke K, Bradley J, Tierney WM, Weinberger M. Use of complementary therapies for arthritis among patients of rheumatologists. Ann Intern Med 1999;131:409 16. 10. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med 1993;328: 246 52. 11. Saag KG, Doebbeling BN, Rohrer JE, Kolluri S, Peterson R, Hermann ME, et al. Variation in tertiary prevention and health service utilization among the elderly: the role of urbanrural residence and supplemental insurance. Med Care 1998; 36:96576. 12. Butler M. Rural-urban continuum codes for metro and rural counties. Washington (DC): Agriculture and Rural Economy Division, Economic Research Service, US Department of Agriculture; 1990. 13. Saag KG, Doebbeling BN, Rohrer JE, Kolluri S, Mitchell TA, Wallace RB. Arthritis health service utilization among the elderly: the role of urbanrural residence and other utilization factors. Arthritis Care Res 1998;11:177 85. 14. Druss BG, Rosenheck RA. Association between use of unconventional therapies and conventional medical services. JAMA 1999;282:651 6. 15. Astin JA. Why patients use alternative medicine: results of a national study. JAMA 1998;279:1548 53. 16. Clinical practice guideline number 14: acute low back problems in adults. Rockville (MD): Agency for Health Care Policy and Research (AHCPR), US Department of Health and Human Services; 1994.

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