Homeopathic medical practice: Long-term results of a cohort study with 3981 patients

Homeopathy is one of the most frequently used and controversial systems of complementary and alternative medicine. It is based on the 'principle of similars', whereby highly diluted preparations of substances that cause symptoms in healthy individuals are used to stimulate healing in patients who have similar symptoms when ill [1]. When a single homeopathic remedy is selected based on a patient's total symptom picture, it is called 'classical' homeopathy [2]. According to a survey in the US [3], the proportion of patients obtaining homeopathic care has quadrupled in the last seven years. A survey in Britain [4] estimated that annual expenditures reached £34.04 million (out-of-pocket £30.74 million, NHS £3.3 million). For Germany, the country in which classical homeopathy originated, a recent survey demonstrated that approximately 10% of men and 20% of women in the general population used homeopathic medicines during the previous year [5]. General trends show a rise in the number of individuals utilising naturopathic and homeopathic therapeutic methods [6].

The General Medical Council in Germany grants an official certification in homeopathy to physicians upon successful completion of a three-year-long training programme. Approximately 4,500 physicians in Germany hold this additional certification [6]. However, with the exception of some randomised, controlled trials including patients with selected diagnoses [2, 7] there is no data on the health care offered by classical homeopathic medical practices. Therefore, it is impossible to assess the state of homeopathic health care and its effectiveness. We designed this project with the goal of systematically collecting data in the area of homeopathic health care for the first time in Germany. The aim of the present study was to determine the spectrum of diagnoses and treatments, as well as the course of disease over time among patients who chose to receive homeopathic treatment.

Patients were included consecutively in this prospective, multi-centre observational study upon their first consultation with a participating physician and were followed up for a total of 24 months. Evaluations were made using standardised questionnaires. In order to provide as representative a picture of homeopathic health care as possible, patients were included in the study regardless of their diagnosis. Patients were eligible for the study if they were consulting the participating physician for the first time and were at least 1 year of age. In order to participate in the study, physicians were required to have passed certified training in classical homeopathy and at least three years of experience in its practice. A total of 187 physicians belonging to four different working groups were contacted either by post or telephone and informed about the study. Of these, 103 physicians chose to participate. Each participating physician was trained in study procedures and was subject to at least one monitoring visit during the study period. All study participants provided written, informed consent, and the study protocol was approved by the appropriate ethics review boards.

A total of 103 physicians participated in the study (51 male, 45 ± 7 years of age; 52 female, 45 ± 7 years of age). Twenty-six percent of the participating physicians were specialists (10% internists, 9% paediatricians, 7% other) and 74% were general practitioners. The average duration of overall medical practice was 17.4 ± 8.4 years with 9.0 ± 4.4 years of practice in homeopathy (range 3–20 years). Forty percent of the physicians were certified to work in the public health care system, and 60% were in private practice.

Patients were recruited for the study between September 1997 and December 1999. Of the patients who met the inclusion criteria, 3981 (68%) chose to participate and were included in the study (for patient selection see Figure 1). Of these, 2851 were adults (71% women) and 1130 were children (48% girls). The baseline characteristics are listed in Table 1.

On average, the homeopathic physicians made 2.6 ± 1.2 diagnoses per patient (2.8 ± 1.1 in adults, 2.3 ± 1.1 in children). Ninety-seven percent of all diagnoses were classified by these physicians as chronic with a median duration of 4.3 ± 2.7 years in children and 10.3 ± 9.8 years in adults. Almost all patients had received conventional treatment (95%) or had already contacted another physician (95%) prior to the start of this study. The most common diagnosis in women was migraine (9.7%), in men allergic rhinitis (10.3%), and in children of both genders atopic dermatitis (20%), for details see [17]. For the most common disease groups see Figure 2.

All patients underwent an initial homeopathic anamnesis, lasting an average of 2.0 ± 0.7 hours. Following enrolment in the study, patients had to wait an average of 57 ± 84 days before undergoing the initial anamnesis. During the 24-month observation period, patients consulted their physicians an average of 7.8 ± 8.4 times. During the study period, half of the patients (50.3%, adults: 50.8%, children 48.9%) noted additional visits to non-study physicians (gynaecologists and dentists excluded). The intake of conventional medication decreased from 45.0% at baseline (adults: 50.2%, children 31.7%) to 26.8% after 24 months (adults: 31.8%, children 14.2%).

In adults, large improvements in quality of life were observed on both component scales (mental and physical) during the first three months of treatment, and continued to improve during the course of the study (see Table 2). Even with the pessimistic assumption that the test-retest correlation of the SF-36 is only 0.7 and that the study population is no more ill than a random sample of the general population, one could expect an improvement of only 3.8 (1.2) score points on the mental (physical) component scale, attributable to regression-to-the-mean [16], markedly lower than the 5.6 (2.6) score points observed in our study (Table 2). Statistically, the baseline quality of life of non-completers was not significantly lower than in other patients (p-values: MCS: p = 0.37; PCS: p = 0.48, Wilcoxon-tests).

Quality of life in young children (age 1–6 years) also improved markedly during the observation period (Table 2), having already risen during the first three months of study therapy as measured on both scales of the KITA questionnaire (mental-physical dimension and aspects of daily living, each p < 0.001, see Table 2). These improvements continued over the course of treatment (p < 0.001, see Table 2). In school children and adolescents, however, an improvement in quality of life was only visible during the first three months of study therapy (p < 0.001, see Table 2).

The diagnosis had no relevant influence on the changes in patient complaints or quality of life as measured in this investigation.

Patient and physician assessments of disease severity and quality of life consistently demonstrated substantial improvements following homeopathic treatment, which were maintained through 24 months' follow up. Improvements were more pronounced in younger patients and in those with greater disease severity compared to older patients and those with less severe disease at baseline.

To our knowledge, the present study is the first to evaluate systematically the range of diagnoses and therapies in classical homeopathic medical practices in Germany and Switzerland. In addition, the study provided information on the course of illness in patients receiving homeopathic treatment, as assessed by patients and physicians.

The methodological strengths of our study include consecutive enrolment of a large sample size, the participation of approximately 2% of all physicians certified to practice homeopathy in Germany and 28% of all members of the Hahnemann Association (an organisation for physicians practicing only 'classical' homeopathy) and the use of standardised outcome instruments also used in studies on conventional therapy.

One limitation of our study is that the observed effects cannot be categorized with respect to specificity, i.e. we cannot draw conclusions as to the beneficial mechanisms. Furthermore patients were allowed to use conventional therapies during the study period in addition to homeopathic treatment. Thus, the observed improvement cannot be attributed to homeopathic treatment alone. The aim of the investigation, however, was not to test the effectiveness of homeopathic treatment alone, but rather provide systematic and detailed information about the current status of homeopathic medical care in routine practice and its effectiveness. These data may also be helpful in the planning of further research projects on homeopathy.

The effects observed by patient and the physician assessment, as well as those seen with regard to quality of life, deserve additional comments. The average severity of the chronic diseases was reduced by approximately 50% after only 3 months of homeopathic treatment, and remained around this level during the follow-up period. Physician assessments tended to be more positive than patient assessments.

The improvements we observed in our patients cannot be attributed solely to regression-to-the-mean, because the improvements were greater than could be expected even under conservative model assumptions. This is supported by the fact that patients did not visit the study physicians when they were feeling the worst, but rather after a long waiting period.

A strength of this study is that patients with all diagnoses were included. Therefore, no disease-specific measurement instruments could be used. To assess the severity of different medical complaints, there is no other generally accepted measuring instrument available. Instead numerical rating scales [8] were applied, which would allow for the determination of illness severity in a diagnosis-independent manner.

Compared to the other quality two of life questionnaires used in our study, the KINDL questionnaire for the age group 7 to 16 years was not sensitive to change, as has been shown in other studies [18, 19]. Other explanations might be that children adapt easier to perceived quality of life and that the dimensions of Quality of life used for adults are not transferable to children. However, there is no other generally accepted measuring instrument available in German-speaking countries.

In the range of baseline diagnoses, chronic illnesses clearly predominated (>95% of diagnoses). Among these, headache and atopic disease (allergic rhinitis, asthma and atopic dermatitis) were the most common diagnoses. As the clinical histories of our patients showed, most of our patients decided to consult a homeopathic physician only after having received conventional treatment. This, together with the extensive initial case taking and the reputation of homeopathy as a "medicine designed to treat the individual as a whole"' causes a selection for chronic illnesses.

We were unable to confirm the common notion that homeopathy is frequently used for trivial complaints or diseases. The duration of disease in study patients was very long and their symptoms were, on average, of moderate severity.

In this study we were not able to evaluate different types of homeopathic strategies. For quality assurance purposes, we avoided selecting a random sample of homeopathic physicians for the study, choosing instead to recruit physicians schooled and certified in 'classical' homeopathy. The results of our study are, therefore, representative only for the classical type of homeopathy that was practised by participating physicians. Compared to conventional medical practices, headache and atopic disease (allergic rhinitis, asthma and atopic dermatitis) were the most common diagnoses in homeopathic practices (as opposed to hypertension, hyperlipidemia and low back pain in 70,000 patients treated conventionally) [9]. An American study [20] found asthma, depression, otitis media, and allergic rhinitis to be the most common diagnoses treated in homeopathic practices, compared to hypertension, upper respiratory tract infection, otitis media and diabetes mellitus, which were treated most commonly in conventional practices.

A health insurance company project that included about 900 patients treated with homeopathy in routine care [21] showed an improvement in quality of life and in physician assessment. In Güthlin's study [21], however, only physicians certified to work in the public health care system were able participate. Homeopaths working in private practices (i.e. the great majority in Germany) were excluded. The advantage of the present study is that doctors in private practice were also included, thus providing a more detailed and broader basis for describing the current status of homeopathic health care. Another controlled study in cooperation with a German health insurance company [22], indicated similar overall effectiveness of homeopathically versus conventionally treated patients for selected diagnoses and in some groups, superiority of homeopathic treatment.

We evaluated for the first time the range of diagnoses and therapies at medical practices offering classical homeopathic treatment in Germany and Switzerland. The findings of our study demonstrate that patients who seek homeopathic treatment are primarily those suffering from long-standing, chronic disease. Both according to physician and patient assessments, the severity of complaints decreased markedly over the 24-month observation period. Younger patients and those with more severe disease appear to benefit most from homeopathic treatment. Among adults and children, we observed an increase in quality of life. Our findings indicate that homeopathic medical therapy may play a beneficial role in the long-term care of patients with chronic diseases.