Evolution of a Policy Disallowing the Use of Alternative Therapies
The evolution of a policy disallowing patients' use of alternative therapies in a health system is described.

The pharmacy and therapeutics (P&T) committee at Children's Hospital of Michigan, a part of the Detroit Medical Center (DMC), was asked to review the appropriateness of allowing inpatients to bring in and use alternative therapy products during their hospitalization. Recognizing the interest of consumers in alternative medicines and patients' growing involvement in their own care, the committee drafted a policy that allowed patients to continue taking dietary supplements after being admitted to the hospital. If the physician had no concerns about potential toxicities or drug interactions for a particular product, he or she would write a medication order allowing it to be used. Purchasing and administering the products were deemed the responsibility of the patient or the family. However, many issues concerning supplements remained unresolved, including questions about safety, efficacy, dosing, drug interactions, ethical conflicts, and liability. Ultimately, the P&T committee decided that the potential risks associated with alternative therapies outweighed potential benefits and adopted a policy disallowing the use of alternative therapies by hospitalized patients. The policy was eventually implemented at all eight DMC hospitals.

A health system responded to patients' desire to continue their use of alternative therapies during hospitalization by drafting a policy allowing such use. However, concerns related to safety, efficacy, ethics, and liability led to the abandonment of the liberal policy and implementation of a highly restrictive one.

The popularity of alternative therapies has grown tremendously in recent years. It is estimated that consumers spent between $4 billion and $5.1 billion on herbal products alone in 1998; sales in 2000 are expected to exceed $12 billion. Eisenberg and colleagues recently reported that 4 out of every 10 Americans used at least one alternative therapy, including herbal dietary supplements, in 1997. Furthermore, their national telephone survey found that 44% of respondents were taking prescription medications; approximately 19% of these reported using a herbal dietary supplement, megavitamin therapy, or both concurrently with the prescription drugs. Few of the patients who were seeing a physician, however, informed the physician about the alternative treatments.

Patients are using alternative therapies in an effort to manage a variety of diseases and disorders, including asthma, cancer, rheumatoid arthritis and other inflammatory conditions, irritable-bowel syndrome, anxiety disorders, depression, low back pain, and headaches. While some of the available products may offer therapeutic benefits, there are substantial concerns about adverse effects, potential interactions with conventional treatments, variable product quality, and effectiveness. Also, beliefs in these products may cause patients to delay seeking assessment by health care professionals or conventional treatments in situations where early treatment might effectively eliminate symptoms or provide a cure.

Probably many patients who are admitted to hospitals use some type of dietary or other supplement at home. Many of these patients want to continue using their supplements while in the hospital. Supplements contain pharmacologically active compounds about which limited safety and efficacy data are available, and, despite not being classified as drugs by the Food and Drug Administration (FDA), they meet the broad definition of "drug" given by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). JCAHO expects health systems to manage these products with the same diligence and care given to any medication brought into the hospital by patients and their families. Supplements should be subjected to medical staff review and approval and governed by institutional policies that regulate the use of non-prescription medications.

These regulatory expectations afford health systems considerable latitude in handling alternative products. Methods for managing supplements in health systems range from absolute prohibition of their use in the inpatient setting to liberal policies that allow use of all such products by patients when hospitalized. However, the paucity of efficacy data and the concerns about product safety and quality complicate this issue for health systems. The use of supplements in the inpatient setting also raises concerns about liability and professional ethics that health systems must consider.

The following case that occurred at Children's Hospital of Michigan (CHM), the pediatric hospital within the Detroit Medical Center (DMC), brought attention to the need to address the issue of alternative therapy use in our health system. Working through the many questions surrounding the use of alternative therapies was instructional. This article describes our experience with the alternative therapy issue and identifies specific factors we considered in developing a policy to address it. A policy that allowed the use of alternative therapies was drafted for the pediatric hospital. However, concerns were raised before the policy was implemented that led to its replacement by a policy disallowing the use of these products.