Abstract
Background
Pediatric patients with chronic illnesses face a multitude of health challenges that are often inadequately addressed by conventional, siloed medical systems. Pediatric integrative medicine (PIM), blending complementary therapies with conventional medicine, offers an interdisciplinary and comprehensive approach to addressing these complex challenges. Despite growing demand for PIM, lifestyle-oriented care, and multimodal biopsychosocial interventions, few studies have described the clinical delivery of PIM within a large academic medical center.
Objectives
To describe the demographics, clinical characteristics, and interventions utilized within a physician-led, PIM clinic at a large, pediatric academic medical center.
Methods
A retrospective review was conducted of 2677 outpatient PIM physician office visits (March 2020–September 2023) among 657 pediatric patients (birth-25 years). Data on demographics, diagnoses, interventions, and supplements were extracted from the electronic health record and summarized using descriptive statistics.
Results
Patients (mean age 12.24 ± 5.20 years) were predominantly female (56%) and White (68%). Common conditions included anxiety (59.2%), fatigue (44.4%), headache (43.1%), abdominal pain (33.6%), constipation (33.0%), nausea (31.7%), vitamin D deficiency (30.1%), myofascial pain (29.5%), and depression (26.8%). Key intervention recommendations included dietary changes (61.8%), myofascial self-care interventions (33.8%), massage therapy (21.0%), acupuncture (19.2%), pacing (18.4%), sleep hygiene (18.3%), and exercise (18.1%). Common supplements recommended included probiotics (49.9%), vitamin D (42.6%), multivitamins (41.9%), fish oil (39.4%), magnesium (32.0%), Chinese herbs (29.7%), and melatonin (22.8%).
Conclusion
PIM can provide whole-person, integrative care within a large academic medical center for pediatric populations with complex presentations. Its self-governed structure within an academic medical center facilitates broad service integration, addressing demands for comprehensive care. Future practice-based research with standardized documentation and outcome measures is needed to understand PIM’s clinical effectiveness.
Introduction
The United States’ pediatric population is facing a rise in chronic illnesses including obesity, diabetes,1,2 asthma, 3 autoimmune conditions, 4 and mental health challenges, including those associated with social media use. 5 The increased prevalence of mental health challenges, especially anxiety, in all age groups, requires evidence-based care strategies that go beyond selective serotonin reuptake inhibitors (SSRIs) and other medications. 6 Novel disease entities such as long-COVID are pushing systems to find care paths for patients with minimally-understood symptom clusters that range from mild to severely debilitating, and for which no existing care rubrics are standardized or evidence-based. 7 Rising rates of pediatric chronic illness have also exposed gaps in our current care environment. These gaps include a lack of access to care models that can address lifestyle factors that influence the development and course of chronic conditions 8 and which might reduce the burden of pediatric poly-prescription medication use. 9
Additionally, the siloing of pediatric medical care into specialty subdivisions can perpetuate erroneous and outdated views that patients’ physical, cognitive, and emotional domains can be parsed and separated from their social context, belief systems, behavior, nutrition, relationships, and physical activity. This approach can leave patients and families feeling frustrated, 10 miss core drivers of disease, 11 delay health restoration, 12 waste resources, and leave primary care providers and specialists feeling disempowered and overburdened. 13 Treating the health burdens facing the U.S. pediatric population clearly demands multimodal, biopsychosocial interventions, 14 but there have been few descriptions of how to deliver such interventions. Public interest in and demand for natural- and lifestyle-oriented care for children has been a prominent and increasing trend, further challenging medical centers traditionally focused on pharmaceutical and surgical interventions to re-examine their offerings and respond to market demands. 15
One emerging approach that can help meet this demand is Pediatric Integrative Medicine (PIM), defined as a relationship-centered form of pediatric care that focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals, and disciplines to achieve optimal health and healing. 16 PIM providers typically employ complementary health care approaches that are blended into and intertwined with conventional medicine. 17 For example, when working with patients with irritable bowel syndrome – where psychosocial stressors, dysbiosis, suboptimal diet, and potentially unidentified infections can exacerbate gastrointestinal distress – PIM care strategies will often incorporate mainstream medications along with probiotics, dietary changes, mind-body coping strategies, acupuncture, cognitive reframing and hypnosis, herbs and supplements, and expanded testing.
PIM is un-siloed by nature. Conversation and care facilitation among specialties is critical to helping patients navigate their health challenges and achieve optimal outcomes. In collaboration with other specialists, PIM physicians can help patients prioritize treatments in an appropriate sequence, starting with the most natural, safest, and most cost-effective choices, and escalating as needed to more intensive, invasive, and potentially more costly strategies. Further, in situations where novel disease entities are encountered and no evidence-based strategies have been identified (eg, long-COVID), integrative thinking can span disciplines and explore treatment strategies that may influence underlying biologic, lifestyle, and mental health factors. Populations with novel diseases and conditions such as chronic fatigue, fibromyalgia, non-epileptic seizures, and postural-orthostatic tachycardic syndrome (POTS) often have no definitive home in a siloed medical system. Thus, PIM may be an ideal fit for such patients.
PIM care approaches that have demonstrated particular benefit include: (1) mind-body approaches for asthma 18 and ADHD19,20; (2) massage therapy and acupuncture for hematologic/oncologic conditions21,22; (3) yoga for irritable bowel syndrome (IBS) 23 ; and (4) various PIM approaches for pain.8,17 For example, training in yogic breathing has been associated with improved asthma control in children. 24 Integrative care approaches incorporating mindfulness-based interventions have demonstrated reductions in anxiety symptoms and improvements in emotional regulation among pediatric populations with anxiety and depression. 25 Further, dietary and probiotic supplement interventions within integrative pediatric care have shown efficacy in reducing gastrointestinal symptoms such as abdominal pain and constipation in children with IBS. 26 Through efforts from professional societies such as the Academic Consortium for Integrative Medicine and Health 27 and the American Academy of Pediatrics Section on Integrative Medicine, 28 knowledge and awareness regarding integrative programs within hospital systems has increased.
Still, relatively less is known about PIM compared to adult integrative care as research has lagged in pediatrics in general and there are fewer providers offering care. 16 The published landscape describing PIM services remains limited in scope, often describing services provided by integrative providers within specific service lines such as oncology, 29 pain management, 30 or gastroenterology, 31 rather than a physician-led, comprehensive, independent PIM service. Studies that have explored such services do offer a view of the heterogeneity of offerings and explore challenges to program development. 17 Clinical informatics infrastructure has also been underdeveloped among PIM providers, making it challenging to compare interventions and treatment impacts across populations and institutions. There remains little specificity on what services PIM clinics offer to children and what brings families to these clinics for care. Further, few studies have described how such services might fit into the dynamic of a pediatric, academic medical center. To address these gaps in the literature, this study describes the demographics, clinical characteristics, and interventions utilized within a physician-led, PIM clinic at a large pediatric academic medical center.
Methods
Setting
University Hospitals (UH) of Cleveland is a nonprofit health system in Northeast Ohio serving the needs of more than 1.2 million unique patients annually. With over 1300 pediatric specialists and 80 general pediatrics practices, UH Rainbow Babies and Children’s (UHRBC) provides pediatric specialty services across over 750,000 patient encounters annually within the UH Health System. 32 UH Connor Whole Health (UHCWH), a center for integrative health and medicine embedded within the UH health system, partners with physicians, providers, and institutes to meet the growing demand for the comprehensive treatment of chronic health conditions and overall wellbeing. UHCWH was founded in 2011 and has since expanded to include providers specializing in modalities such as acupuncture, chiropractic, massage, integrative medicine, expressive therapies, osteopathic manipulation, and lifestyle medicine.
Connor Whole Health Pediatrics
The UH Connor Whole Health Pediatrics (CWHP) program was initiated to identify and fill gaps in care within the pediatric service lines within the existing UH system. The framework for CWHP was to provide whole person care utilizing a biopsychosocial model, 33 integrating mainstream and complementary practices.
Establishment
CWHP was launched in March of 2020 through philanthropic funding. A pediatrician with dual training as a Medical Doctor and a Licensed Acupuncturist (National Certification Commission for Acupuncture and Oriental Medicine certified) was recruited to establish services. UHRBC care privileges for providing acupuncture, massage/body-work therapies, herbal medicine, and general medical care were obtained for both inpatient and outpatient care. Neither admitting privileges nor surgical or direct inpatient management was sought. The provider undertook all standard onboarding training offered by the hospital system and maintains all core competency requirements, vaccination requirements, and continuing and internal education requirements. Ohio licensure was obtained for both the Medical Doctor and Licensed Acupuncturist licensure groups. In alignment with the hospital system, all notes, orders, and other interactions were documented through the health system’s electronic health record (EHR) and email systems.
The purpose of CWHP was not to substitute for or compete with primary or subspecialty care, but rather to offer supplemental services to augment standard care offered by those practices. CWHP services included lifestyle medicine consultations, supplements, herbal medicine, acupuncture, body work therapies (eg, myofascial work, gua sha, and cupping), cognitive reframing, and pharmaceutical treatments. Patients could access CWHP through (1) a single, consultative visit; (2) a short series of visits to address a specific concern; or (3) long-term care for one or more issues. Patients were expected to maintain primary care services through outside practices, as core primary care components (eg, 24/7 call coverage, same day appointments, vaccine delivery, throat swabs, and other care) were not possible through CWHP. By July of 2020, outpatient clinics were established at three locations, offering access to care downtown and in the eastern and western suburbs. Virtual care was offered extensively at the onset and has remained a predominant means of accessing care along with in-person, outpatient visits. Though inpatient consults were made available, due to limitations of the COVID pandemic, minimal inpatient work was done at onset.
Promotion
To promote awareness and understanding throughout UHRBC, the physician met with individual providers across numerous specialties and offered grand rounds to providers from the departments and divisions of pediatrics, psychiatry, psychology, and hematology/oncology. Introductory PIM concepts were presented along with condition-specific evidence explaining the rationale for integrative approaches. A strong foundation in evidence-based medicine was core to the presentations and discussions. There was also considerable interest and need to explain how to access and obtain reimbursement for PIM services. Additional publicity and outreach efforts were conducted in collaboration with the UH public relations and development departments. News stories highlighting mind-body interventions, wellness, and whole health concepts were solicited and performed. Public events were hosted offering families tips for care emphasizing whole health, and discussion groups were offered where families could ask questions and learn more about natural medicine and holistic care. Meetings with donors were also held, cultivating those relationships and exploring potential points of collaboration and philanthropic support.
Referrals
Physician referrals to CWHP were not necessary to initiate care, and patients could self-refer. However, electronic referrals were encouraged to promote interdisciplinary collaboration. Referrals from CWHP back to other UH providers were readily made, and a key service gap was identified related to helping patients navigate the health system and find compatible providers. Since UHCWH providers specializing in chiropractic, acupuncture, and massage were already present, the CWHP medical director helped cultivate interests and skills related to pediatric care, with a goal of increasing flow through these specialties and expanding access to integrative modalities.
Collaborators
The CWHP medical director engaged in collaboration with physicians and researchers from psychiatry, psychology, sleep medicine, rheumatology, pain management, gastroenterology, endocrinology, hematology/oncology, and neurology. Mind-body and natural approaches for managing anxiety were of greatest interest to psychiatric, psychologic, and sleep medicine providers. Referrals back to these specialties were also frequent for collaborative care, especially for the detection and management of sleep apnea and management of circadian rhythm sleep disorders. Nonpharmacologic approaches to pain management and headache care were predominant interests among healthcare professionals from pain management, palliative care, neurology, and hematology/oncology. Gastroenterology physicians were particularly interested in care for IBS and unexplained (after workup) abdominal pain. Collaborative care for lifestyle and integrative management for pediatric patients with type II diabetes was the area of greatest interest for endocrinology.
The clinic ultimately began to serve as a center for the management of complex conditions such as long-COVID and other chronic fatigue syndromes. Many specific complaints presented in clusters in this population, especially POTS/orthostatic issues, myalgias, changes to taste or smell, and most of the cases of “dizziness” and “fatigue.” These conditions had no specific home within the hospital system otherwise.
Financial Model
Because the provider was a medical doctor and part of the UH system, insurance paneling was also part of the hiring process. This process facilitated access for patients from most major medical carriers in the area, as well as Medicaid and some Medicare patients. A billing code did need to be developed to allow for cash pay patients, and market appropriate rates were established for initial and follow up visits ($100 per 30-minute increment). Initial visits for cash pay were coded uniformly, and follow-up visits were conducted on a time-basis with 30-minute billing increments.
Participants and Design
This study is a retrospective review of all outpatient clinical encounters between March 2020 (CWHP initiation) and September 2023 among children, adolescents, and young adults aged birth through 25 years of age being seen by the CWHP medical doctor. The end date of September 2023 was set due to the UH health system’s transition from an Allscripts-based EHR to an Epic-based EHR.
Ethics and Permissions
Conduct of this study was approved by the UH Cleveland Medical Center Institutional Review Board as a retrospective chart review (STUDY20240394) of an EHR repository (STUDY20230179) with a waiver of informed consent.
Data Collected
We extracted the following data from all records meeting eligibility criteria: (1) demographic information including age, race, ethnicity, and sex; (2) clinical characteristics including International Classification of Disease 10th Edition (ICD-10) codes for all relevant diagnoses and chief complaints listed in the provider’s notes; (3) provider documentation data including history of present illness (HPI), orders, interventions, and supplements. All EHR data, including full note documentation, were extracted via a single, structured query language script from the UH Electronic Data Warehouse. We applied text mining functions including str_extract_all from the stringr package 34 and regmatches, gregepr, sub, and gsub from base R version 4.4.2 to detect patterns (eg, “supplements:”, “primary diagnosis,” “intervention recommendations”) and extracted clinical information from providers’ free-text notes. The lead physician also curated anecdotal findings from clinical practice within clinical documentation and concurrent notes.
Data Analysis
Descriptive statistics (eg, means, standard deviations, counts, and percentages) were calculated for patient demographics, clinical characteristics, interventions, and supplements. We extracted data from clinical narratives and analyzed descriptive statistics using R Version 4.4.2 and RStudio Version 2024.12.0 + 467. Anecdotal findings were summarized in narrative form.
Results
Sample Demographics
Demographics
aSex, race, and ethnicity are reported exactly as they were entered into the EHR and may not reflect patients’ gender, racial, or ethnic identities.
Conditions and Diagnoses
Conditions and Diagnoses
Table summarizes instances of text indicating the presence of these conditions and diagnoses within at least one clinical note among the patient sample. Abbreviations: ADHD, attention-deficit hyperactivity disorder; PNES, Psychogenic nonepileptic seizures.
Interventions and Supplements
Recommended Interventions and Supplements
Table summarizes instances of text indicating the presence of these recommended interventions or supplements within at least one clinical note among the patient sample.
Anecdotal Findings
Anxiety
Most patients presenting with anxiety were either already receiving or aware of pharmacologic interventions, but desired more nonpharmacologic treatment options to better manage their anxiety. Cognitive reframing techniques (eg, managing internal dialogs, perspective setting, habit formation and retraining, and desensitization techniques) were frequently taught within clinic visits to help patients develop new anxiety management skills. Patients particularly valued insights from Chinese medicine and historical perspectives on anxiety. Use of Chinese herbal strategies for anxiety were also employed including particularly Jia Wei Xiao Yao San35-37 and Wen Dan Tang.38,39
Long-COVID
It also became evident that some anxiety patterns were tied to long-COVID (situationally and biochemically), and those presentations required additional approaches such as the use of antihistamines. Most of the patients presenting with a fatigue complaint either had their fatigue emerge in conjunction with developing long-COVID or were found to have pre-existing Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Primary strategies for managing fatigue included pacing as an energy management 40 strategy and Low Dose Naltrexone (LDN) 41 as a pharmacologic approach. Pacing is a specific, evidence-based technique known in the ME/CFS realm that decreases fatigue by employing strategic, short activity breaks before patients reach a threshold of exhaustion. Some patients required additional, pharmacologic approaches such as methylphenidate and amphetamine-dextroamphetamine medications and occasionally modafinil. Many patients with long-COVID also presented with nausea. While other factors (eg, unrecognized infections) played a role for some, general nausea was a common complaint in about 30-40% of patients with long-COVID. The GI Map from Diagnostic Solutions 42 was valuable for assessing microbiome status and directing clinical care for some. This was an out-of-pocket test, however, and was not available to all patients.
Dietary Interventions and Nutritional Management
Many patients presented with diets high in sugar and processed foods and low in fiber and nutrient density. These diets are known to contribute to a myriad of health problems. 43 General dietary recommendations centered on working towards a highly plant-inclusive, high nutrient density, low simple carbohydrate, high antioxidant, low processed food diet. Dietary plans were tailored to fit within patients’ and families’ budgets and preferences, rather than being presented in an “all-or-nothing” fashion. Variations in acceptability and home resources had to be navigated.
Many patients also presented with food restrictions. Focus was often placed on “swaps” for foods in a slow, steady manner to gradually transform the diet and to facilitate manageable change. Switches to whole grain and higher protein pastas, for example, was a frequently implementable step. Changing snacks away from high-chemical, artificially colored products to simpler, less “flavor blasted” options was also feasible for many, as was intentionally adding in more of the fruits and vegetables that kids identified that they liked (but didn’t always have available). Other common and practical substitutions included water with a splash of high-quality juice in place soda or other high-sugar drinks. Whenever the recommendation to add in something healthy could be made, that approach was taken rather than imposing restrictions.
Encouraging dietary transformation as a family group was also emphasized, when possible, instead of trying to impose restrictions on the child while other household members continued to consume suboptimal choices. The ‘why’ of the changes were also made explicit, and presenting the suggestions as an intentional experiment instead of a “forever loss” helped ease into the transformations. Numerous food sensitivities were also considered and frequently identified. These included non-celiac gluten sensitivity, milk protein intolerance, sucrose and fructose intolerances, and other food and food-chemical sensitivities. Recognition and validation of “hungry-angry” patterns with appropriate, pre-emptive feeding strategies were also a component of care, meaningfully improving behaviors previously thought to be attention deficit disorder, “anxiety,” and/or behavioral aggression.
Probiotics and Supplements
Several clinical encounters focused on the appropriate use of probiotics and supplements. Patients rarely presented having utilized probiotics that were appropriately potent and formulated, despite a high historic receipt of antibiotics. Accordingly, a subset of patients presented with dysbiosis resulting from their dietary patterns and antibiotic exposures. Probiotics were frequently prescribed in this context. Similarly, vitamin D deficiency was quite common (30.1%) and examined using 25-OH vitamin D levels. Because of vitamin D’s global importance to health, correction was also done as part of an overall optimization strategy. Related to this, seasonal mood imbalances were not identified previously for a number of patients, and use of light-therapy was helpful as a non-pharmacologic support.
Pain Management
Myofascial pain was rarely identified as the cause of patients’ pain patterns prior to being seen at CWHP, indicating a clinical care gap in the broader system. Self-care intervention techniques were predominantly directed towards teaching home management strategies for myofascial pain, a condition which was often directly related to many patients’ headache complaints. In this context, patients were taught self-massage techniques, how to use gua sha and cupping at home, and other strategies such as stretching, warming, and how to understand ways posture and carrying heavy items such as backpacks may contribute to pain development. Many patients presented after a comprehensive workup was unrevealing otherwise. Working to empower patients to recognize this etiology and teaching them to self-treat was a clinical goal, with an intent on making them more independent of the medical system and less reliant on pharmaceutical pain treatments. Gua Sha, 44 a system of care originating in Chinese medicine utilizing pressure application via a smooth-edged tool drawn along taut bands of muscle (aka “Graston Therapy” in western physical therapy), was predominantly used for its powerful impact on myofascial pain and was frequently taught to families for home use.
Sleep
Sleep disruption and insomnia were also common, and families often needed information on how to engage in appropriate sleep-hygiene. Those service lines were often underutilized in the system, demonstrating an opportunity for PIM to engage in interdisciplinary care and referal back to existing hospital divisions. Use of screens before bed was very common along with poor adherence to circadian rhythms and sleep routines. Basic provision of sleep support services were provided along with frequent referrals to sleep psychology and sleep medicine. Herbal medicine was also used for sleep support, particularly Chinese herbal strategies (frequently Zhi Bai Di Huang Wan for presentations of frequent night waking with night heat and daytime irritability and emotional inflexibility), and consideration of iron deficiency and management of that was needed for a subgroup.
Discussion
The purpose of this study was to characterize the demographics, clinical characteristics, and interventions utilized within a physician-led PIM clinic at a large pediatric academic medical center. Our data describe (1) a population presenting to PIM care with multiple physical and mental-health comorbidities and (2) a collaborative care model embedded within a large healthcare system focused on helping pediatric patients engage in a combination of lifestyle, integrative, and supplement-based interventions. This model may be well-suited to particularly challenging medical conditions with a mix of underlying mental health, lifestyle, diet, and multisystem etiology. Importantly, PIM does not preclude the use of pharmaceuticals nor referrals for surgical interventions. PIM takes into account other approaches and health optimization strategies that are often lacking. Prevalent conditions within this study such as vitamin D deficiency 45 and myofascial-based pain 46 are examples of pathologies that are well understood within mainstream medicine, but which still remain largely unaddressed in the current care system. 47 Many pediatric patients often lack access to evidence-based, nonpharmacologic modalities to help manage their pain and anxiety, and the CWHP program was well suited to fill those gaps.
Patients presenting to CWHP had multiple complaints related to their mental health (anxiety [59.2%], depression [26.8%]), pain (headache [43.1%], abdominal [33.6%], myofascial [29.5%]), and gastrointestinal issues (constipation [33.0%], nausea [31.7%], appetite loss [23.7%]). Integrating diverse medical perspectives, such as those from Chinese medicine, contributed to a clinical environment that supported patients in conceptualizing their symptoms within a broader health framework, which helped destigmatize their experiences.
Regarding long-COVID, functional neurologic disorders (FND) were unusually prevalent in this sample. The incidence of pediatric FND has been estimated to be between 1 and 18/100,000. 48 Having 15 cases among a group of 657 (approximately 1/44) highlights an unusual prevalence among patients presenting to PIM. CWHP providers saw these cases increase substantially in conjunction with long-COVID, and more research is needed to determine specific PIM effects within the FND population and the link between COVID-19 exposure and FND.49-51
Establishing therapeutic relationships with families was also a strength and a challenge for the program. Longer visits were critical to providing comprehensive care and maintaining a holistic care plan, but often came at the cost of receiving less revenue per clinic day. Thus, diverse funding methods had to be pursued to sustain the PIM visit model. The program continues to explore options, such as shared medical appointments (aka group medical visits) to determine if quality and value can be maintained along with consistent revenue. It is noted that shared medical appointments, in particular, may fulfill numerous core goals of holistic care such as improved self-efficacy and social support. 52
It is unusual for PIM clinics to be self-governed within an academic medical center’s integrative health and medicine services. This structure allows for considerably greater autonomy in determining care offerings and patterns of care delivery. It also provided an alternative vision to the selective offering of specific services within existing hospital divisions (eg, acupuncture for pain and nausea management within oncology). If possible, the establishment of a free-standing, self-governed division of integrative medicine allows for more complete and rapid incorporation of a broader array of services than might be possible as a sub-division of another department. This structure also facilitates the development of research priorities and can create a context for the recruitment and cultivation of providers with interest and expertise in this care framework. Leadership within UHCWH also advocated for and practiced integrative medicine, so there was no learning curve needed to explain the treatment modalities or care philosophy. Providers practicing within other divisions, such as oncology, pain management, or family medicine, may not encounter this awareness of practice, necessitating more in-service training for colleagues and potentially more discomfort with integrative health and medicine modalities.
Integrating PIM services within the hospital system did demand conforming with the core structural requirements that other providers maintain. Adhering in a timely fashion to requirements that the hospital must maintain, such as continuing education, annual trainings, and other factors that can affect the hospital’s certifications are noticed and appreciated by leadership. Supporting the health system’s efforts to create a positive image and environment adds value beyond the patient care itself and can help programs stabilize and develop. Relationships matter when collaborating with colleagues, leadership, nurses, support staff, and all members of the healthcare community. Especially when offering novel care options and approaches, minimizing disruptions in relationships and culture overall is paramount.
The hospital system must also justify the cost/benefit status of all employees, and this can extend beyond direct patient revenue. Referrals back to other providers in the system, ordering lab work and other studies, and being a draw for patients into the system are all quantifiable components of value. Being a magnet source for patients seeking PIM care has intrinsic value, and promoting the hospital itself through news spots, public speaking, conference representation, publications, and professional work at local, state, and national leadership levels all help to promote better patient care. It is not realistic to expect that one-on-one patient care visits will fund all aspects of a comprehensive, PIM program. As for many mainstream providers in academic medical systems, grants, philanthropic funding, and operational support are needed to support programs. Internal department champions as well as support from hospital leadership are needed to continually transform and improve medical care.
Strengths of this study include using EHR data to describe real-world delivery of a novel PIM service within a pediatric academic medical center and using text mining functions to extract diagnostic and intervention data from clinical documentation. There were several limitations to this study. First, given the variation in referrals (i.e., verbal vs electronic), we were unable to describe the demand for CWHP services in terms of referring providers and reasons for referral (eg, pain management, fatigue). Second, while the Caucasian population reflected in this sample (68%) does reflect the overall distribution of the general Cuyahoga county population (63% Caucasian), 53 19% of patients had a race designation that was “declined, missing, or unknown.” Our known percentage of Black/African American patients (9.4%) was considerably less than the county rate of 30.4%. This makes it difficult to determine if CWHP access is distributed equitably throughout the region. Future research is needed to examine if race, income disparities, or cultural factors impact access to PIM care.
Third, the clinic also lacked standard documentation procedures and embedded patient-reported outcome measures. Thus, we were unable to describe effects on critical outcomes within this population such as anxiety, fatigue, physical activity, depression, and sleep disturbance. Because data were drawn from the written notes, documentation variations, even by a single provider, make it difficult to obtain certainty that all conditions, interventions, and other data were captured. Pharmaceuticals were utilized with some patients, for example, but capturing this retrospectively was difficult due to how prescribing data was encoded. Finally, we were unable to capture subsequent healthcare utilization (eg, chiropractic, acupuncture, massage, psychiatry) after CWHP care initiation. Additionally, because the providing physician was also a licensed acupuncturist, referrals back to the acupuncture service were more limited than they might have been otherwise. In general, the care provided at this clinic was strongly influenced by the training, interests, and skills of the providing physician. Other clinics may develop differently and have different needs and priorities based on the qualities of that clinic’s leadership and available providers.
Conclusions
Patients seeking PIM services within a large academic medical center often present with multiple, comorbid physical and mental health conditions. Through employing a combination of lifestyle medicine interventions, supplements, herbal medicine, cognitive reframing, acupuncture, body work therapies (eg, myofascial work, gua sha, and cupping), alongside conventional care approaches, PIM physicians may help fill gaps in service delivery and improve patient and provider experience. Moving forward, research efforts should aim to better characterize PIM practices through systematic research and documentation. Embedded patient-reported outcome measures would assist in directing goals of care and quantifying effectiveness within different pediatric populations. As institutions continue to refine their approaches, a commitment to flexibility, evidence-based practices, and comprehensive documentation will remain pivotal in shaping the future of this field.
Footnotes
Acknowledgements
We thank the patients who received the integrative health and medicine modalities analyzed in this study. We would also like to thank the following collaborators on this study: study coordinators Tracy Segall, MSHS and Lucas Jones, PhD; Supervisors Francoise Adan, MD and David Vincent, DC; Clinic coordination including Jessica Garrity, MA and Tierra Jones. We also thank the philanthropic supporters of the clinic, including especially the Connor Family, Stephanie and Juan Antunez; Kathy and Jim Pender; Carran and Russ Gannaway.
Ethical Considerations
Conduct of this study was approved by the UH Cleveland Medical Center Institutional Review Board as a retrospective chart review (STUDY20240394) of an EHR repository (STUDY20230179) with a waiver of informed consent.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is supported by the Elisabeth Severance Prentiss Foundation.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The datasets generated and/or analyzed during the current study are not publicly available due to privacy restrictions as the databases contain information that could compromise the privacy of research participants. However, the de-identified datasets are available from the corresponding author on reasonable request.