Co-creation of an evidence-based toolkit to facilitate communication on complementary medicine between conventional and complementary healthcare practitioners in the Netherlands

Co-creation of an evidence-based toolkit to facilitate communication on complementary medicine between conventional and complementary healthcare practitioners in the Netherlands | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Co-creation of an evidence-based toolkit to facilitate communication on complementary medicine between conventional and complementary healthcare practitioners in the Netherlands Louise TC Mulder, Martine Busch, Armelle Demmers, Herman A van Wietmarschen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4268398/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : The Dutch health care system is in need for guidance and implementation of complementary care of which shared decision making, communication and referral between conventional and complementary care practitioners are major components. A Dutch quality register for complementary healthcare practitioners (RBCZ) was interested to adopt and implement an improved version of a communication toolkit developed in an earlier project. The aim of this study was to improve the communication and collaboration between member practitioners of RBCZ and conventional healthcare practitioners. Methods : The set of communication tools was updated and expanded with new tools in a co-creation process with conventional and complementary healthcare practitioners in three field labs; Utrecht, Amsterdam and the north of the Netherlands. Thematic focus group discussions were held to define the content and implementation of the toolkit. A pragmatic evidence-based decision aid for the respective complementary care modalities was developed based on a literature assessment and Strength Of Recommendation Taxonomy (SORT) criteria. Results The final evidence-based toolkit consisted of seven communication tools, covering the themes: getting to know each other, communication, frame letters, decision aid with evidence-based recommendations for 13 complementary therapies and 6 indications, and support for communication of the RBCZ members/professional associations and implementation. Conclusions : The evidence-based toolkit will be made available to 25 professional associations covering over 9.500 complementary healthcare practitioners in the Netherland (RBCZ). The regional collaboration amongst complementary healthcare practitioners was strengthened as well as between complementary and conventional healthcare practitioners. communication healthcare practitioners decision aid complementary care field labs SORT implementation INTRODUCTION The Dutch healthcare system is under pressure and faces many challenges with the rising number of elderly and people with chronic conditions [1], increasing workload for healthcare professionals[2] and rising healthcare costs. This has enforced a paradigm shift towards patient-centred care where lifestyle, prevention and patient’s ownership regarding their health (self-management) are becoming increasingly important [3], [4]. These newly demanding changes in healthcare could be partly met by the use of the various types of complementary care which are commonly based on whole person health, a holistic view of the human being, patient-centred care and on promoting the self-healing capacity of the body [5]. Data on the use of complementary care in the Netherlands is scarce. Kemppainen et al. reported that 14.1% of the Dutch population had used at least one complementary therapy over the last 12 months in 2016[6]. In various patient populations this number is higher, for instance the use of complementary care in people with chronic joint pain is estimated to be as high as 86% [7], one third of children visiting a paediatrician use complementary care [8] and 42.4% of children visiting a paediatric oncologist use complementary care [9]. Although complementary care is generally being applied on a small scale in hospital settings, often unstructured and without any policy and procedures, there has been an increase in the interest and use of complementary therapies over the past decades, especially in oncology, in psychiatry and in palliative care settings for symptoms such as anxiety, stress, pain and fatigue [10]. This is also reflected in the growing number of initiatives regarding non-pharmacological interventions in hospitals and nursing homes and integrative outpatient clinics [11], [10]. Therefore, there is need for guidance and implementation of complementary care, since the infrastructure of the Dutch healthcare system does not facilitate this [11]. Guidelines on complementary therapies for general practitioners (GPs) were developed in 2008 (revisioned in 2022) by the Royal Dutch Medical Association [12]. However, these guidelines only describe conditions under which a GP is allowed to practice complementary care himself, but does not give any guidance about communication, referral or collaboration. In 2016, a first model was developed for the integration of complementary therapies into primary healthcare in the Netherlands, with patients’ needs as starting point [13]. An important step is to build an integrative collaborative network of GPs and complementary care practitioners [14]. Moreover, shared decision making was introduced to facilitate discussions on complementary care between patients and GPs. Shared decision making includes discussion of the patients’ health problems and history, complementary therapy options which enables the patient to make safe and well-informed decisions consistent with her values and preferences. However, patients mostly do not discuss their complementary therapy use during a consultation with their GP. They expressed the need that they would rather want their GP to listen, to inform them about complementary care options and if necessary, to refer them to or collaborate with complementary healthcare practitioners (HCPs) [7]. Patients would benefit from an active involvement of GPs concerning communication and shared-decision making on possible referral to complementary therapies. On the other hand, the main barriers in primary care to communicate, collaborate with and refer to complementary care are the lack of knowledge about complementary therapies, their effectivity and safety, lack of concrete information to provide to patients and lack of knowledge about the reliability and professional standards of complementary care practitioners [13]. In a previous project in the Netherlands, needs and wishes were assessed of complementary HCPs of five modalities (acupuncture, chiropractic, osteopathy, homeopathy and naturopathy) and GPs regarding communication and collaboration in complementary care in a series of focus group discussions [15]. The result was a first evidence-based communication toolkit aimed to be used by complementary HCPs to contact and communicate with GPs about their treatment of mutual patients. It was concluded that communication between conventional and complementary HCPs should be further strengthened and the tools should be further expanded, optimized and implemented. Since this toolkit was targeted solely towards GPs, it was desired to extend towards other conventional HCPs, such as medical specialists, nurse practitioners and physiotherapists. This paper describes the process and outcome of a co-creation research project that aimed to strengthen communication and collaboration between complementary and conventional HCPs and improve mutual collaboration between complementary HCPs in the Netherlands. In three field labs the existing communication toolkit was assessed and updated, new communication tools were developed, and implementation strategies were discussed. Additionally, researchers aimed to develop an evidence based decision aid for complementary care for 13 complementary therapies and 6 indications. METHODS This participatory research project was conducted in the Netherlands from November 2021 – November 2023 by a project team consisting of researchers from Louis Bolk Institute, Van Praag Institute and RBCZ. It comprised creating field labs with complementary and conventional healthcare professionals as well as a literature search on complementary therapies for a set of indications. Organizing the field labs In collaboration with RBCZ, the largest umbrella association which certifies, registers and represents the interests of complementary and alternative HCPs in the Netherlands, three multidisciplinary regional field labs were composed [16], [17]. Recruitment of complementary healthcare practitioners The board of RBCZ was responsible for the recruitment of the professional associations. 88% (n = 16) of the RBCZ professional associations who filled in a need assessment (n = 18) regarding conducting research stated their interest in participating in the field labs. Professional affiliated associations of RBCZ were contacted by RBCZ and asked to participate. In total, 13 professional associations were included in the study. Each professional association willing to cooperate in the study delegated two member practitioners, who served as representatives of that professional association and complementary therapy in the field lab. Based on the geographic locations of the practices of the representatives put forward by the professional associations, three regions of the Netherlands were selected to set up the field lab. The inclusion criteria for the professional associations were: (1) enough members in the specific region to ensure widespread multidisciplinary collaboration; (2) some indication of scientific evidence for the complementary therapy concerned; (3) previous collaboration with conventional HCPs was desired but not mandatory. The complementary practitioners of each field lab had a first online meeting to get to know each other and to identify which type of conventional HCPs should be invited to complement each group. Recruitment of conventional healthcare practitioners Snowball sampling technique was used to recruit individual conventional HCPs, mainly via the network of the Van Praag Institute and Louis Bolk Institute. An invitation to participate was sent out through the newsletters of two academies for integrative medicine and a national network of family nurse practitioners. Various health centers and regional support structures for primary care in the three regions were contacted through an invitation letter by email. Respondents received more information about the study by email and conversations by phone. Each field lab consisted of a combination of 15–17 HCPs, with a maximum of 10 complementary HCPs and 5–7 conventional HCPs. Advisory board Next to the field labs, an advisory board was installed with complementary HCPs (n = 27) from the 13 professional associations, who could not be included in the field labs, mainly because they were not located in the region. These practitioners represented the same therapies included in the field labs and met twice during the project. The advisory board gave advice and feedback on structuring collaboration between conventional and complementary HCPs in the region, mutual collaboration among complementary HCPs and implementation of the communication tools. Next to the advisory board, all boards of the professional associations of RBCZ met twice during the project, at the start and at the end to reflect on the process, to give input on the communication tools and to advise on implementation of the results. Content of the field labs First, a joint online kick-off meeting was organized for all conventional and complementary HCPs participating in the three field labs, the advisory board, and the board of RBCZ. The goal of the project, field lab approach, roles of stakeholders, and focus groups were presented to everyone involved. Themes and content of the focus groups In order to extend and further develop the existing communication toolkit and to strengthen communication between the various HCPs four focus group discussions were set up per field lab and guided by two researchers. It was assured that at least one representative per professional association (five in total) and at least three conventional HCP were present during each focus group meetings. The following themes were discussed: (1) working with and implementing existing communication tools, development of new communication tools, (2) perceived needs regarding communication and collaboration between the participating conventional and complementary HCPs, (3) how to improve communication, (4) indications for which it could potentially relevant to collaborate with complementary HCPs, (5) safety of complementary therapies and (6) implementation of the communication tools. The existing communication toolkit was extended via an iterative and co-creation method. After each focus group the input was collected, combined, a brief thematic analysis was performed and presented for feedback in the next focus group meetings. In addition, input from the advisory board was collected and presented, and discussed in each focus group meeting. Consequently, consensus was reached regarding the content and quality of the communication tools, meeting the needs of both complementary and conventional HCPs. After the fourth and last focus group meeting of each field lab, the researchers developed the concept versions of the tools, which were sent by email to all field lab participants for a last round of feedback. Implementation and dissemination of the results The concept versions of the tools were presented to RBCZ. Two meetings with researchers, a RBCZ board member and the RBCZ web designer were organised to discuss options for design and dissemination of the tools. Thereafter, the concept versions of the tools were then discussed with the advisory board after which the final version was developed and presented to the boards of the professional associations. Finally, the final versions were communicated to all the participants of the field labs. Development of the decision aid for complementary care One of the communication tools contained an overview of scientific evidence for a number of complementary therapies for a set of indications. Indications were chosen based on the focus group discussions which is described in the result section below. Literature search The literature search was performed in the electronic database Pubmed from March – August 2023. MeshTerms were determined for each indication and complementary therapy. In case no MeshTerm was found, alternative search terms were used based on input of the focus groups and existing literature. Search strings were composed of MeSH terms and additional terms for the complementary therapies and indications combined (Appendix I). Professional associations were asked to provide literature from their own databases. Titles and abstracts were screened for inclusion by one author (LM). Studies were excluded in case the content did not cover the indication and therapy concerned, the paper was not accessible or language was not English, Dutch, French or German. Evidence grading Two authors (LM and HvW) independently reviewed and graded the included studies. Evidence grading was based on the Strength of Recommendation Taxonomy (SORT) method [18]. This method addresses the quality, quantity, and consistency of evidence which allows rating the quality of an individual study and of a body of evidence for each complementary therapy and indication. Moreover, since the SORT method follows a patient-centred approach this leads to an easy translation from the strength of a recommendation to clinical practice [18]. First, the level of evidence was determined for each individual study included (1–3). Secondly, a strength of recommendation was given to the body of evidence for a certain indication and complementary therapy following a specific algorithm: resulting in an A, B or C-level recommendation. An A-level recommendation is based on consistent and good-quality patient-oriented evidence; a B-level recommendation is based on inconsistent or limited-quality patient-oriented evidence; and a C-level recommendation is based on consensus, usual practice, expert opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening. Further details on evidence grading can be found in the paper by Ebell et al. [18]. Recommendations were based on the highest quality evidence available, and followed the traditional hierarchy of the evidence pyramid [19]. Thus, in case the available meta-analyses for an indication provided an A recommendation, no further literature was assessed for that indication. If not, the systematic reviews were assessed. In case of an A-level recommendation based on the systematic reviews, the assessment was finished. If not, the individual randomized clinical studies were assessed and eventually other studies lower on the evidence pyramid. Any discrepancies in grading between the two authors were solved through discussion. RESULTS Organizing field labs Over a period of three months three multidisciplinary field labs were established in the following three regions: Amsterdam (1), Utrecht (2) and in the north of the Netherlands (3). Thereafter, over a period of 1,5 years, four focus group meetings were organised per field lab, resulting in 12 focus group meetings of two hours each. In Amsterdam and Utrecht these meetings were held live, in the northern region three meetings were live and one was online. It was planned for each field lab to consist of a combination of a maximum of 15–17 participants, composed of maximum of 10 (5x2 representatives per complementary therapy) different complementary HCPs and 5–7 different conventional HCPs. However, due to time or distance restraints, and health issues, the total number of HCPs was varying from 9–12 in field lab 1 (Amsterdam), 8–12 in field lab 2 (Utrecht) and 6–14 in field lab 3 (North). The final composition for each field lab can be found in Table 1 . The remaining 27 complementary HCPs who stated their interest in participating, joined the advisory board. Table 1 Composition of the three field labs including the represented complementary therapies and conventional healthcare professionals Region Amsterdam Region Utrecht Region North Complementary therapy - Gestalt therapy - Hypnotherapy - Drawing/Art therapy - Integrative psychotherapy - Body-oriented psychotherapy - Shiatsu - Psychosocial therapy - Energy therapy - Craniosacral therapy - Counselling - Classic massage /shiatsu - Orthomolecular medicine - Reflexology - Classical homeopathy - Yin therapy Conventional healthcare professionals - General practitioner (3) - Medical doctor (general) - Physiotherapist - Psychiatrist (elderly) - General practice nurse (2; mental health, somatics) - Gynaecologist - General practitioner - Medical doctor (MUPS) - Physiotherapist - Psychologist (3) - General practice nurse - Internist-infectious disease specialist - General practitioner - Physiotherapist (3) - Cesar therapist - Advisor regional support structure primary care Results of the field labs A brief thematic analysis was performed on the written reports of all 12 focus group meetings which resulted in five major overarching themes: different perspectives and working methods, patient-centred approach, ways of communication, networking and evidence of complementary care. Different perspectives and working methods Participants were seriously aware of the fundamental differences in working methods and perspectives between conventional and complementary HCPs, such as using a symptom-oriented versus a holistic perspective. They were eager and open to cooperate and find solutions to overcome differences in “language” and to connect with each other. Participants were also encouraged to visit each other’s websites to better understand the therapies and professional standards involved. All agreed that collaboration between conventional and complementary HCPs should be simplified, communication should be short, concise, solution driven in both directions and should be patient-centred. Patient-centred approach Participants acknowledged that the patients’ responsibility for their own health remains constant, regardless the possible differences in opinion among HCPs regarding the definition of the primary symptom. The importance of shared decision making was emphasized and participants agreed that the final responsibility for treatment choice always remains with the patient. Nevertheless, the patient should be appropriately guided in her process to obtain accurate, reliable and personalized information in order to find an appropriate healthcare professional. Additionally, it was crucial to consider quality and safety aspects of the complementary therapy and clarity on reimbursement for patients. Ways of communication Lack of time was an important barrier in communication expressed by conventional healthcare professionals. Especially GPs, who already experience a high administrative burden, asked to keep the number of communication tools to a minimum and combine tools together. Participants suggested a more neutral tone of the existing communication tools, to express an equivalent relationship between GPs and complementary HCPs. They also wanted the terminology to respond to recent developments in healthcare, such as the importance of discussing lifestyle changes and the concept of positive health, and be tailored towards the perception and experiences of conventional health care practitioners, such as the use of CD-10-CM medical diagnosis codes. Conventional HCPs wanted communication to be short, concise, simple and reporting should be done at all times, always with the patients consent. Conventional HCPs preferred to be contacted by telephone in case of peer consultation, in case safety of the patient was at risk and for coordination regarding medication intake. Complementary HCPs preferred written communication, to report by letter or email to GPs at the start of a treatment, in case of changes and to report on effectivity after completing their treatment. It was emphasized that open and honest communication on effectivity was warranted. Conventional HCPs also wanted to receive reports about complementary treatments that did not show efficacy. This would add to the credibility and reliability of complementary therapies. Networking Participants considered making use of already existing protocols and contact systems used by GPs with regards to reporting and referral which could serve as facilitator for the integration of collaboration. Additionally, peer learning groups were mentioned as an option to strengthen collaboration between conventional and complementary HCPs. Moreover, it was deemed important to make an overview of existing networks and collaborations which could be contacted. A network of practicing complementary HCPs on local, regional and national level was desired by both types of HCPs. The need was expressed for uniting various types of complementary HCPs in a certain region and for them to introduce themselves as a network to conventional HCPs, although there was awareness that not every GP would be open to collaboration. Evidence of complementary therapies In general, scientific evidence can be seen as a language to connect all types of HCPs. However, the perspective on the value of scientific evidence may differ between complementary and conventional HCPs. Simultaneously, it was emphasized that evidence-based medicine is more than using evidence from research. The relationship and building trust between patient and healthcare professional are equally important for the effectivity of a treatment. Moreover, it was highlighted that one complementary therapy can be applicable to various indications due to its holistic nature and all HCPs realised that the literature assessment would not always take these holistic aspects of complementary therapies into account. It was considered necessary to provide more information and context about complementary care with regards to the following subjects: the ethical framework on weighing effectivity and safety, evidence on psychosocial therapies, the body-mind connection and patient-tailored advise. Development of the communication tools Based on the thematic analysis of the 12 focus group meetings and the previous communication toolkit [20], a new version of the toolkit was created. The final evidenced-based communication toolkit consists of seven communication tools, covering the following themes; getting to know each other, communication between complementary and conventional HCPs, letter formats, decision aid for complementary care with recommendations, grading evidence, support for communication of RBCZ affiliated professional associations and implementation (Table 2 ). Except for Tool #3, existing of four letter formats, and Tool #4, the decision aid for complementary care, all tools consist of a short explanation of the topic and practical suggestions, tips and resources. Some are specific for the Dutch healthcare context, others are more generally applicable. Table 2 Overview of the communication toolkit Tool For whom Content 1 How to get to know each other Complementary HCPs - First contact and request for personal meeting: 8 tips (e.g. how to find open minded GP’s) - Preparation for personal meeting: 5 tips (e.g. know your evidence) - Personal meeting: to inform GP about complementary treatment options; 7 tips (e.g. keep it simple and short) 2 How to communicate with conventional healthcare practitioners Complementary HCPs To inform GP about: - patient registration and discharge (9 tips, including what protected digital applications to use) - need for peer consultation (2 tips, e.g. about medication) - referral back to GP (if patient doesn’t respond to treatment or diagnosis can’t be treated) 3 Letter formats (in addition to Tool #2) Complementary HCPs To inform GP about: - patient registration - need for peer consultation - patient discharge To report treatment to company doctor, e.g. in relation to burn out treatment 4 Decision aid for complementary care Complementary and conventional HCPs Context, Evidence, Ethical framework, and recommendations for 13 complementary therapies and 6 indications, based on the SORT method for grading patient-oriented evidence 5 Grading evidence RBCZ Explanation of and guidelines for using the SORT method 6 How to support members to improve communication RBCZ/professional associations - Suggested activities, e.g. facilitating local/regional networks of members, peer-to-peer coaching and define key figures - Materials, e.g. complementary information for education 7 How to implement decision aid for complementary care RBCZ Suggested activities (internal/external) for implementation of decision aid, to include in a comprehensive long-term communication plan of RBZC Development of the decision aid for complementary care The decision aid for complementary care consists of an evidence overview with recommendations, an ethical framework to guide shared decision making [21] and introductory texts including information on complementary care, the content and how to use it. The evidence overview is presented below (Table 3 ). Selection of indications The participating complementary HCPs listed the most frequent indications they treated and for which scientific evidence for effectiveness could be expected. Subsequently, the participating conventional HCPs provided input, based on their clinical experiences, about which indications were high in need of treatment options and could potentially benefit from complementary treatment. The top indications mentioned five times or more by complementary healthcare professionals, were depressive symptoms (11), trauma (9), anxiety (9), burnout (9), pain (neck, shoulder, low back, (7)), sleeping disorders (7), stress (6), medically unexplained physical symptoms (MUPS) (5), fatigue (5) and cancer related symptoms (5). Conventional healthcare professionals were not inclined to refer patients with severe depressive symptoms, anxiety disorders or complex trauma to complementary HCPs but rather refer these patients to conventional mental HCPs. Therefore, trauma and anxiety disorders were not selected for the decision aid. Nevertheless, depressive symptoms were selected since it was most frequently mentioned by complementary HCPs. Conventional HCPs saw more potential for referral for MUPS (3), fatigue (3), stress (3) and irritable bowel syndrome (3). After 2 discussion rounds, a final selection of 6 indications were to be included in the decision aid for complementary care: chronic low back pain, depressive symptoms, medically unexplained physical symptoms (MUPS), irritable bowel syndrome, burnout, and chronic fatigue syndrome. Search terms for complementary therapies During the focus group meetings search terms were discussed for each of the complementary therapies involved. Not all of them were captured through separate search terms. Integrative psychotherapy e.g. consists of a variety of psychological treatment modalities. It was decided to include this therapy in the decision aid on the basis of available evidence for at least one of the following therapies: gestalt therapy, body-oriented therapy or hypnotherapy, since these therapies were considered to be part of integrative psychotherapy. No evidence was found for yin therapy, a rather new multifaceted therapy. Since it partly overlaps with yoga, yoga was chosen as the most relevant search term. Yin therapy could be included in the decision aid in case of evidence available for yoga, shiatsu, orthomolecular therapy or craniosacral therapy. Due to time restraints, it was decided to exclude classical massage and focus solely on shiatsu, as the participating professional association represented both therapies. ‘Supplements’, ‘probiotics’, ‘phytotherapy’ and ‘herbal therapy’ were used as additional search terms for orthomolecular therapy. Evidence based recommendations An overview was made of the total number of hits, meta-analyses, systematic reviews, and randomized controlled trials (RCT’s) for each of the 6 indications and 12 complementary therapies (excluding integrative psychotherapy) (appendix II). No literature was available for 21 indication–complementary therapy combinations (17%). Meta-analyses were available for one-third (33%) of the indication–therapy combinations, systematic reviews were available for 15% and RCTs were available for 46% of the indication–therapy combinations. An overview of the evidence grading based on the SORT criteria can be found in Table 3 , in detail in appendix III. Table 3 Overview of the evidence grading for 13 therapies and 6 indications Indication Shiatsu Yin therapy/yoga * Orthomolecular medicine Homeopathy Reflexology Energy therapy Craniosacral therapy Counselling Gestalt therapy Body-oriented psychotherapy Drawing/Art therapy Hypnotherapy Integrative psychotherapy** Chronic low back pain B A A B A B B B C 0 0 B yes Depressive symptoms B A A B B B - A B B A B yes Medically unexplained symptoms (MUPS/MUS) 0 B B 0 0 C 0 0 C B 0 B yes Irritable Bowel Syndrome (IBS) 0 B A B - C 0 B 0 B 0 A yes Burnout B B B 0 0 B 0 B 0 B B B yes Chronic fatigue syndrome (CFS) 0 B B B 0 - 0 B 0 0 C C yes * Literature search based on evidence for effectivity of yoga; people may also be referred to yin therapy based on available evidence of at least one of the following therapies: shiatsu, orthomolecular or craniosacral therapy; ** No specific literature search performed; yes = people may be referred to integrative psychotherapy based on available evidence of at least one of the following therapies: gestalt therapy, body-oriented psychotherapy or hypnotherapy. 0 = no literature available; - = evidence for no effect; A = based on consistent and good-quality patient-oriented evidence; B = recommendation is based on inconsistent or limited-quality patient-oriented evidence; C = recommendation is based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening. Implementation and dissemination In the last focus groups and advisory board meetings implementation and dissemination of the communication tools were discussed. Various roles and responsibilities were identified. As RBCZ is an umbrella organization it will embed all communication tools in its communication strategy to make them available for the affiliated professional associations. Own means of communication to be used are webinars, newsletters, symposia and congresses. Another route of implementation could be through education, both medical and complementary. Several medical and nursing schools in the Netherlands offer elective courses in integrative medicine/nursing, in which information about the decision aid could be included. The individual professional associations will communicate about the tools to their individual members and to a diversity of stakeholders, such as the schools in complementary therapies they are connected to. The decision aid for complementary care is the most specific and broadly usable tool. It is primarily a conversation starter between patient and conventional healthcare professional regarding complementary care. RBCZ will therefore design the decision aid as both a physical and digital tool, also to be accessed via a QR code. Comprehensive implementation activities for the decision aid will be provided in the RBCZ communication strategy. DISCUSSION From the beginning the project was very positively received by both complementary and conventional HCPs. They enjoyed the open and informative discussions, leading to more mutual respect for each other’s professionalism and commitment to the health and well-being of patients. The choice for a co-creative regional field lab improved the collaboration between participants in those regions. For instance, an active working group was established with complementary and conventional HCPs to develop letter formats on communication. Additionally, a platform of over 40 complementary HCPs was launched in Utrecht with joint activities to approach the city’s health services and policy makers. Furthermore, the field labs improved peer consultations between complementary HCPs in the regions. An important part of the project was the development of the evidence based decision aid for 6 indications and 13 complementary care modalities. Decision aids are known to help resolve medical decisions and have positive effects on communication between patient and HCP [22]. Deciding on which indications to include in the decision aid and how the evidence was graded resulted in many discussions and even frictions in the groups, mainly because of differences in perspective on what evidence means, differences in needs between conventional and complementary HCPs regarding evidence, and opinions on whether complementary therapies, being holistic by concept, fit in the evidence based model of scientific bio-medical thinking. This supports the advice provided by Clifford et al. based on a systematic review of decision aids that such aids should include patient and practice evidence as well as information on contextual factors [23]. Therefore, the decision aid for complementary care is not envisioned as a standalone tool but as part of a broader set of communication tools. The tools will be disseminated by RBCZ as part of a broader communication strategy, in line with similar implementation strategies for decision aids for complementary care in the Netherlands [24]. We compared the evidence grading in this paper with the online medical Essential Evidence database containing 742 chapters mainly used by primary care physicians which is also graded using the SORT criteria [25]. The overall evidence for the recommendations in this database is grade A for 18% of the recommendations and grade B for 34% of the recommendations. In our decision aid 15% of the recommendations received grade A and 46% received a grade B. This indicates that the current status of evidence for the complementary therapies that were assessed in this project is comparable to the overall evidence for primary care interventions. The main strength of the project was the regionally organised multidisciplinary collaboration which successfully served the needs of both complementary as well as conventional HCPs. Bringing those different HCPs together stimulated synergy and new ideas. The evidence based strategy using the SORT criteria allowed for better acceptance of complementary HCPs and can improve communication between complementary and conventional HCPs. Furthermore, the final set of communication tools was well received by RBCZ during a meeting with the boards of the 25 professional associations. This study has several limitations. Regarding the evidence based decision aid, finding the appropriate search terms for some complementary therapies was not always a straightforward task, since they include multiple modalities, some of which could also be regarded as conventional interventions such as cognitive behaviour therapy. Since there is generally a lack of funding for researching complementary therapies [26], the availability of good quality studies for these therapies is limited while the practitioner and patient experiences are often very positive. Furthermore, the classical method of the randomized controlled trial is not always suitable to capture the holistic nature of complementary therapies [27], [28]. Therefore, the decision aid for complementary care must be seen as primarily a tool to start communicating about evidence for complementary therapies. These discussions should then also include the practitioners experiences and the patients preferences in line with the original vision of evidence based medicine [29]. RBCZ will stimulate implementation of the tools by the 25 professional associations and over registered 9.500 complementary HCPs. The communication tools will be made available on RBCZ’s website. The decision aid for complementary care will be expanded to represent a larger number of therapies covered by the RBCZ professional associations. Further research is needed to evaluate the actual use of the communication tools in practice and the implementation process. The outcomes facilitate the possibility for the worlds of complementary care and conventional health care to meet and integrate. Better integration of complementary care in conventional healthcare system might contribute to a more sustainable healthcare ecosystem. CONCLUSION This participatory research project succeeded in bringing together complementary and conventional HCPs in three regions in the Netherlands. A set of communication tools was developed including an evidence based decision aid for complementary care, for 13 therapies and six indications, which will be made available to 25 professional associations covering over 9.500 complementary HCPs. During the project the collaboration amongst complementary HCPs was strengthened as well as between complementary and conventional HCPs. Abbreviations GP general practitioner HCP healthcare practitioner Declarations FUNDING The project was funded by RBCZ. RBCZ participated in the project by delivering representatives of the professional organisations and organizing meetings. RBCZ had no influence on the literature search, evidence grading and recommendations resulting from this project. Author Contribution LTCM assisted with the focus group meetings, conducted the literature search and grading of the evidence, wrote the draft of the paper, prepared all the visuals for the paper. HAvW conceptualized and designed the project, collected data, assisted in the literature search and grading of the evidence, wrote and edited the paper, acquired funding and supervised the project. MB conceptualized and designed the project, setup the field labs, conducted focus group meetings, collected data, assisted in writing the paper. AD co-designed the project, assisted in setting up the field labs, organised meetings, and reviewed the paper. All authors approved of the final version of the paper. Acknowledgement The authors first of all would like to acknowledge the enthusiasm and dedication with which the representatives of the participated professional associations and the individual conventional healthcare practitioners participated in the field labs. We also thank the board of RBCZ for their full support in conducting the project by promoting the project, communication with the professional associations, organizing meetings, discussing the results and willingness to implement the results in the organisation. We also thank the boards of the professional associations for their support. Data Availability The communication tools which are developed in this study are not attached but are available from the corresponding author upon reasonable request. CREDIT AUTHOR STATEMENT LM assisted with the focus group meetings, conducted the literature search and grading of the evidence, wrote the draft of the paper, prepared all the visuals for the paper. HVW conceptualized and designed the project, collected data, assisted in the literature search and grading of the evidence, wrote and edited the paper, acquired funding and supervised the project. MB conceptualized and designed the project, setup the field labs, conducted focus group meetings, collected data, assisted in writing the paper. AD co-designed the project, assisted in setting up the field labs, organised meetings, and reviewed the paper. All authors approved of the final version of the paper. References RIVM, ‘Effecten van vergrijzing steeds beter zichtbaar in uitgaven gezondheidszorg’. Geraadpleegd: 4 december 2023. [Online]. Beschikbaar op: https://www.rivm.nl/nieuws/effecten-van-vergrijzing-steeds-beter-zichtbaar-in-uitgaven-gezondheidszorg Centraal Bureau voor de Statistiek, ‘Werkdruk en arbeidstevredenheid in de zorg’, Centraal Bureau voor de Statistiek. Geraadpleegd: 4 december 2023. [Online]. Beschikbaar op: https://www.cbs.nl/nl-nl/longread/statistische-trends/2022/werkdruk-en-arbeidstevredenheid-in-de-zorg?onepage=true W. en S. Ministerie van Volksgezondheid, ‘De participerende patiënt - Advies - Raad voor Volksgezondheid en Samenleving’. Geraadpleegd: 4 december 2023. [Online]. Beschikbaar op: https://www.raadrvs.nl/documenten/publicaties/2013/06/20/de-participerende-patient Ministerie van Volksgezondheid, ‘Disussienota Zorg voor de toekomst’, dec. 2020. V. Maizes, D. Rakel, en C. Niemiec, ‘Integrative medicine and patient-centered care’, Explore N. Y. N , vol. 5, nr. 5, pp. 277-289, 2009, doi: 10.1016/j.explore.2009.06.008. L. M. Kemppainen, T. T. Kemppainen, J. A. Reippainen, S. T. Salmenniemi, en P. H. Vuolanto, ‘Use of complementary and alternative medicine in Europe: Health-related and sociodemographic determinants’, Scand. J. Public Health , vol. 46, nr. 4, pp. 448-455, jun. 2018, doi: 10.1177/1403494817733869. M. C. Jong, L. van de Vijver, M. Busch, J. Fritsma, en R. Seldenrijk, ‘Integration of complementary and alternative medicine in primary care: What do patients want?’, Patient Educ. Couns. , vol. 89, nr. 3, pp. 417-422, dec. 2012, doi: 10.1016/j.pec.2012.08.013. A. M. Vlieger, E. M. van de Putte, en H. Hoeksma, ‘[The use of complementary and alternative medicine in children at a general paediatric clinic and parental reasons for use]’, Ned. Tijdschr. Geneeskd. , vol. 150, nr. 11, pp. 625-630, mrt. 2006. M. Singendonk, G.-J. Kaspers, M. Naafs-Wilstra, A. S. Meeteren, J. Loeffen, en A. Vlieger, ‘High prevalence of complementary and alternative medicine use in the Dutch pediatric oncology population: a multicenter survey’, Eur. J. Pediatr. , vol. 172, nr. 1, pp. 31-37, jan. 2013, doi: 10.1007/s00431-012-1821-6. M. C. Jong, M. Busch, en E. W. Baars, ‘Integrative medicine in Dutch curative and long-term healthcare centres: Mapping the field’, Eur. J. Integr. Med. , vol. 28, pp. 14-19, jun. 2019, doi: 10.1016/j.eujim.2019.04.003. M. Busch, M. Jong, en E. W. Baars, ‘Complementaire zorg in ziekenhuizen, verpleeghuizen en GGZ‐instellingen. Een eerste inventarisatie’, 2014. KNMG, ‘Niet-reguliere behandelwijzen’. Geraadpleegd: 12 december 2023. [Online]. Beschikbaar op: https://www.knmg.nl/actueel/dossiers/niet-reguliere-behandelwijzen M. C. Jong, M. Busch, L. van de Vijfer, M. Jong, J. Fritsma, en R. Seldenrijk, ‘Pragmatic Model for Integrating Complementary and Alternative Medicine in Primary Care Management of Chronic Musculoskeletal Pain’, Prim. Healthc. , vol. 6, nr. 2, 2016, Geraadpleegd: 9 november 2023. [Online]. Beschikbaar op: https://urn.kb.se/resolve?urn=urn:nbn:se:miun:diva-29120 S. Timmermans, ‘The Engaged Patient: The Relevance of Patient–Physician Communication for Twenty-First-Century Health’, J. Health Soc. Behav. , vol. 61, nr. 3, pp. 259-273, sep. 2020, doi: 10.1177/0022146520943514. H. van Wietmarschen en M. Busch, ‘COmmunicatie en verwijzing COmplementaire Zorg – COCOZ’, Louis Bolk Instituut. Geraadpleegd: 15 november 2023. [Online]. Beschikbaar op: https://www.louisbolk.nl/publicaties/communicatie-en-verwijzing-complementaire-zorg-cocoz D. L. Morgan, Focus groups as qualitative research , vol. 16. Sage publications, 1996. Geraadpleegd: 25 oktober 2023. [Online]. Beschikbaar op: https://books.google.nl/books?hl=nl&lr=&id=LxF5CgAAQBAJ&oi=fnd&pg=PT6&dq=Morgan,+D.+L.+(1996).+Focus+groups+as+qualitative+research+(Vol.+16).+Sage+publications.&ots=3uTnwP1TE9&sig=iMPtix4G6u396DChWQar0jBO8Vw M. Gundumogula, ‘Importance of Focus Groups in Qualitative Research’, Int. J. Humanit. Soc. Stud. , vol. 8, nr. 11, nov. 2020, doi: 10.24940/theijhss/2020/v8/i11/HS2011-082. M. H. Ebell e.a. , ‘Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature’, J. Am. Board Fam. Pract. , vol. 17, nr. 1, pp. 59-67, 2004, doi: 10.3122/jabfm.17.1.59. A. L. Rosner, ‘Evidence-based medicine: Revisiting the pyramid of priorities’, J. Bodyw. Mov. Ther. , vol. 16, nr. 1, pp. 42-49, jan. 2012, doi: 10.1016/j.jbmt.2011.05.003. Louis Bolk Instituut, ‘COCOZ: Communicatie over complementaire zorg’, COCOZ: Communicatie over complementaire zorg. [Online]. Beschikbaar op: https://www.louisbolk.nl/projecten/cocoz-communicatie-voor-complementaire-zorg M. H. Cohen en K. J. Kemper, ‘Complementary therapies in pediatrics: a legal perspective’, Pediatrics , vol. 115, nr. 3, pp. 774-780, mrt. 2005, doi: 10.1542/peds.2004-1093. D. Stacey e.a. , ‘Decision aids for people facing health treatment or screening decisions’, Cochrane Database Syst. Rev. , vol. 4, nr. 4, p. CD001431, apr. 2017, doi: 10.1002/14651858.CD001431.pub5. A. M. Clifford, J. Ryan, C. Walsh, en A. McCurtin, ‘What information is used in treatment decision aids? A systematic review of the types of evidence populating health decision aids’, BMC Med. Inform. Decis. Mak. , vol. 17, nr. 1, p. 22, feb. 2017, doi: 10.1186/s12911-017-0415-7. M. C. Jong e.a. , ‘Development of an evidence-based decision aid on complementary and alternative medicine (CAM) and pain for parents of children with cancer’, Support. Care Cancer , vol. 28, nr. 5, pp. 2415-2429, mei 2020, doi: 10.1007/s00520-019-05058-8. M. H. Ebell, R. Sokol, A. Lee, C. Simons, en J. Early, ‘How good is the evidence to support primary care practice?’, BMJ Evid.-Based Med. , 2017, Geraadpleegd: 26 oktober 2023. [Online]. Beschikbaar op: https://ebm.bmj.com/content/ebmed/early/2017/05/29/ebmed-2017-110704.full.pdf F. Fischer e.a. , ‘A research roadmap for complementary and alternative medicine - what we need to know by 2020’, Complement. Med. Res. , vol. 21, nr. 2, Art. nr. 2, apr. 2014, doi: 10.1159/000360744. G. S. Kienle e.a. , ‘Contributing to Global Health: Development of a Consensus-Based Whole Systems Research Strategy for Anthroposophic Medicine’, Evid.-Based Complement. Altern. Med. ECAM , vol. 2019, p. 3706143, 2019, doi: 10.1155/2019/3706143. C. M. Witt, ‘Efficacy, effectiveness, pragmatic trials--guidance on terminology and the advantages of pragmatic trials’, Forsch. Komplementarmedizin 2006 , vol. 16, nr. 5, pp. 292-294, okt. 2009, doi: 10.1159/000234904. D. L. Sackett, W. M. Rosenberg, J. A. Gray, R. B. Haynes, en W. S. Richardson, ‘Evidence based medicine: what it is and what it isn’t’, BMJ , vol. 312, nr. 7023, pp. 71-72, jan. 1996, doi: 10.1136/bmj.312.7023.71. Additional Declarations No competing interests reported. Supplementary Files AppendixI.docx AppendixII.docx AppendixIII.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4268398","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":293110081,"identity":"12ffa9f3-67f8-46fe-a8a5-e771a4641402","order_by":0,"name":"Louise TC Mulder","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIie3QsQqDMBCA4ZTAOTSaNV36DAFBLJQ+S0Rw7eYsCOnUhykFZyXg6NxCB6fOjh2ENkq3QszYIf9wJAffkCDkcv1hwTR6QIh6+iBQjQIybQwEpiH03JRfAmQ+WBCu5rsVWWdM5PtjqHDL+vGxBVJDbyZ+xUSX7SoFGUvkMwS/8PgiSaTikSIRSwqVSIqAWZA3D0tNxGhPas7xREATv1gg2L/Goks5U5DG81tII42EeufLbcgPnJ7K5v7SP0ZJ2rLBQBD+Xa0KE3C5XC6XRR/mg0KaULvHggAAAABJRU5ErkJggg==","orcid":"","institution":"Louis Bolk Instituut","correspondingAuthor":true,"prefix":"","firstName":"Louise","middleName":"TC","lastName":"Mulder","suffix":""},{"id":293110082,"identity":"370db345-9d7b-4a57-9e09-65251d2f3b78","order_by":1,"name":"Martine Busch","email":"","orcid":"","institution":"Van Praag Instituut","correspondingAuthor":false,"prefix":"","firstName":"Martine","middleName":"","lastName":"Busch","suffix":""},{"id":293110083,"identity":"9006eb0f-46a0-4ec3-b772-55eaaaa480cd","order_by":2,"name":"Armelle Demmers","email":"","orcid":"","institution":"RBCZ","correspondingAuthor":false,"prefix":"","firstName":"Armelle","middleName":"","lastName":"Demmers","suffix":""},{"id":293110084,"identity":"4de8c4dc-7304-4e34-99b4-ee2b874fbe38","order_by":3,"name":"Herman A van Wietmarschen","email":"","orcid":"","institution":"Louis Bolk Instituut","correspondingAuthor":false,"prefix":"","firstName":"Herman","middleName":"A van","lastName":"Wietmarschen","suffix":""}],"badges":[],"createdAt":"2024-04-15 08:44:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4268398/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4268398/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78003413,"identity":"52c32c78-9783-4f87-9ad2-5d311c120910","added_by":"auto","created_at":"2025-03-07 17:38:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1014721,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4268398/v1/4d8a4942-ac07-4b70-b38f-1a3a9920e820.pdf"},{"id":55150374,"identity":"244e5833-bc5e-47f9-984c-b9021e47b5fb","added_by":"auto","created_at":"2024-04-23 10:14:20","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20649,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixI.docx","url":"https://assets-eu.researchsquare.com/files/rs-4268398/v1/49705ec95c48fe45042ff7bf.docx"},{"id":55150375,"identity":"8be725d9-7128-429b-9c3a-53066372c958","added_by":"auto","created_at":"2024-04-23 10:14:20","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":21186,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixII.docx","url":"https://assets-eu.researchsquare.com/files/rs-4268398/v1/bed9499de55ad40b0b1a6187.docx"},{"id":55150376,"identity":"6b141d8e-8396-489b-a112-9c34dc86520c","added_by":"auto","created_at":"2024-04-23 10:14:20","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":220506,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixIII.docx","url":"https://assets-eu.researchsquare.com/files/rs-4268398/v1/ac6c36068257470e88038c9e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Co-creation of an evidence-based toolkit to facilitate communication on complementary medicine between conventional and complementary healthcare practitioners in the Netherlands","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe Dutch healthcare system is under pressure and faces many challenges with the rising number of elderly and people with chronic conditions [1], increasing workload for healthcare professionals[2] and rising healthcare costs. This has enforced a paradigm shift towards patient-centred care where lifestyle, prevention and patient\u0026rsquo;s ownership regarding their health (self-management) are becoming increasingly important [3], [4]. These newly demanding changes in healthcare could be partly met by the use of the various types of complementary care which are commonly based on whole person health, a holistic view of the human being, patient-centred care and on promoting the self-healing capacity of the body [5].\u003c/p\u003e \u003cp\u003eData on the use of complementary care in the Netherlands is scarce. Kemppainen et al. reported that 14.1% of the Dutch population had used at least one complementary therapy over the last 12 months in 2016[6]. In various patient populations this number is higher, for instance the use of complementary care in people with chronic joint pain is estimated to be as high as 86% [7], one third of children visiting a paediatrician use complementary care [8] and 42.4% of children visiting a paediatric oncologist use complementary care [9].\u003c/p\u003e \u003cp\u003eAlthough complementary care is generally being applied on a small scale in hospital settings, often unstructured and without any policy and procedures, there has been an increase in the interest and use of complementary therapies over the past decades, especially in oncology, in psychiatry and in palliative care settings for symptoms such as anxiety, stress, pain and fatigue [10]. This is also reflected in the growing number of initiatives regarding non-pharmacological interventions in hospitals and nursing homes and integrative outpatient clinics [11], [10]. Therefore, there is need for guidance and implementation of complementary care, since the infrastructure of the Dutch healthcare system does not facilitate this [11].\u003c/p\u003e \u003cp\u003e Guidelines on complementary therapies for general practitioners (GPs) were developed in 2008 (revisioned in 2022) by the Royal Dutch Medical Association [12]. However, these guidelines only describe conditions under which a GP is allowed to practice complementary care himself, but does not give any guidance about communication, referral or collaboration.\u003c/p\u003e \u003cp\u003eIn 2016, a first model was developed for the integration of complementary therapies into primary healthcare in the Netherlands, with patients\u0026rsquo; needs as starting point [13]. An important step is to build an integrative collaborative network of GPs and complementary care practitioners [14]. Moreover, shared decision making was introduced to facilitate discussions on complementary care between patients and GPs. Shared decision making includes discussion of the patients\u0026rsquo; health problems and history, complementary therapy options which enables the patient to make safe and well-informed decisions consistent with her values and preferences.\u003c/p\u003e \u003cp\u003eHowever, patients mostly do not discuss their complementary therapy use during a consultation with their GP. They expressed the need that they would rather want their GP to listen, to inform them about complementary care options and if necessary, to refer them to or collaborate with complementary healthcare practitioners (HCPs) [7]. Patients would benefit from an active involvement of GPs concerning communication and shared-decision making on possible referral to complementary therapies. On the other hand, the main barriers in primary care to communicate, collaborate with and refer to complementary care are the lack of knowledge about complementary therapies, their effectivity and safety, lack of concrete information to provide to patients and lack of knowledge about the reliability and professional standards of complementary care practitioners [13].\u003c/p\u003e \u003cp\u003e In a previous project in the Netherlands, needs and wishes were assessed of complementary HCPs of five modalities (acupuncture, chiropractic, osteopathy, homeopathy and naturopathy) and GPs regarding communication and collaboration in complementary care in a series of focus group discussions [15]. The result was a first evidence-based communication toolkit aimed to be used by complementary HCPs to contact and communicate with GPs about their treatment of mutual patients. It was concluded that communication between conventional and complementary HCPs should be further strengthened and the tools should be further expanded, optimized and implemented. Since this toolkit was targeted solely towards GPs, it was desired to extend towards other conventional HCPs, such as medical specialists, nurse practitioners and physiotherapists.\u003c/p\u003e \u003cp\u003eThis paper describes the process and outcome of a co-creation research project that aimed to strengthen communication and collaboration between complementary and conventional HCPs and improve mutual collaboration between complementary HCPs in the Netherlands. In three field labs the existing communication toolkit was assessed and updated, new communication tools were developed, and implementation strategies were discussed. Additionally, researchers aimed to develop an evidence based decision aid for complementary care for 13 complementary therapies and 6 indications.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e This participatory research project was conducted in the Netherlands from November 2021 \u0026ndash; November 2023 by a project team consisting of researchers from Louis Bolk Institute, Van Praag Institute and RBCZ. It comprised creating field labs with complementary and conventional healthcare professionals as well as a literature search on complementary therapies for a set of indications.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eOrganizing the field labs\u003c/h2\u003e \u003cp\u003eIn collaboration with RBCZ, the largest umbrella association which certifies, registers and represents the interests of complementary and alternative HCPs in the Netherlands, three multidisciplinary regional field labs were composed [16], [17].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment of complementary healthcare practitioners\u003c/h2\u003e \u003cp\u003eThe board of RBCZ was responsible for the recruitment of the professional associations. 88% (n\u0026thinsp;=\u0026thinsp;16) of the RBCZ professional associations who filled in a need assessment (n\u0026thinsp;=\u0026thinsp;18) regarding conducting research stated their interest in participating in the field labs. Professional affiliated associations of RBCZ were contacted by RBCZ and asked to participate. In total, 13 professional associations were included in the study. Each professional association willing to cooperate in the study delegated two member practitioners, who served as representatives of that professional association and complementary therapy in the field lab. Based on the geographic locations of the practices of the representatives put forward by the professional associations, three regions of the Netherlands were selected to set up the field lab.\u003c/p\u003e \u003cp\u003e The inclusion criteria for the professional associations were: (1) enough members in the specific region to ensure widespread multidisciplinary collaboration; (2) some indication of scientific evidence for the complementary therapy concerned; (3) previous collaboration with conventional HCPs was desired but not mandatory.\u003c/p\u003e \u003cp\u003eThe complementary practitioners of each field lab had a first online meeting to get to know each other and to identify which type of conventional HCPs should be invited to complement each group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment of conventional healthcare practitioners\u003c/h2\u003e \u003cp\u003eSnowball sampling technique was used to recruit individual conventional HCPs, mainly via the network of the Van Praag Institute and Louis Bolk Institute. An invitation to participate was sent out through the newsletters of two academies for integrative medicine and a national network of family nurse practitioners. Various health centers and regional support structures for primary care in the three regions were contacted through an invitation letter by email. Respondents received more information about the study by email and conversations by phone.\u003c/p\u003e \u003cp\u003eEach field lab consisted of a combination of 15\u0026ndash;17 HCPs, with a maximum of 10 complementary HCPs and 5\u0026ndash;7 conventional HCPs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAdvisory board\u003c/h2\u003e \u003cp\u003e Next to the field labs, an advisory board was installed with complementary HCPs (n\u0026thinsp;=\u0026thinsp;27) from the 13 professional associations, who could not be included in the field labs, mainly because they were not located in the region. These practitioners represented the same therapies included in the field labs and met twice during the project. The advisory board gave advice and feedback on structuring collaboration between conventional and complementary HCPs in the region, mutual collaboration among complementary HCPs and implementation of the communication tools.\u003c/p\u003e \u003cp\u003eNext to the advisory board, all boards of the professional associations of RBCZ met twice during the project, at the start and at the end to reflect on the process, to give input on the communication tools and to advise on implementation of the results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eContent of the field labs\u003c/h2\u003e \u003cp\u003e First, a joint online kick-off meeting was organized for all conventional and complementary HCPs participating in the three field labs, the advisory board, and the board of RBCZ. The goal of the project, field lab approach, roles of stakeholders, and focus groups were presented to everyone involved.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eThemes and content of the focus groups\u003c/h2\u003e \u003cp\u003e In order to extend and further develop the existing communication toolkit and to strengthen communication between the various HCPs four focus group discussions were set up per field lab and guided by two researchers. It was assured that at least one representative per professional association (five in total) and at least three conventional HCP were present during each focus group meetings.\u003c/p\u003e \u003cp\u003eThe following themes were discussed: (1) working with and implementing existing communication tools, development of new communication tools, (2) perceived needs regarding communication and collaboration between the participating conventional and complementary HCPs, (3) how to improve communication, (4) indications for which it could potentially relevant to collaborate with complementary HCPs, (5) safety of complementary therapies and (6) implementation of the communication tools.\u003c/p\u003e \u003cp\u003eThe existing communication toolkit was extended via an iterative and co-creation method. After each focus group the input was collected, combined, a brief thematic analysis was performed and presented for feedback in the next focus group meetings. In addition, input from the advisory board was collected and presented, and discussed in each focus group meeting. Consequently, consensus was reached regarding the content and quality of the communication tools, meeting the needs of both complementary and conventional HCPs. After the fourth and last focus group meeting of each field lab, the researchers developed the concept versions of the tools, which were sent by email to all field lab participants for a last round of feedback.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eImplementation and dissemination of the results\u003c/h2\u003e \u003cp\u003eThe concept versions of the tools were presented to RBCZ. Two meetings with researchers, a RBCZ board member and the RBCZ web designer were organised to discuss options for design and dissemination of the tools. Thereafter, the concept versions of the tools were then discussed with the advisory board after which the final version was developed and presented to the boards of the professional associations. Finally, the final versions were communicated to all the participants of the field labs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eDevelopment of the decision aid for complementary care\u003c/h2\u003e \u003cp\u003eOne of the communication tools contained an overview of scientific evidence for a number of complementary therapies for a set of indications. Indications were chosen based on the focus group discussions which is described in the result section below.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLiterature search\u003c/h2\u003e \u003cp\u003eThe literature search was performed in the electronic database Pubmed from March \u0026ndash; August 2023. MeshTerms were determined for each indication and complementary therapy. In case no MeshTerm was found, alternative search terms were used based on input of the focus groups and existing literature. Search strings were composed of MeSH terms and additional terms for the complementary therapies and indications combined (Appendix I). Professional associations were asked to provide literature from their own databases. Titles and abstracts were screened for inclusion by one author (LM). Studies were excluded in case the content did not cover the indication and therapy concerned, the paper was not accessible or language was not English, Dutch, French or German.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEvidence grading\u003c/h2\u003e \u003cp\u003eTwo authors (LM and HvW) independently reviewed and graded the included studies. Evidence grading was based on the Strength of Recommendation Taxonomy (SORT) method [18]. This method addresses the quality, quantity, and consistency of evidence which allows rating the quality of an individual study and of a body of evidence for each complementary therapy and indication. Moreover, since the SORT method follows a patient-centred approach this leads to an easy translation from the strength of a recommendation to clinical practice [18].\u003c/p\u003e \u003cp\u003eFirst, the level of evidence was determined for each individual study included (1\u0026ndash;3). Secondly, a strength of recommendation was given to the body of evidence for a certain indication and complementary therapy following a specific algorithm: resulting in an A, B or C-level recommendation. An A-level recommendation is based on consistent and good-quality patient-oriented evidence; a B-level recommendation is based on inconsistent or limited-quality patient-oriented evidence; and a C-level recommendation is based on consensus, usual practice, expert opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening. Further details on evidence grading can be found in the paper by Ebell et al. [18].\u003c/p\u003e \u003cp\u003e Recommendations were based on the highest quality evidence available, and followed the traditional hierarchy of the evidence pyramid [19]. Thus, in case the available meta-analyses for an indication provided an A recommendation, no further literature was assessed for that indication. If not, the systematic reviews were assessed. In case of an A-level recommendation based on the systematic reviews, the assessment was finished. If not, the individual randomized clinical studies were assessed and eventually other studies lower on the evidence pyramid. Any discrepancies in grading between the two authors were solved through discussion.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eOrganizing field labs\u003c/h2\u003e \u003cp\u003eOver a period of three months three multidisciplinary field labs were established in the following three regions: Amsterdam (1), Utrecht (2) and in the north of the Netherlands (3). Thereafter, over a period of 1,5 years, four focus group meetings were organised per field lab, resulting in 12 focus group meetings of two hours each. In Amsterdam and Utrecht these meetings were held live, in the northern region three meetings were live and one was online.\u003c/p\u003e \u003cp\u003eIt was planned for each field lab to consist of a combination of a maximum of 15\u0026ndash;17 participants, composed of maximum of 10 (5x2 representatives per complementary therapy) different complementary HCPs and 5\u0026ndash;7 different conventional HCPs. However, due to time or distance restraints, and health issues, the total number of HCPs was varying from 9\u0026ndash;12 in field lab 1 (Amsterdam), 8\u0026ndash;12 in field lab 2 (Utrecht) and 6\u0026ndash;14 in field lab 3 (North). The final composition for each field lab can be found in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The remaining 27 complementary HCPs who stated their interest in participating, joined the advisory board.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComposition of the three field labs including the represented complementary therapies and conventional healthcare professionals\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegion Amsterdam\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRegion Utrecht\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRegion North\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplementary therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Gestalt therapy\u003c/p\u003e \u003cp\u003e- Hypnotherapy\u003c/p\u003e \u003cp\u003e- Drawing/Art therapy\u003c/p\u003e \u003cp\u003e- Integrative psychotherapy\u003c/p\u003e \u003cp\u003e- Body-oriented psychotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Shiatsu\u003c/p\u003e \u003cp\u003e- Psychosocial therapy\u003c/p\u003e \u003cp\u003e- Energy therapy\u003c/p\u003e \u003cp\u003e- Craniosacral therapy\u003c/p\u003e \u003cp\u003e- Counselling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e- Classic massage /shiatsu\u003c/p\u003e \u003cp\u003e- Orthomolecular medicine\u003c/p\u003e \u003cp\u003e- Reflexology\u003c/p\u003e \u003cp\u003e- Classical homeopathy\u003c/p\u003e \u003cp\u003e- Yin therapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConventional healthcare professionals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- General practitioner (3)\u003c/p\u003e \u003cp\u003e- Medical doctor (general)\u003c/p\u003e \u003cp\u003e- Physiotherapist\u003c/p\u003e \u003cp\u003e- Psychiatrist (elderly)\u003c/p\u003e \u003cp\u003e- General practice nurse (2; mental health, somatics)\u003c/p\u003e \u003cp\u003e- Gynaecologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- General practitioner\u003c/p\u003e \u003cp\u003e- Medical doctor (MUPS)\u003c/p\u003e \u003cp\u003e- Physiotherapist\u003c/p\u003e \u003cp\u003e- Psychologist (3)\u003c/p\u003e \u003cp\u003e- General practice nurse\u003c/p\u003e \u003cp\u003e- Internist-infectious disease specialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e- General practitioner\u003c/p\u003e \u003cp\u003e- Physiotherapist (3)\u003c/p\u003e \u003cp\u003e- Cesar therapist\u003c/p\u003e \u003cp\u003e- Advisor regional support structure primary care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eResults of the field labs\u003c/h2\u003e \u003cp\u003eA brief thematic analysis was performed on the written reports of all 12 focus group meetings which resulted in five major overarching themes: different perspectives and working methods, patient-centred approach, ways of communication, networking and evidence of complementary care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eDifferent perspectives and working methods\u003c/h2\u003e \u003cp\u003eParticipants were seriously aware of the fundamental differences in working methods and perspectives between conventional and complementary HCPs, such as using a symptom-oriented versus a holistic perspective. They were eager and open to cooperate and find solutions to overcome differences in \u0026ldquo;language\u0026rdquo; and to connect with each other. Participants were also encouraged to visit each other\u0026rsquo;s websites to better understand the therapies and professional standards involved. All agreed that collaboration between conventional and complementary HCPs should be simplified, communication should be short, concise, solution driven in both directions and should be patient-centred.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePatient-centred approach\u003c/h2\u003e \u003cp\u003eParticipants acknowledged that the patients\u0026rsquo; responsibility for their own health remains constant, regardless the possible differences in opinion among HCPs regarding the definition of the primary symptom. The importance of shared decision making was emphasized and participants agreed that the final responsibility for treatment choice always remains with the patient. Nevertheless, the patient should be appropriately guided in her process to obtain accurate, reliable and personalized information in order to find an appropriate healthcare professional. Additionally, it was crucial to consider quality and safety aspects of the complementary therapy and clarity on reimbursement for patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eWays of communication\u003c/h2\u003e \u003cp\u003eLack of time was an important barrier in communication expressed by conventional healthcare professionals. Especially GPs, who already experience a high administrative burden, asked to keep the number of communication tools to a minimum and combine tools together.\u003c/p\u003e \u003cp\u003e Participants suggested a more neutral tone of the existing communication tools, to express an equivalent relationship between GPs and complementary HCPs. They also wanted the terminology to respond to recent developments in healthcare, such as the importance of discussing lifestyle changes and the concept of positive health, and be tailored towards the perception and experiences of conventional health care practitioners, such as the use of CD-10-CM medical diagnosis codes.\u003c/p\u003e \u003cp\u003e Conventional HCPs wanted communication to be short, concise, simple and reporting should be done at all times, always with the patients consent. Conventional HCPs preferred to be contacted by telephone in case of peer consultation, in case safety of the patient was at risk and for coordination regarding medication intake. Complementary HCPs preferred written communication, to report by letter or email to GPs at the start of a treatment, in case of changes and to report on effectivity after completing their treatment. It was emphasized that open and honest communication on effectivity was warranted. Conventional HCPs also wanted to receive reports about complementary treatments that did not show efficacy. This would add to the credibility and reliability of complementary therapies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eNetworking\u003c/h2\u003e \u003cp\u003eParticipants considered making use of already existing protocols and contact systems used by GPs with regards to reporting and referral which could serve as facilitator for the integration of collaboration. Additionally, peer learning groups were mentioned as an option to strengthen collaboration between conventional and complementary HCPs.\u003c/p\u003e \u003cp\u003eMoreover, it was deemed important to make an overview of existing networks and collaborations which could be contacted. A network of practicing complementary HCPs on local, regional and national level was desired by both types of HCPs. The need was expressed for uniting various types of complementary HCPs in a certain region and for them to introduce themselves as a network to conventional HCPs, although there was awareness that not every GP would be open to collaboration.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eEvidence of complementary therapies\u003c/h2\u003e \u003cp\u003eIn general, scientific evidence can be seen as a language to connect all types of HCPs. However, the perspective on the value of scientific evidence may differ between complementary and conventional HCPs. Simultaneously, it was emphasized that evidence-based medicine is more than using evidence from research. The relationship and building trust between patient and healthcare professional are equally important for the effectivity of a treatment. Moreover, it was highlighted that one complementary therapy can be applicable to various indications due to its holistic nature and all HCPs realised that the literature assessment would not always take these holistic aspects of complementary therapies into account.\u003c/p\u003e \u003cp\u003eIt was considered necessary to provide more information and context about complementary care with regards to the following subjects: the ethical framework on weighing effectivity and safety, evidence on psychosocial therapies, the body-mind connection and patient-tailored advise.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eDevelopment of the communication tools\u003c/h2\u003e \u003cp\u003eBased on the thematic analysis of the 12 focus group meetings and the previous communication toolkit [20], a new version of the toolkit was created. The final evidenced-based communication toolkit consists of seven communication tools, covering the following themes; getting to know each other, communication between complementary and conventional HCPs, letter formats, decision aid for complementary care with recommendations, grading evidence, support for communication of RBCZ affiliated professional associations and implementation (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Except for Tool #3, existing of four letter formats, and Tool #4, the decision aid for complementary care, all tools consist of a short explanation of the topic and practical suggestions, tips and resources. Some are specific for the Dutch healthcare context, others are more generally applicable.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of the communication toolkit\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTool\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFor whom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eContent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow to get to know each other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComplementary HCPs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e- First contact and request for personal meeting: 8 tips (e.g. how to find open minded GP\u0026rsquo;s)\u003c/p\u003e \u003cp\u003e- Preparation for personal meeting: 5 tips (e.g. know your evidence)\u003c/p\u003e \u003cp\u003e- Personal meeting: to inform GP about complementary treatment options; 7 tips (e.g. keep it simple and short)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow to communicate\u0026nbsp;with conventional healthcare practitioners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComplementary HCPs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo inform GP about:\u003c/p\u003e \u003cp\u003e- patient registration and discharge (9 tips, including what protected digital applications to use)\u003c/p\u003e \u003cp\u003e- need for peer consultation (2 tips, e.g. about medication)\u003c/p\u003e \u003cp\u003e- referral back to GP (if patient doesn\u0026rsquo;t respond to treatment or diagnosis can\u0026rsquo;t be treated)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLetter formats (in addition to Tool #2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComplementary HCPs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo inform GP about:\u003c/p\u003e \u003cp\u003e- patient registration\u003c/p\u003e \u003cp\u003e- need for peer consultation\u003c/p\u003e \u003cp\u003e- patient discharge\u003c/p\u003e \u003cp\u003eTo report treatment to company doctor, e.g. in relation to burn out treatment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDecision aid for complementary care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComplementary and conventional HCPs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eContext, Evidence, Ethical framework, and recommendations for 13 complementary therapies and 6 indications, based on the SORT method for grading patient-oriented evidence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrading evidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRBCZ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExplanation of and guidelines for using the SORT method\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow to support members to improve communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRBCZ/professional associations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e- Suggested activities, e.g. facilitating local/regional networks of members, peer-to-peer coaching and define key figures\u003c/p\u003e \u003cp\u003e- Materials, e.g. complementary information for education\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow to implement decision aid for complementary care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRBCZ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSuggested activities (internal/external) for implementation of decision aid, to include in a comprehensive long-term communication plan of RBZC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eDevelopment of the decision aid for complementary care\u003c/h2\u003e \u003cp\u003eThe decision aid for complementary care consists of an evidence overview with recommendations, an ethical framework to guide shared decision making [21] and introductory texts including information on complementary care, the content and how to use it. The evidence overview is presented below (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eSelection of indications\u003c/h2\u003e \u003cp\u003eThe participating complementary HCPs listed the most frequent indications they treated and for which scientific evidence for effectiveness could be expected. Subsequently, the participating conventional HCPs provided input, based on their clinical experiences, about which indications were high in need of treatment options and could potentially benefit from complementary treatment.\u003c/p\u003e \u003cp\u003eThe top indications mentioned five times or more by complementary healthcare professionals, were depressive symptoms (11), trauma (9), anxiety (9), burnout (9), pain (neck, shoulder, low back, (7)), sleeping disorders (7), stress (6), medically unexplained physical symptoms (MUPS) (5), fatigue (5) and cancer related symptoms (5). Conventional healthcare professionals were not inclined to refer patients with severe depressive symptoms, anxiety disorders or complex trauma to complementary HCPs but rather refer these patients to conventional mental HCPs. Therefore, trauma and anxiety disorders were not selected for the decision aid. Nevertheless, depressive symptoms were selected since it was most frequently mentioned by complementary HCPs. Conventional HCPs saw more potential for referral for MUPS (3), fatigue (3), stress (3) and irritable bowel syndrome (3). After 2 discussion rounds, a final selection of 6 indications were to be included in the decision aid for complementary care: chronic low back pain, depressive symptoms, medically unexplained physical symptoms (MUPS), irritable bowel syndrome, burnout, and chronic fatigue syndrome.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eSearch terms for complementary therapies\u003c/h2\u003e \u003cp\u003eDuring the focus group meetings search terms were discussed for each of the complementary therapies involved. Not all of them were captured through separate search terms. Integrative psychotherapy e.g. consists of a variety of psychological treatment modalities. It was decided to include this therapy in the decision aid on the basis of available evidence for at least one of the following therapies: gestalt therapy, body-oriented therapy or hypnotherapy, since these therapies were considered to be part of integrative psychotherapy. No evidence was found for yin therapy, a rather new multifaceted therapy. Since it partly overlaps with yoga, yoga was chosen as the most relevant search term. Yin therapy could be included in the decision aid in case of evidence available for yoga, shiatsu, orthomolecular therapy or craniosacral therapy. Due to time restraints, it was decided to exclude classical massage and focus solely on shiatsu, as the participating professional association represented both therapies. \u0026lsquo;Supplements\u0026rsquo;, \u0026lsquo;probiotics\u0026rsquo;, \u0026lsquo;phytotherapy\u0026rsquo; and \u0026lsquo;herbal therapy\u0026rsquo; were used as additional search terms for orthomolecular therapy.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eEvidence based recommendations\u003c/h2\u003e \u003cp\u003eAn overview was made of the total number of hits, meta-analyses, systematic reviews, and randomized controlled trials (RCT\u0026rsquo;s) for each of the 6 indications and 12 complementary therapies (excluding integrative psychotherapy) (appendix II). No literature was available for 21 indication\u0026ndash;complementary therapy combinations (17%). Meta-analyses were available for one-third (33%) of the indication\u0026ndash;therapy combinations, systematic reviews were available for 15% and RCTs were available for 46% of the indication\u0026ndash;therapy combinations. An overview of the evidence grading based on the SORT criteria can be found in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, in detail in appendix III.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of the evidence grading for 13 therapies and 6 indications\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"14\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShiatsu\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYin therapy/yoga *\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOrthomolecular medicine\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHomeopathy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eReflexology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEnergy therapy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCraniosacral therapy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCounselling\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGestalt therapy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eBody-oriented psychotherapy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eDrawing/Art therapy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eHypnotherapy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e \u003cp\u003eIntegrative psychotherapy**\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChronic low back pain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepressive symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedically unexplained symptoms (MUPS/MUS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIrritable Bowel Syndrome (IBS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBurnout\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChronic fatigue syndrome (CFS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* Literature search based on evidence for effectivity of yoga; people may also be referred to yin therapy based on available evidence of at least one of the following therapies: shiatsu, orthomolecular or craniosacral therapy; ** No specific literature search performed; yes\u0026thinsp;=\u0026thinsp;people may be referred to integrative psychotherapy based on available evidence of at least one of the following therapies: gestalt therapy, body-oriented psychotherapy or hypnotherapy. 0\u0026thinsp;=\u0026thinsp;no literature available; - = evidence for no effect; A\u0026thinsp;=\u0026thinsp;based on consistent and good-quality patient-oriented evidence; B\u0026thinsp;=\u0026thinsp;recommendation is based on inconsistent or limited-quality patient-oriented evidence; C\u0026thinsp;=\u0026thinsp;recommendation is based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eImplementation and dissemination\u003c/h2\u003e \u003cp\u003e In the last focus groups and advisory board meetings implementation and dissemination of the communication tools were discussed. Various roles and responsibilities were identified. As RBCZ is an umbrella organization it will embed all communication tools in its communication strategy to make them available for the affiliated professional associations. Own means of communication to be used are webinars, newsletters, symposia and congresses. Another route of implementation could be through education, both medical and complementary. Several medical and nursing schools in the Netherlands offer elective courses in integrative medicine/nursing, in which information about the decision aid could be included.\u003c/p\u003e \u003cp\u003eThe individual professional associations will communicate about the tools to their individual members and to a diversity of stakeholders, such as the schools in complementary therapies they are connected to.\u003c/p\u003e \u003cp\u003eThe decision aid for complementary care is the most specific and broadly usable tool. It is primarily a conversation starter between patient and conventional healthcare professional regarding complementary care. RBCZ will therefore design the decision aid as both a physical and digital tool, also to be accessed via a QR code. Comprehensive implementation activities for the decision aid will be provided in the RBCZ communication strategy.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eFrom the beginning the project was very positively received by both complementary and conventional HCPs. They enjoyed the open and informative discussions, leading to more mutual respect for each other\u0026rsquo;s professionalism and commitment to the health and well-being of patients. The choice for a co-creative regional field lab improved the collaboration between participants in those regions. For instance, an active working group was established with complementary and conventional HCPs to develop letter formats on communication. Additionally, a platform of over 40 complementary HCPs was launched in Utrecht with joint activities to approach the city\u0026rsquo;s health services and policy makers. Furthermore, the field labs improved peer consultations between complementary HCPs in the regions.\u003c/p\u003e \u003cp\u003eAn important part of the project was the development of the evidence based decision aid for 6 indications and 13 complementary care modalities. Decision aids are known to help resolve medical decisions and have positive effects on communication between patient and HCP [22]. Deciding on which indications to include in the decision aid and how the evidence was graded resulted in many discussions and even frictions in the groups, mainly because of differences in perspective on what evidence means, differences in needs between conventional and complementary HCPs regarding evidence, and opinions on whether complementary therapies, being holistic by concept, fit in the evidence based model of scientific bio-medical thinking. This supports the advice provided by Clifford et al. based on a systematic review of decision aids that such aids should include patient and practice evidence as well as information on contextual factors [23]. Therefore, the decision aid for complementary care is not envisioned as a standalone tool but as part of a broader set of communication tools. The tools will be disseminated by RBCZ as part of a broader communication strategy, in line with similar implementation strategies for decision aids for complementary care in the Netherlands [24].\u003c/p\u003e \u003cp\u003e We compared the evidence grading in this paper with the online medical Essential Evidence database containing 742 chapters mainly used by primary care physicians which is also graded using the SORT criteria [25]. The overall evidence for the recommendations in this database is grade A for 18% of the recommendations and grade B for 34% of the recommendations. In our decision aid 15% of the recommendations received grade A and 46% received a grade B. This indicates that the current status of evidence for the complementary therapies that were assessed in this project is comparable to the overall evidence for primary care interventions.\u003c/p\u003e \u003cp\u003e The main strength of the project was the regionally organised multidisciplinary collaboration which successfully served the needs of both complementary as well as conventional HCPs. Bringing those different HCPs together stimulated synergy and new ideas. The evidence based strategy using the SORT criteria allowed for better acceptance of complementary HCPs and can improve communication between complementary and conventional HCPs. Furthermore, the final set of communication tools was well received by RBCZ during a meeting with the boards of the 25 professional associations.\u003c/p\u003e \u003cp\u003eThis study has several limitations. Regarding the evidence based decision aid, finding the appropriate search terms for some complementary therapies was not always a straightforward task, since they include multiple modalities, some of which could also be regarded as conventional interventions such as cognitive behaviour therapy. Since there is generally a lack of funding for researching complementary therapies [26], the availability of good quality studies for these therapies is limited while the practitioner and patient experiences are often very positive. Furthermore, the classical method of the randomized controlled trial is not always suitable to capture the holistic nature of complementary therapies [27], [28]. Therefore, the decision aid for complementary care must be seen as primarily a tool to start communicating about evidence for complementary therapies. These discussions should then also include the practitioners experiences and the patients preferences in line with the original vision of evidence based medicine [29].\u003c/p\u003e \u003cp\u003eRBCZ will stimulate implementation of the tools by the 25 professional associations and over registered 9.500 complementary HCPs. The communication tools will be made available on RBCZ\u0026rsquo;s website. The decision aid for complementary care will be expanded to represent a larger number of therapies covered by the RBCZ professional associations. Further research is needed to evaluate the actual use of the communication tools in practice and the implementation process. The outcomes facilitate the possibility for the worlds of complementary care and conventional health care to meet and integrate. Better integration of complementary care in conventional healthcare system might contribute to a more sustainable healthcare ecosystem.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003e This participatory research project succeeded in bringing together complementary and conventional HCPs in three regions in the Netherlands. A set of communication tools was developed including an evidence based decision aid for complementary care, for 13 therapies and six indications, which will be made available to 25 professional associations covering over 9.500 complementary HCPs. During the project the collaboration amongst complementary HCPs was strengthened as well as between complementary and conventional HCPs.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eGP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;general practitioner\u003c/p\u003e\n\u003cp\u003eHCP \u0026nbsp; \u0026nbsp; healthcare practitioner\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFUNDING\u003c/h2\u003e\n\u003cp\u003eThe project was funded by RBCZ. RBCZ participated in the project by delivering representatives of the professional organisations and organizing meetings. RBCZ had no influence on the literature search, evidence grading and recommendations resulting from this project.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eLTCM assisted with the focus group meetings, conducted the literature search and grading of the evidence, wrote the draft of the paper, prepared all the visuals for the paper. HAvW conceptualized and designed the project, collected data, assisted in the literature search and grading of the evidence, wrote and edited the paper, acquired funding and supervised the project. MB conceptualized and designed the project, setup the field labs, conducted focus group meetings, collected data, assisted in writing the paper. AD co-designed the project, assisted in setting up the field labs, organised meetings, and reviewed the paper. All authors approved of the final version of the paper.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors first of all would like to acknowledge the enthusiasm and dedication with which the representatives of the participated professional associations and the individual conventional healthcare practitioners participated in the field labs. We also thank the board of RBCZ for their full support in conducting the project by promoting the project, communication with the professional associations, organizing meetings, discussing the results and willingness to implement the results in the organisation. We also thank the boards of the professional associations for their support.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe communication tools which are developed in this study are not attached but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eCREDIT AUTHOR STATEMENT\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eLM assisted with the focus group meetings, conducted the literature search and grading of the evidence, wrote the draft of the paper, prepared all the visuals for the paper. HVW conceptualized and designed the project, collected data, assisted in the literature search and grading of the evidence, wrote and edited the paper, acquired funding and supervised the project. MB conceptualized and designed the project, setup the field labs, conducted focus group meetings, collected data, assisted in writing the paper. AD co-designed the project, assisted in setting up the field labs, organised meetings, and reviewed the paper. All authors approved of the final version of the paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRIVM, \u0026lsquo;Effecten van vergrijzing steeds beter zichtbaar in uitgaven gezondheidszorg\u0026rsquo;. Geraadpleegd: 4 december 2023. [Online]. 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Niemiec, \u0026lsquo;Integrative medicine and patient-centered care\u0026rsquo;, \u003cem\u003eExplore N. Y. N\u003c/em\u003e, vol. 5, nr. 5, pp. 277-289, 2009, doi: 10.1016/j.explore.2009.06.008.\u003c/li\u003e\n\u003cli\u003eL. M. Kemppainen, T. T. Kemppainen, J. A. Reippainen, S. T. Salmenniemi, en P. H. Vuolanto, \u0026lsquo;Use of complementary and alternative medicine in Europe: Health-related and sociodemographic determinants\u0026rsquo;, \u003cem\u003eScand. J. Public Health\u003c/em\u003e, vol. 46, nr. 4, pp. 448-455, jun. 2018, doi: 10.1177/1403494817733869.\u003c/li\u003e\n\u003cli\u003eM. C. Jong, L. van de Vijver, M. Busch, J. Fritsma, en R. Seldenrijk, \u0026lsquo;Integration of complementary and alternative medicine in primary care: What do patients want?\u0026rsquo;, \u003cem\u003ePatient Educ. Couns.\u003c/em\u003e, vol. 89, nr. 3, pp. 417-422, dec. 2012, doi: 10.1016/j.pec.2012.08.013.\u003c/li\u003e\n\u003cli\u003eA. M. Vlieger, E. M. van de Putte, en H. 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Beschikbaar op: https://urn.kb.se/resolve?urn=urn:nbn:se:miun:diva-29120\u003c/li\u003e\n\u003cli\u003e S. Timmermans, \u0026lsquo;The Engaged Patient: The Relevance of Patient\u0026ndash;Physician Communication for Twenty-First-Century Health\u0026rsquo;, \u003cem\u003eJ. Health Soc. \u003c/em\u003e\u003cem\u003eBehav.\u003c/em\u003e, vol. 61, nr. 3, pp. 259-273, sep. 2020, doi: 10.1177/0022146520943514.\u003c/li\u003e\n\u003cli\u003e H. van Wietmarschen en M. Busch, \u0026lsquo;COmmunicatie en verwijzing COmplementaire Zorg \u0026ndash; COCOZ\u0026rsquo;, Louis Bolk Instituut. Geraadpleegd: 15 november 2023. [Online]. Beschikbaar op: https://www.louisbolk.nl/publicaties/communicatie-en-verwijzing-complementaire-zorg-cocoz\u003c/li\u003e\n\u003cli\u003e D. L. Morgan, \u003cem\u003eFocus groups as qualitative research\u003c/em\u003e, vol. 16. Sage publications, 1996. Geraadpleegd: 25 oktober 2023. [Online]. Beschikbaar op: https://books.google.nl/books?hl=nl\u0026amp;lr=\u0026amp;id=LxF5CgAAQBAJ\u0026amp;oi=fnd\u0026amp;pg=PT6\u0026amp;dq=Morgan,+D.+L.+(1996).+Focus+groups+as+qualitative+research+(Vol.+16).+Sage+publications.\u0026amp;ots=3uTnwP1TE9\u0026amp;sig=iMPtix4G6u396DChWQar0jBO8Vw\u003c/li\u003e\n\u003cli\u003e M. Gundumogula, \u0026lsquo;Importance of Focus Groups in Qualitative Research\u0026rsquo;, \u003cem\u003eInt. J. Humanit. Soc. Stud.\u003c/em\u003e, vol. 8, nr. 11, nov. 2020, doi: 10.24940/theijhss/2020/v8/i11/HS2011-082.\u003c/li\u003e\n\u003cli\u003e M. H. Ebell \u003cem\u003ee.a.\u003c/em\u003e, \u0026lsquo;Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature\u0026rsquo;, \u003cem\u003eJ. Am. Board Fam. Pract.\u003c/em\u003e, vol. 17, nr. 1, pp. 59-67, 2004, doi: 10.3122/jabfm.17.1.59.\u003c/li\u003e\n\u003cli\u003e A. L. Rosner, \u0026lsquo;Evidence-based medicine: Revisiting the pyramid of priorities\u0026rsquo;, \u003cem\u003eJ. Bodyw. Mov. Ther.\u003c/em\u003e, vol. 16, nr. 1, pp. 42-49, jan. 2012, doi: 10.1016/j.jbmt.2011.05.003.\u003c/li\u003e\n\u003cli\u003e Louis Bolk Instituut, \u0026lsquo;COCOZ: Communicatie over complementaire zorg\u0026rsquo;, COCOZ: Communicatie over complementaire zorg. [Online]. Beschikbaar op: https://www.louisbolk.nl/projecten/cocoz-communicatie-voor-complementaire-zorg\u003c/li\u003e\n\u003cli\u003e M. H. Cohen en K. J. Kemper, \u0026lsquo;Complementary therapies in pediatrics: a legal perspective\u0026rsquo;, \u003cem\u003ePediatrics\u003c/em\u003e, vol. 115, nr. 3, pp. 774-780, mrt. 2005, doi: 10.1542/peds.2004-1093.\u003c/li\u003e\n\u003cli\u003e D. Stacey \u003cem\u003ee.a.\u003c/em\u003e, \u0026lsquo;Decision aids for people facing health treatment or screening decisions\u0026rsquo;, \u003cem\u003eCochrane Database Syst. Rev.\u003c/em\u003e, vol. 4, nr. 4, p. CD001431, apr. 2017, doi: 10.1002/14651858.CD001431.pub5.\u003c/li\u003e\n\u003cli\u003e A. M. Clifford, J. Ryan, C. Walsh, en A. McCurtin, \u0026lsquo;What information is used in treatment decision aids? A systematic review of the types of evidence populating health decision aids\u0026rsquo;, \u003cem\u003eBMC Med. Inform. Decis. Mak.\u003c/em\u003e, vol. 17, nr. 1, p. 22, feb. 2017, doi: 10.1186/s12911-017-0415-7.\u003c/li\u003e\n\u003cli\u003e M. C. Jong \u003cem\u003ee.a.\u003c/em\u003e, \u0026lsquo;Development of an evidence-based decision aid on complementary and alternative medicine (CAM) and pain for parents of children with cancer\u0026rsquo;, \u003cem\u003eSupport. Care Cancer\u003c/em\u003e, vol. 28, nr. 5, pp. 2415-2429, mei 2020, doi: 10.1007/s00520-019-05058-8.\u003c/li\u003e\n\u003cli\u003e M. H. Ebell, R. Sokol, A. Lee, C. Simons, en J. Early, \u0026lsquo;How good is the evidence to support primary care practice?\u0026rsquo;, \u003cem\u003eBMJ Evid.-Based Med.\u003c/em\u003e, 2017, Geraadpleegd: 26 oktober 2023. [Online]. Beschikbaar op: https://ebm.bmj.com/content/ebmed/early/2017/05/29/ebmed-2017-110704.full.pdf\u003c/li\u003e\n\u003cli\u003e F. Fischer \u003cem\u003ee.a.\u003c/em\u003e, \u0026lsquo;A research roadmap for complementary and alternative medicine - what we need to know by 2020\u0026rsquo;, \u003cem\u003eComplement. Med. Res.\u003c/em\u003e, vol. 21, nr. 2, Art. nr. 2, apr. 2014, doi: 10.1159/000360744.\u003c/li\u003e\n\u003cli\u003e G. S. Kienle \u003cem\u003ee.a.\u003c/em\u003e, \u0026lsquo;Contributing to Global Health: Development of a Consensus-Based Whole Systems Research Strategy for Anthroposophic Medicine\u0026rsquo;, \u003cem\u003eEvid.-Based Complement. Altern. Med. ECAM\u003c/em\u003e, vol. 2019, p. 3706143, 2019, doi: 10.1155/2019/3706143.\u003c/li\u003e\n\u003cli\u003e C. M. Witt, \u0026lsquo;Efficacy, effectiveness, pragmatic trials--guidance on terminology and the advantages of pragmatic trials\u0026rsquo;, \u003cem\u003eForsch. Komplementarmedizin 2006\u003c/em\u003e, vol. 16, nr. 5, pp. 292-294, okt. 2009, doi: 10.1159/000234904.\u003c/li\u003e\n\u003cli\u003e D. L. Sackett, W. M. Rosenberg, J. A. Gray, R. B. Haynes, en W. S. Richardson, \u0026lsquo;Evidence based medicine: what it is and what it isn\u0026rsquo;t\u0026rsquo;, \u003cem\u003eBMJ\u003c/em\u003e, vol. 312, nr. 7023, pp. 71-72, jan. 1996, doi: 10.1136/bmj.312.7023.71.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"communication, healthcare practitioners, decision aid, complementary care, field labs, SORT, implementation","lastPublishedDoi":"10.21203/rs.3.rs-4268398/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4268398/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: The Dutch health care system is in need for guidance and implementation of complementary care of which shared decision making, communication and referral between conventional and complementary care practitioners are major components. A Dutch quality register for complementary healthcare practitioners (RBCZ) was interested to adopt and implement an improved version of a communication toolkit developed in an earlier project. The aim of this study was to improve the communication and collaboration between member practitioners of RBCZ and conventional healthcare practitioners.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: The set of communication tools was updated and expanded with new tools in a co-creation process with conventional and complementary healthcare practitioners in three field labs; Utrecht, Amsterdam and the north of the Netherlands. Thematic focus group discussions were held to define the content and implementation of the toolkit. A pragmatic evidence-based decision aid for the respective complementary care modalities was developed based on a literature assessment and Strength Of Recommendation Taxonomy (SORT) criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eThe final evidence-based toolkit consisted of seven communication tools, covering the themes: getting to know each other, communication, frame letters, decision aid with evidence-based recommendations for 13 complementary therapies and 6 indications, and support for communication of the RBCZ members/professional associations and implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: The evidence-based toolkit will be made available to 25 professional associations covering over 9.500 complementary healthcare practitioners in the Netherland (RBCZ). The regional collaboration amongst complementary healthcare practitioners was strengthened as well as between complementary and conventional healthcare practitioners.\u003c/p\u003e","manuscriptTitle":"Co-creation of an evidence-based toolkit to facilitate communication on complementary medicine between conventional and complementary healthcare practitioners in the Netherlands","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-23 10:14:15","doi":"10.21203/rs.3.rs-4268398/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1a73862e-70bf-4392-bbaf-8dbafcdd66ce","owner":[],"postedDate":"April 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-07T17:38:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-23 10:14:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4268398","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4268398","identity":"rs-4268398","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}