Some general practitioners, as well as non-medical practitioners, provide alternative therapies. Such provision ranges from 16% of general practitioners in Australia,¹¹ Britain^12,13 and Canada¹⁴ to 30% in New Zealand.^15,16 In addition, the proportion of doctors who refer patients to non-medical therapists ranges from 59%-72% in Britain^12,13 to 60% in the United States,¹⁷ 68% in Canada,^14,18 80% in New Zealand^15,16 and 90% in Holland.⁶

In Australia one such therapy, acupuncture, is of particular interest in that, although it is used by doctors as part of their normal general practice in many countries, including the UK,¹³ Canada¹⁴ and Holland,⁶ it is used most extensively by doctors in New Zealand^15,16 and Australia.¹¹

Acupuncture is not part of the standard medical curriculum in Australia, but it is recognised as a standard medical therapeutic technique in that it attracts a Medicare rebate (as item 173) when it is performed by a medical practitioner. Other alternative therapies do not attract a rebate or are not so clearly specified. Given this level of government recognition and its use by one in seven Australian general practitioners,¹¹ acupuncture can be considered an addition to general practice in Australia -- a complementary, rather than an alternative, therapy.

In this article we examine the characteristics of patients claiming for acupuncture provided by general practitioners, as an extension of our previous report on the characteristics of general practitioners using acupuncture.¹¹

The first dataset was time-series data for the financial years 1984-85 to 1996-97. It includes the number of services and benefits claimed for acupuncture (1984-1990, item 980; 1991-1997, item 173) by State/Territory, age and sex.

The second dataset consisted of all Medicare services claimed by patients in the calendar year 1996 -- each case representing an individual patient. We analysed a 1:10 systematic random sample of these data, which included 1 575 173 patients. The data included five variables that measured the frequency of acupuncture claims, frequency of non-acupuncture items, sex, age groupings and postcode. Postcodes were reclassified into 62 categories (consolidated to 12 for presentation) derived from an Australian Bureau of Statistics socioeconomic disadvantage index (SDI).¹⁹ SDI groupings were used as proxy measures of socioeconomic status.

The 1996 data were analysed using the SAS procedure proc logistic.²⁰ A logistic regression model was fitted to the data to analyse a dichotomous dependent variable (1 = acupuncture service claims, 0 = other service claims). Models were also fitted to four dependent variables representing acupuncture use as quartiles of total service use (ie, 0-25%, 26%-50%, 51%-75%, 76%-100%). Logistic regression odds ratios adjusted for sex, age and SDI were calculated.

The University of Tasmania Ethics Committee (Human Experimentation) approved the study.

Separate analyses (not shown) indicate that women make about two-thirds of all claims, except in the Northern Territory, where women make only 55% of claims. When age is examined by sex the picture is more complex. In 1996-97, boys aged 14 years or younger (51.6%; 95% CI, 50.5%-52.7%) were slightly more likely than girls (48.5%; 95% CI, 47.3%-49.5%) to make claims for acupuncture, whereas among older people the pattern was 35% men (95% CI, 34.9%-35.1%) and 65% women (95% CI, 64.9%-65.1%). From 1984 to 1987 claims for both men and women increased with age, peaking at age 55-64 years. However, from 1988 the peak age for women shifted to 45-54 years. There has also been an increase in claims among people 70 years or older, from 7.25% in 1984 to 18% in 1996.  

Analyses of the 1996 data (not shown) suggest that, while women (52.7%; 95% CI, 52.6%-52.8%) are more likely than men (47.3%; 95% CI, 47.2%-47.4%) to claim for all types of medical services, their claims for acupuncture are proportionately higher, with 61.7% of those claiming for acupuncture being women (odds ratio [OR], 1.45). These sex differences remain after adjusting for age and SDI (Box).

However, acupuncture claims expressed as quartiles (ie, 0-25%, 26%-50%, 51%-75%, 76%-100%) by sex show a different pattern. Sex-based differences tend to decrease as the proportion of acupuncture claims rises. From a logistic regression model (not shown) controlling for age and SDI, no sex-based differences were found for acupuncture claims in the group claiming acupuncture as 76%-100% of all claims (OR, 1.03; 95% CI, 0.91-1.16).

As a proportion of all claims, acupuncture claims increased linearly with age (Box), peaking for the 65-69 years age group, then declining.

Acupuncture claims tend to be highest in the areas just above the most socioeconomically disadvantaged. Patients in SDI area 2 are 1.7 times (95% CI, 1.58-1.85) more likely to have claimed for acupuncture than those in the area 6 reference group, although the odds ratios for other SDI categories do not exceed 1.3 (Box).

The consistent State/Territory differentials in acupuncture claims are difficult to explain. One possible factor may be ease of access to providers because of the small size of Tasmania and the concentration of the South Australian population in Adelaide. Another may be that these two States have high unemployment, and Medicare-funded acupuncture, unlike medication or physiotherapy, does not require patients to pay for treatment.

Acupuncture claims are made more by women than men, and are age-related. The differential between claims made by women and men is greater than the usual disproportion for medical-service claims. This finding appears to lend support to previous research that suggests women are more receptive to alternative techniques.^9,10,21 However, this apparent receptiveness varies by age, with boys more likely than girls to receive acupuncture. Further, the peak age for acupuncture claims by women has varied, shifting in 1988 from 55-64 years to 45-54 years. These age variations suggest that the decision to use acupuncture is not solely a function of women's receptiveness to alternative therapies, but is a function of either sex/age-based differences in presenting complaints or doctors' changing willingness to use acupuncture.

The increase in claims for acupuncture by middle-aged and elderly patients is also likely to relate to the presenting complaints of patients, or perhaps the lack of success of conventional treatment in alleviating their problems. However, the very weak relationship between high Medicare claims and high acupuncture claims suggests that acupuncture is being used as an alternative to, rather than in conjunction with, other treatments. Whether acupuncture is used after other treatments have failed, as suggested by American² and Canadian²¹ research, cannot be ascertained from these HIC data. However, focus groups conducted by one of us (G E) with general practitioner users of acupuncture suggest that it is seen by family doctors as most useful for chronic pain, a symptom more likely to present in middle-aged and elderly patients.²²

The higher rate of claims for acupuncture in areas in the lower levels of the SDI scale is contrary to most previous research on alternative therapies,^9,10,21 which suggests they are used predominantly by wealthier segments of the community. The fact that these data relate to a Medicare-funded complementary procedure is important in considering this divergence from previous findings.

Differences in the rate of acupuncture claims by SDI are not related to the proportion of doctors providing acupuncture in different SDI areas.¹¹ This suggests either that the use of acupuncture is demand-driven rather than supply-driven or that doctors providing acupuncture in low-SDI areas do so to a greater extent through Medicare funding than their colleagues in other SDI areas. However, we recognise that a degree of caution is necessary when interpreting the SDI results, as postcode-based SDI measures may be subject to misclassification error.²³

The funding system for Australian healthcare (Medicare and the Health Insurance Commission) provided data which are not available anywhere else in the world. This, coupled with the fact that acupuncture attracts a Medicare rebate if performed by a doctor, enabled us to produce this study, the only national-level study of the characteristics of patients treated with acupuncture. However, the advantages of this dataset are also its disadvantages. The data do not include acupuncture services provided by doctors conducted privately or for insurance companies. Nor do they include the provision of acupuncture by non-medical practitioners. Therefore, these results are not representative of overall acupuncture use or alternative therapies in general.

Nevertheless, our results are important at the national level. Acupuncture, a therapy not taught in the standard undergraduate medical curriculum, has been adopted by doctors and used as a complementary therapy throughout Australia. The current Medicare rebate for acupuncture is $18.45, $2.55 less than a standard consultation. Doctors choosing acupuncture are not doing so for monetary reasons. For some doctors it is now an established complementary therapy, apparently chosen for clinical reasons, and a therapy used more frequently with women and elderly patients than with men or young adults and children.

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Division of Community and Rural Health, University of Tasmania, Launceston, TAS.
Gerard F Gill, MAE, FRACGP, Clinical Senior Lecturer.

Department of General Practice, University of Adelaide, SA.
Justin J Beilby, MPH, FRACGP, Senior Lecturer.

Reprints will not be available from the authors.
Correspondence: Dr G Easthope, School of Sociology and Social Work, University of Tasmania, GPO Box 252-17, Hobart, TAS 7001
Email: Gary.EasthopeATutas.edu.au

©MJA 1999
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