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New Clues on How Hypnosis Works

June 26, 2009 -- University of Geneva researchers say they found in a series of experiments using functional magnetic resonance imaging (fMRI) that brain activity is different under hypnosis.

Their study is published in journal Neuron.

The study concludes that hypnosis induces a disconnection of motor commands from normal voluntary processes under the influence of brain circuits involved in executive control and self-imagery, Yann Cojan, PhD, of the Neuroscience Center and Medical School at the University of Geneva, tells WebMD in an email.

The researchers used fMRI to scan brains of 12 people who were tested on hand movement before and after hypnosis for left hand paralysis.

Despite the paralysis, neurons in the motor cortex region were still firing away in preparation for the task, Cojan tells WebMD.

He says his team confirmed "subjective reports of hypnotic phenomenon" and also that "functional connectivity is a very important process in the brain" that hypnosis is capable of modifying.

What was surprising was that the cortex appeared to be ignoring parts of the brain with which it normally communicates in controlling movement, the researchers say.

Hypnosis produced changes in areas involved in attention, and also modified connections between the brain's motor cortex and other regions, Cojan tells WebMD.

Besides the 12 who were hypnotized, the researchers also scanned the brains of six people who had not been hypnotized but who had been told to feign hand paralysis for testing. They comprised the comparison group.

"These results suggest that hypnosis may enhance self-monitoring processes to allow internal representations generated by the suggestion to guide behavior but does not act through direct motor inhibition," Cojan says in a news release. "These findings make an important new step toward establishing neurobiological foundations for the striking impact of hypnosis on the brain and behavior."

In the study participants, messages weren't sent through normal brain channels, so when hypnotized subjects were told to move their left hands, they couldn't, Cojan says.

Hypnosis, the researchers found, induces a disconnect in normal voluntary processes involved in planning to move a body part. "Hypnosis is a very old tool in many medical domains but it is still unclear how it works," Cojan says.

日期:2009年6月28日 - 来自[Health News]栏目
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Breast Cancer Surgery: Hypnosis Helps

Aug. 28, 2007 -- Women may feel less pain and have an easier recovery from breast cancer surgery if they have a hypnosis session first, a new study shows.

The study included 200 women who were due to get breast cancer surgery at New York's Mount Sinai Medical Center.

Specifically, the women were scheduled to get surgery for a breast biopsy or a lumpectomy (surgery to remove a breast tumor while saving as much of the breast as possible).

The researchers randomly split the women into two groups. One group of women got a 15-minute hypnosis session within an hour of their surgery.

The hypnosis session, conducted by psychologists trained to use hypnosis in a medical setting, included guided relaxation, pleasant visual imagery, and soothing techniques.

For comparison, the other group of women spent 15 minutes within an hour of their surgery talking with a psychologist who was supportive but didn't use hypnosis, imagery, or relaxation.

The researchers -- who included Guy Montgomery, PhD, of Mount Sinai School of Medicine's oncological sciences department -- tracked the women during and after their surgery.

The women in the hypnosis group required less anesthesia medication than women who didn't get hypnosis.

After surgery, the women in the hypnosis group reported less intense pain and less nausea, fatigue, discomfort, and emotional upset than?those who hadn't gotten hypnosis.

"Overall, the present data support the use of hypnosis with breast cancer surgery patients," report Montgomery and colleagues.

Of course, that's in addition to the use of anesthesia and painkillers.

Hypnosis also trimmed the hospital's surgical costs.

The operations typically cost the hospital $8,561 per patient, but the cost dropped by about $772 for the hypnotized patients, mainly due to shorter surgeries, note the researchers.

The study adds to other research that demonstrate that hypnosis "substantially reduces pain and anxiety during surgical procedures while decreasing medication use, procedure time, and cost," says an editorial published with the study.

"If a drug were to do that, everyone would be using it by now," writes editorialist David Spiegel, MD, of the psychiatry and behavioral sciences department at Stanford University's medical school.

日期:2007年8月30日 - 来自[Health News]栏目

Cost Analysis of Adjunct Hypnosis with Sedation during Outpatient Interventional Radiologic Procedures

 1 From the Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, West Campus 308 CC, Boston, MA 02215. From the 1999 RSNA scientific assembly. Received February 28, 2001; revision requested April 13; revision received June 25; accepted August 15. E.V.L. supported by grant RO1 AT00002-04 from the National Center for Complementary and Alternative Medicine. 


     ABSTRACT

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ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
 
PURPOSE: To compare the cost of standard intravenous conscious sedation with that of sedation with adjunct self-hypnotic relaxation during outpatient interventional radiologic procedures.

MATERIALS AND METHODS: Data were reviewed from a prospective randomized study in which patients undergoing vascular and renal interventional procedures underwent either standard sedation (n = 79) or sedation with adjunct hypnosis (n = 82). These data were used to construct a decision analysis model to compare the cost of standard sedation with the cost of sedation with adjunct hypnosis. Multiple sensitivity analyses were performed to assess the applicability of these results to other institutions with different cost structures with respect to the following variables: cost of the hypnosis provider, cost of room time for interventional radiologic procedure, hours of observation after the procedure, and frequency and cost of complications associated with over- or undersedation.

RESULTS: According to data from this experience, the cost associated with standard sedation during a procedure was $638, compared with $300 for sedation with adjunct hypnosis, which resulted in a savings of $338 per case with hypnosis. Although hypnosis was known to reduce room time, hypnosis remained more cost-effective even if it added an additional 58.2 minutes to the room time.

CONCLUSION: Use of adjunct hypnosis with sedation reduces cost during interventional radiologic procedures.

 

Index terms: Anesthesia • Cost-effectiveness • Hypnosis • Interventional procedures


     INTRODUCTION

Top
ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
 
Hypnotic and behavioral interventions have been shown to be effective in reducing pain and anxiety associated with invasive medical procedures (18). Although authors of several reports (5,9,10) allude to the cost-effectiveness of these interventions, it is difficult to find supportive numeric data that would favor generalized introduction into clinical practice. Results of a recent prospective randomized study (6) showed that adjunct self-hypnotic relaxation provided to patients during interventional radiologic procedures was associated with greater patient comfort, fewer adverse side effects, and shorter room times than when patients underwent only intravenous conscious sedation. The purpose of our study was to compare the cost of standard intravenous conscious sedation with that of sedation with adjunct self-hypnotic relaxation during outpatient interventional radiologic procedures.


     MATERIALS AND METHODS

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ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
 
Patients
Input data originated from a prospective randomized study (6) in which the authors assessed the effect of adjunct self-hypnotic relaxation on patient comfort during percutaneous vascular and renal procedures. The patient pool included consecutive consenting patients referred to the Section of Vascular and Interventional Radiology at the University of Iowa Hospital and Clinics, Iowa City, in 1997 and 1998. The study was approved by the investigational review board for human use and the hospital’s nursing committee, and all patients signed an informed consent form prior to enrollment.

Patients were enrolled in the study if they had been referred for any of the following interventional radiologic procedures: diagnostic arteriography, diagnostic venography, thrombolysis, angioplasty, vascular stent placement, placement of vena cava filters, transjugular hepatic biopsy, nephrostomy or nephroureterostomy. Exclusion criteria were severe chronic obstructive pulmonary disease, psychosis, intolerance of midazolam or fentanyl, pregnancy, or inability to hear or understand English. Patients underwent screening with the Mini-Mental State Examination (11). If they passed with a score of at least 24 of a maximum of 30 points, they were randomly assigned to one of three groups. Levels of anxiety or hypnotizability were neither inclusion nor exclusion criteria.

Seventy-nine patients (36 men, 43 women; age range, 18–92 years; median age, 57 years) were randomly assigned to a group undergoing standard intravenous conscious sedation; 82 patients (38 men, 44 women; age range, 19–82 years; median age, 54 years) were randomly assigned to a hypnosis group having additional self-hypnotic relaxation. The physical status classification, according to the American Society of Anesthesiologists, of the patients ranged from 1 to 4, with a mean of 2.23, defined as follows: 1, healthy patient; 2, mild systemic disease; 3, severe systemic disease; 4, acute life-threatening condition. There were no significant differences in group composition with regard to age, weight, sex, disease category, type and complexity of procedure, number of prior procedures, and baseline pain and anxiety levels.

Standard Intravenous Conscious Sedation
All patients were attended by a special procedures nurse and had access to patient-controlled anesthesia with delivery of 0.5 mg of midazolam and 25 µg of fentanyl per request for as many as four requests, with lockout times (when the patient could not access medication) of 5 minutes, followed by a lockout time of 15 minutes. Patients indicated the desire for medication with activation of a bell that signaled the attending nurse to deliver the drugs. Medication was withheld when the systolic pressure was less than 89 mm Hg, oxygen saturation was less than 89%, or patients developed slurred speech or became difficult to arouse.

The patient-controlled analgesia model was chosen to reduce the possibility of unblinded experimenter bias toward using more drugs in control patients and to ensure that all patients had the same access to drugs. Patient-controlled anesthesia is well suited for acute pain management during and after medical procedures and is thought to enhance comfort while providing patients with a means of control (12,13). In a pilot trial (Lang EV, unpublished observation, 1995) prior to this study, use of a patient-controlled anesthesia pump was tested but was found to be potentially hazardous. Since drug-induced cardiorespiratory emergencies are treated differently from those induced by other causes, rapid knowledge of the drug history becomes important, and entering the recording mechanism of a patient-controlled anesthesia pump could cause undue delay. Therefore, patients were given a reusable attention bell (cost, $3.50 at office supply stores) that signaled the attending nurse, rather than a machine, to deliver drugs through an indwelling intravenous access route.

To ensure that patients who would hesitate to use the bell would not undergo undue distress, rules for overriding patient-determined analgesia were defined and agreed on by the study and procedure personnel prior to the study. Overriding criteria included de novo increase in systolic blood pressure beyond 180 mm Hg, spontaneous complaints, verbal request for drugs, or significant perceived distress. In addition, all patients received 1% lidocaine for local anesthesia for all access sites—typically 10 mL for vascular access and 30–40 mL for percutaneous renal access.

Self-hypnotic Relaxation
The self-hypnotic relaxation intervention was structured in the procedure room by one of four providers (one nurse, one psychology graduate student, two medical students) and has been described in detail previously (14). It included the following standardized behaviors: matching the patient’s verbal and nonverbal communication pattern (ie, preference for modes of expression, sitting next to rather than towering over a supine patient); attentive listening; provision of control; swift response to patient requests; encouragement; use of emotionally neutral descriptors ("What are you experiencing?"); avoidance of negative descriptors ("How bad is your pain?"); and reading of a hypnotic induction script, with a provision for management of anxiety and pain, if needed. In summary, patients were instructed to roll their eyes upward, close their eyes, breathe deeply, concentrate on a sensation of floating, and immerse themselves in a safe and comfortable place (for full text, see reference 14).

The completion time of the hypnotic induction script was 5–10 minutes, and hypnosis was performed while the patient was prepared for the procedure. Since all hypnotic inductions were performed in the procedure suite, the time involved was included in the overall procedure time and, thus, in the cost analysis. All patient-provider interactions were videotaped, and 60 (25%) of 240 were randomly selected to check for adherence to the protocol. Fidelity of treatment administration was invariably high among the providers, and thus not significantly different.

Analysis of variance showed that there was no difference among providers with respect to room time; analysis was performed by using the logarithmic transformation of the procedure times because of skewness of distribution of the raw time data. To assess for theoretic differences among future providers, the reader can refer to two sensitivity analyses (described later) that would reflect the skill of the provider structuring the hypnosis: a sensitivity analysis performed for the effect of room time with hypnosis and another sensitivity analysis for the effect of undersedation with hypnosis.

Decision Analysis Model
The cost of the hypnosis treatment, compared with that of standard treatment, was assessed with a decision analysis model  by using commercial software (DATA; TreeAge, Williamstown, Mass). For both treatments, with the decision analysis model the following possible outcomes were used for outpatient interventional radiologic procedures: (a) uncomplicated sedation, (b) oversedation, or (c) undersedation.


fig.ommitted  Figure 1. Basic decision tree used to build the model and perform sensitivity analyses. The P values are probabilities of the event at the decision branch used in this decision model. OBS. = observation.

 

 

fig.ommitted  TABLE 1. Data Used to Build the Cost Analysis Model

 

 
Uncomplicated sedation was assumed to be associated with no additional cost. Oversedation or undersedation could result in (a) no additional cost, (b) cost associated with additional intense observation, (c) cost associated with sustained observation, or (d) cost associated with hospital admission. Probabilities of occurrence and associated cost for each of these scenarios were derived from our prior experience with the 161 patients. Costs of materials administered during treatment of oversedation or undersedation were omitted because of their negligible contribution—for example, costs for oxygen tubing, emesis basins, and drugs such as nifedipine or atropine were all less than $1. The analysis was conducted from the perspective of the hospital.

Basic Decision Tree
Since the goal of this study was to provide a generalizable cost assessment for outpatient interventional radiologic procedures, input data for cost were derived from year 2000 costs at Beth Israel Deaconess Medical Center, Boston, Mass, and are listed in ; sensitivity analyses were included to allow for extrapolation to cost structures at other institutions. For the basic decision analysis tree, the assumption was made that all patients would leave the hospital after a 4-hour recovery period unless extended observation or admission were required.

Room time encompassed the period from the patients’ entry into the procedure suite until their transfer to the recovery unit. Average procedure time was 78 minutes in the standard group and 61 minutes in the hypnosis group. Costs for room time included equipment amortization and personnel cost based on local salaries and fringe benefits for one physician, one nurse, one technologist, and one optional additional provider structuring the hypnotic intervention .

The basic decision tree assumptions were that the nurse already present structured the hypnosis intervention and, thus, the cost for an optional additional hypnosis provider would be $0. To allow for the possibility of an additional hypnosis provider in a subsequent sensitivity analysis (Materials and Methods, last section), the cost of one additional health care provider, a psychologist, was included in the room time. In either event, the cost of nursing time was included for the duration of the entire procedure.

Recovery cost included four possible components : (a) immediate postprocedure time (eg, sheath removal, groin compression); (b) basic recovery time (eg, monitoring vital signs); (c) additional intense recovery time, when required; and (d) sustained observation time, when required. We assumed that one physician and one nurse were required for the immediate postprocedure care and that one nurse was able to monitor up to four patients during the basic recovery time. All patients required immediate postprocedure time and basic recovery time.


fig.ommitted 
 
Figure 2. Diagram of patient flow after an outpatient interventional radiologic procedure.

 

 
If over- or undersedation occurred, we assumed that patients would require additional intense recovery time and that this would have to be monitored by a nurse and physician. The following times were assumed for additional intense recovery time for complications of sedation with hypnosis: oversedation leading to sustained observation or admission, 15 or 30 minutes, respectively; undersedation leading to sustained observation or admission, 30 or 60 minutes, respectively. The following times were assumed for additional intense recovery time for complications of sedation with standard care: oversedation leading to sustained observation or admission, 30 or 60 minutes, respectively; undersedation leading to sustained observation or admission, 45 or 60 minutes, respectively.

If after the intense recovery time the patients still exhibited the effects of over- or undersedation, we allowed for an additional 30–60 minutes of sustained observation time monitored by a nurse. After the time in the interventional radiologic recovery area, all patients either were sent to the day care unit for an additional 4 hours of "outpatient" observation or, if complications necessitated, were admitted to the hospital.

To calculate admission cost for undersedation, we used the average cost weights of diagnosis-related group (DRG) 130, peripheral vascular disorders with complications (cost weight, 0.9427) and DRG 131, peripheral vascular disorders without complications (cost weight, 0.6067). The average cost weight for undersedation was 0.7747. To calculate admission cost caused by oversedation, we used the average cost weight of DRG 99, respiratory signs and symptoms with complications (cost weight, 0.6738) and DRG 100, respiratory signs and symptoms without complications (cost weight, 0.5150). The average cost weight for oversedation was 0.5944. In both instances, the Medicare blended rate paid to Beth Israel Deaconess Medical Center, Boston, in 1999 ($4,273) was assumed. The blended rate included technical but not professional fees.

The cost weight is the severity factor assigned to each DRG by the Health Care Financing Administration, or HCFA. It is multiplied by the blended rate—the standardized rate that each hospital is paid— to calculate the exact reimbursement for a specific DRG. For example, if a DRG has a cost weight of 2 and a blended rate of $5,000, the hospital would be paid $10,000 for that DRG. An average of two cost weights was used in the basic decision tree to account for institutional variations in DRG coding. Subsequently (Materials and Methods, last section), sensitivity analyses were performed to assess the effect that specific DRG coding of complications may have on our conclusions. The two cost weights for each complication defined the range of the sensitivity analyses.

Oversedation
Oversedation included all events associated with depression of cardiorespiratory or mental status. Oxygen desaturation was included only when a decrease to less than 89% persisted longer than 2 minutes and required placement of a nasal oxygen cannula.

Standard group.—Sixteen (20%) of 79 patients showed signs of oversedation. Six patients with oxygen desaturation incurred no additional cost, except for the nasal oxygen cannula, which was considered a no-cost item. Six patients required intense observation because of prolonged hypoxemia with or without associated cardiovascular depression (n = 5) and slow resolution of slurred speech (n = 1). Four patients qualified for admission—three because of drowsiness and/or unresponsiveness and one because of continued bradycardia, hypotension, and recurrent bleeding from the puncture site.

Hypnosis group.—Oversedation affected nine (11%) of 82 patients and required no treatment in five patients, except for a nasal cannula. Four patients needed intense observation—one for prolonged hypoxemia with distracting behavior during the procedure, one for transient hypoxemia in recovery, one for being poorly arousable in recovery, and one for bradycardia.

Undersedation
Undersedation included all events associated with incidents requiring staff attention, such as discomfort in recovery, persistent new hypertension, and distracting, attention-seeking patient behavior.

Standard group.—Undersedation was observed in 24 (30%) of 79 patients. One patient did not need further treatment for transient tachycardia. Twenty-one patients required intense observation for distracting behavior (n = 10), discomfort (n = 6), hypertension (n = 3), or recurrent bleeding from the puncture site (n = 2). Two patients qualified for admission because of recurrent bleeding.

Hypnosis group.—Undersedation was encountered in eight (10%) of 82 patients because of discomfort (n = 4), hypertension (n = 1), and distracting behavior (n = 3). All incidents required intense observation.

Sensitivity Analyses
Sensitivity analyses were performed to address how changes in individual input parameters would affect overall outcome and to extrapolate the applicability of these results to those of other institutions with different cost structures. Outcome was considered not sensitive to a parameter if change in the value of this parameter over a given range did not affect overall cost superiority of a treatment (ie, standard or hypnosis treatment). If outcome was sensitive to a parameter, a threshold analysis was performed to determine at what value one strategy became preferable to the other.

Sensitivity analyses were performed for the following parameters : (a) cost of an additional hypnosis provider of $0–$10/min; (b) room time for use of hypnosis of 25–200 minutes; (c) hours of additional observation after the procedure for complications related to over- or undersedation of 0–5 hours; (d) probability of oversedation with standard treatment with P values between .00 and .50; (e) probability of undersedation with hypnosis treatment with P values between .00 and .50; (f) cost for admission caused by undersedation of $0–$10,000; (g) cost weight for admission caused by undersedation of 0.6067–0.9427; (h) cost for admission due to oversedation of $0–$10,000; (i) cost weight for admission due to oversedation of 0.5150–0.6738; (j) a blended rate of $2,500–$10,000; and (k) hourly cost of the procedure room of $2.50–$10/min.


fig.ommitted  TABLE 2. Sensitivity Analyses for Several Variables Used in the Cost Analysis Model

 

 

     RESULTS

Top
ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
 
Basic Decision Tree
 illustrates the decision analysis tree with the associated probabilities of each outcome (derived from reference 6). Average sedation cost for standard treatment was $638 and for hypnosis treatment was $300, which resulted in an average savings of $338 per case with hypnosis.

Sensitivity Analyses
Data used in the sensitivity analyses are presented in . The sensitivity analysis allowed us to calculate the effect that changing one variable would have on the total costs associated with hypnosis or standard therapy. The lower and upper boundaries correspond to the lowest and highest values assumed for each variable tested. These boundaries were chosen to reflect a reasonable range of variation that may be encountered in different clinical practices. In most cases, the range was chosen so that the baseline value was near the center of the range.

Effect of an additional hypnosis provider.—When an additional provider is included to structure the hypnosis treatment, savings realized by using hypnosis decrease to a threshold of a salary of $5.50/min; when the salary is greater than this amount, standard treatment is more cost-effective . The threshold of $5.50/min corresponds to $330/h, or $633,600/y plus 30% fringe benefits. When the basic decision tree is recalculated for a scenario that includes a staff psychologist at an annual salary of $70,000 plus fringe benefits, the sedation cost with hypnosis is $348. This still leaves a cost superiority of $290 ($638 minus $348) per case.


fig.ommitted  Figure 3. Graph shows the effect of adding a health care provider structuring hypnosis during the procedure. Savings with adjunct hypnosis decrease with increasing reimbursement, in dollars per minute, to this additional provider up to a threshold of $5.50/min, or $330/h (dashed line), beyond which it is more costly to provide adjunct hypnosis. The expected value is the cost in dollars for standard therapy  versus that for hypnosis .

 

 
Effect of room time and postprocedure observation time.—When sensitivity analysis was performed with room time of 25–200 minutes while keeping all other variables constant, a threshold value of 136.2 minutes resulted for adjunct hypnosis . Thus, as long as average room time with hypnosis does not exceed 136.2 minutes, for a case that would take 78 minutes with standard conditions, hypnosis remains less costly on average. Hypnosis was always more cost-effective over a range of postprocedure observation times of 0–5 hours because of complications of over- or undersedation.


fig.ommitted Figure 4. Graph shows the effect of room time in minutes required for an interventional radiologic procedure by using hypnosis divided by the expected value, which is the cost in dollars for standard therapy  versus that for hypnosis . The cost of standard therapy is constant at an average procedure duration of 78 minutes. According to conditions of the basic decision tree, a procedure with hypnosis lasts, on average, 61 minutes. The threshold value (dashed line) is the room time at which the cost of hypnosis is equal to the cost of standard therapy. As long as interventional radiologic procedures performed with hypnosis require fewer than 136.2 minutes, it is more cost-effective to perform hypnosis than to perform standard therapy.

 

 
Effect of the probability of oversedation during standard treatment.—Standard treatment was always more expensive than hypnosis treatment over a range of probability between 0% and 50% of oversedation from standard therapy. When the probability of oversedation from standard therapy is 0%, standard therapy costs $189 more than hypnosis. When the probability of oversedation from standard therapy is 50%, the cost of standard therapy is $558 more than the cost of hypnosis.

Effect of the probability of undersedation with hypnosis treatment.—Standard treatment was always more expensive than hypnosis treatment over a range of probability of 0%–50% of undersedation from hypnosis therapy. When the probability of undersedation from hypnosis therapy is 0%, standard therapy costs $352 more than hypnosis. When the probability of undersedation from hypnosis therapy is 50%, the cost of standard therapy is $290 more than the cost of hypnosis.

Effect of blended rates and cost weights.—The savings with hypnosis increase with an increase in the blended rate, ranging from $250 ($550 for standard therapy minus $300 for hypnosis) at a blended rate of $2,500 and reaching $623 ($923 minus $300) at a blended rate of $10,000. We then tested whether the use of the specific DRG used to estimate the cost of complications associated with oversedation or undersedation had an effect on our results. If the cost weight for the DRG used for complications from oversedation increases from 0.5150 (DRG 100) to 0.6738 (DRG 99), the savings from the use of hypnosis increase from $321 to $356. If the cost weight for the DRG used for complications associated with undersedation increases from 0.6067 (DRG 131) to 0.9427 (DRG 130), the savings from the use of hypnosis increase from $320 to $357. Thus, as the costs of complications increase, the net savings associated with the use of hypnosis, compared with those associated with standard therapy, increase.

Effect of the hourly procedure room cost.—Our base case assumption was that each minute in the procedure room cost $4.50. As the cost of procedure room time varied between $2.50 and $10 per minute, the savings realized by using hypnosis increased from $304 per case to $431 per case.


     DISCUSSION

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ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
 
With use of adjunct hypnosis, the savings, on average, was $338 per case in conditions of the basic decision tree. The savings depended strongly on the Medicare blended rate of the institution, which ranged from $250 per case at a blended rate of $2,500 to $623 per case at a blended rate of $10,000. Thus, high-cost academic centers with high Medicare blended rates are expected to gain most from use of the hypnotic intervention.

The basic decision tree assumption was that hypnosis was provided by an interventional team member, such as a specially trained nurse or technologist. Members of surgical teams can be highly effective in structuring hypnosis during invasive medical procedures (3,1518) and may be superior to outside personnel (5). If an additional person were to be added to structure hypnosis, cost savings would be less, but still remain substantial at $290 per case. This latter number was derived from a decision tree by using the equivalent of a staff psychologist’s salary of $70,000/y plus 30% fringe benefits. Sensitivity analysis showed that adjunct hypnosis is less costly than standard sedation unless the additional person were to demand more than $330/h. This rate of reimbursement surpasses by far that of most nonphysician specialists and interventionalists, making even their participation in hypnosis worth their time.

If procedure personnel structure hypnosis, the cost of training and continued support should be accounted for. Typically, 24 hours of classroom instruction, supervised clinical instruction, and a second 8-hour workshop suffice for medical personnel to achieve sufficient skills in the methods (6,18). Continued supervision through a psychologist or a physician experienced in hypnosis on a biweekly basis is highly desirable.

Whether using procedure personnel is more resource-sensitive than adding a psychologist, who does not need additional training and supervision, depends on personnel turnover and recurrent training cost. The up-front costs of establishing a procedure team–based hypnosis program depend on the level of participation rate of the personnel desired. The cheapest alternative may be to have individual procedure personnel trained at a hypnosis course administered by one of the hypnosis societies (eg, Society for Clinical and Experimental Hypnosis, American Society of Clinical Hypnosis, New England Society of Hypnosis) or other accredited continuing medical education programs. Training an entire team for the procedure has the advantage of creating a supportive climate and providing team members enhanced communication skills that can also be used in nonpatient interactions.

On the basis of which model is chosen and how many persons are selected for training or whether outside trainers are invited, up-front costs are an estimated $3,000–$15,000 (estimated on the basis of the prior training cost incurred). From a hospital perspective, these costs are recuperated after using self-hypnotic relaxation in 10–50 patients.

When offered hypnosis training, personnel commonly voice concerns that inducing and maintaining hypnosis in the procedure suite is performed may prolong room time. In the case of adjunct hypnosis, as was used in this study, room time actually decreased from 78 to 61 minutes despite the fact that hypnosis was induced in the procedure suite (6). However, even if hypnosis were to add time to the procedure, it would still be less costly than standard sedation. Specifically, hypnosis could add up to an additional 58.2 minutes to the procedure time and still have a cost superiority, compared with the cost of standard treatment . These results should dispel concerns that introduction of the self-hypnotic intervention would reduce efficiency or be too costly.

Costs of standard conscious sedation are heavily influenced by the probability of oversedation with intravenously administered sedatives and narcotics. The average amount of sedatives and narcotics administered in standard sedation in patients in this study (1.9 drug units; with one drug unit equaling 1 mg of midazolam or 50 µg of fentanyl) is well within the range of doses commonly used for similar procedures (19) and within the customary range of drugs used in the institution of this study for these types of procedures. Higher doses risk higher probabilities of oversedation; lower doses may result in a less cooperative patient. Hypnotic adjuncts are clinically helpful in that they can provide comfort with less need for intravenous drugs (0.9 units in this study) and thus less risk of oversedation. On the other hand, individuals who are not responsive to the hypnotic intervention may either demand more drugs, and thus be exposed to the risk of oversedation, or remain undersedated. Undersedation with hypnosis also affects cost. Sensitivity analysis shows that even if the probability of undersedation were to reach 80%, hypnosis would still be less costly than standard therapy, with a savings of $86.

One potential limitation is the use of DRGs to estimate the cost of complications related to over- and undersedation. Although the DRG may not directly correspond to the actual cost of care provided by the hospital, we believe that it is a reasonable proxy. In addition, the use of DRGs incorporates the blended rate paid to each hospital. The blended rate takes into account the hospital’s patient population and regional variations in cost. Thus, by varying the severity of the blended rate, our analysis can be easily generalized to other institutions.

The superior clinical effect of hypnosis has already been described in the original article (6) from which the cost data of this study are derived. Thus, this current analysis does not aim at demonstrating the effect of hypnosis on clinical well-being (ie, its effectiveness) but merely on the effect of hypnosis on cost. Several of these events labeled as oversedation or undersedation do not qualify as complications in the sense of morbidity reporting but rather represent a highly self-critical reporting of any event in deviation of an ideal equilibrium among comfort level, dose of medication, and side effects of medication.

A second limitation is that the cost of room time for the procedure varies among institutions. However, the sensitivity analysis performed on the cost of the procedure room demonstrates that the cost superiority of hypnosis persisted at all values tested from $2.50 to $10 per minute (base case, $4.50/min).

We have previously shown that adjunct hypnosis with intravenous conscious sedation during interventional radiologic procedures is effective in reducing pain, anxiety, and procedure time. Findings of this cost analysis show substantial cost savings when adjunct hypnosis is used. Therefore, the choice between greater patient comfort and lower cost need not be made. Medical benefits of hypnosis for the patient notwithstanding, adjunct hypnosis during procedures is a clinically feasible and cost-saving practice.

 

     REFERENCES

日期:2007年5月14日 - 来自[2001年第1卷第2期]栏目
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Cost Analysis of Adjunct Hypnosis with Sedation during Outpatient Interventional Radiologic Procedures1

1 From the Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, West Campus 308 CC, Boston, MA 02215. From the 1999 RSNA scientific assembly. Received February 28, 2001; revision requested April 13; revision received June 25; accepted August 15. E.V.L. supported by grant RO1 AT00002-04 from the National Center for Complementary and Alternative Medicine.

Top
ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES

  1. Sampimon RLH, Woodruff MF. Some observations concerning the use of hypnosis as a substitute for anesthesia. Med J Aust 1946; 1:393-395.

  2. Levitan AA, Harbaugh TE. Hypnotizability and hypnoanalgesia: hypnotizability of patients using hypnoanalgesia during surgery. Am J Clin Hypn 1992; 34:223-226.

  3. Faymonville ME, Mambourg PH, Joris J, et al. Psychological approaches during conscious sedation: hypnosis versus stress reducing strategies—a prospective randomized study. Pain 1997; 73:361-367.

  4. Erickson JC, III. The use of hypnosis in anesthesia: a master class commentary. Int J Exp Clin Hypn 1994; 42:8-12.

  5. Blankfield RP. Suggestion, relaxation, and hypnosis as adjuncts in the care of surgery patients: a review of the literature. Am J Clin Hypn 1991; 33:172-186.

  6. Lang EV, Benotsch EG, Fick LJ, et al. Adjunctive non-pharmacologic analgesia for invasive medical procedures: a randomised trial. Lancet 2000; 355:1486-1490.

  7. John ME, Parrino JP. Practical hypnotic suggestion in ophthalmic surgery. Am J Ophthalmol 1983; 96:540-542.

  8. Rodger BP. The art of preparing the patient for anesthesia. Anesthesiology 1961; 22:548-554.

  9. Rapkin DA, Straubing M, Holyroyd JC. Guided imagery, hypnosis and recovery from head and neck cancer surgery: an exploratory study. Int J Clin Exp Hypn 1991; 39:215-226.

  10. Meurisse M, Hamoir E, Defechereux T, et al. Bilateral neck exploration under hypnosedation: a new standard of care in primary hyperparathyroidism?. Ann Surg 1999; 229:401-408.

  11. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189-198.

  12. Duggleby W, Lander J. Patient-controlled analgesia for older adults. Clin Nurs Res 1992; 1:107-113.

  13. Schelling G, Weber W, Mendl G, Braun H, Cullman H. Patient controlled analgesia for shock wave lithotripsy: the effect of self-administered alfentanil on pain intensity and drug requirement. J Urol 1996; 155:43-47.

  14. Lang EV, Lutgendorf S, Logan H, Benotsch E, Laser E, Spiegel D. Nonpharmacologic analgesia and anxiolysis for interventional radiological procedures. Semin Interv Radiol 1999; 16:113-123.

  15. Meurisse M, Defechereux T, Hamoir E, et al. Hypnosis with conscious sedation instead of general anaesthesia? Applications in cervical endocrine surgery. Acta Chir Belg 1999; 99:151-158.

  16. Esdaile J. Hypnosis in medicine and surgery 1846. Reissued (with a different title), New York, New York: Julian, 1957.

  17. Lang EV, Joyce JS, Spiegel D, Hamilton D, Lee K. Self-hypnotic relaxation during interventional radiological procedures: effects on pain perception and intravenous drug use. Int J Exp Clin Hyp 1996; 44:106-119.

  18. Lang EV, Berbaum KS. Educating interventional radiology personnel in nonpharmacologic analgesia: effect on patients’ pain perception. Acad Radiol 1997; 4:753-757.

  19. Lang EV, Chen F, Fick LJ, Berbaum KS. Determinants of intravenous conscious sedation for arteriography. J Vasc Interv Radiol 1998; 9:407-412.

     ABSTRACT

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ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES

 
PURPOSE: To compare the cost of standard intravenous conscious sedation with that of sedation with adjunct self-hypnotic relaxation during outpatient interventional radiologic procedures.

MATERIALS AND METHODS: Data were reviewed from a prospective randomized study in which patients undergoing vascular and renal interventional procedures underwent either standard sedation (n = 79) or sedation with adjunct hypnosis (n = 82). These data were used to construct a decision analysis model to compare the cost of standard sedation with the cost of sedation with adjunct hypnosis. Multiple sensitivity analyses were performed to assess the applicability of these results to other institutions with different cost structures with respect to the following variables: cost of the hypnosis provider, cost of room time for interventional radiologic procedure, hours of observation after the procedure, and frequency and cost of complications associated with over- or undersedation.

RESULTS: According to data from this experience, the cost associated with standard sedation during a procedure was $638, compared with $300 for sedation with adjunct hypnosis, which resulted in a savings of $338 per case with hypnosis. Although hypnosis was known to reduce room time, hypnosis remained more cost-effective even if it added an additional 58.2 minutes to the room time.

CONCLUSION: Use of adjunct hypnosis with sedation reduces cost during interventional radiologic procedures.

 

Index terms: Anesthesia • Cost-effectiveness • Hypnosis • Interventional procedures


     INTRODUCTION

Top
ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
 
Hypnotic and behavioral interventions have been shown to be effective in reducing pain and anxiety associated with invasive medical procedures (18). Although authors of several reports (5,9,10) allude to the cost-effectiveness of these interventions, it is difficult to find supportive numeric data that would favor generalized introduction into clinical practice. Results of a recent prospective randomized study (6) showed that adjunct self-hypnotic relaxation provided to patients during interventional radiologic procedures was associated with greater patient comfort, fewer adverse side effects, and shorter room times than when patients underwent only intravenous conscious sedation. The purpose of our study was to compare the cost of standard intravenous conscious sedation with that of sedation with adjunct self-hypnotic relaxation during outpatient interventional radiologic procedures.


     MATERIALS AND METHODS

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ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
 
Patients
Input data originated from a prospective randomized study (6) in which the authors assessed the effect of adjunct self-hypnotic relaxation on patient comfort during percutaneous vascular and renal procedures. The patient pool included consecutive consenting patients referred to the Section of Vascular and Interventional Radiology at the University of Iowa Hospital and Clinics, Iowa City, in 1997 and 1998. The study was approved by the investigational review board for human use and the hospital’s nursing committee, and all patients signed an informed consent form prior to enrollment.

Patients were enrolled in the study if they had been referred for any of the following interventional radiologic procedures: diagnostic arteriography, diagnostic venography, thrombolysis, angioplasty, vascular stent placement, placement of vena cava filters, transjugular hepatic biopsy, nephrostomy or nephroureterostomy. Exclusion criteria were severe chronic obstructive pulmonary disease, psychosis, intolerance of midazolam or fentanyl, pregnancy, or inability to hear or understand English. Patients underwent screening with the Mini-Mental State Examination (11). If they passed with a score of at least 24 of a maximum of 30 points, they were randomly assigned to one of three groups. Levels of anxiety or hypnotizability were neither inclusion nor exclusion criteria.

Seventy-nine patients (36 men, 43 women; age range, 18–92 years; median age, 57 years) were randomly assigned to a group undergoing standard intravenous conscious sedation; 82 patients (38 men, 44 women; age range, 19–82 years; median age, 54 years) were randomly assigned to a hypnosis group having additional self-hypnotic relaxation. The physical status classification, according to the American Society of Anesthesiologists, of the patients ranged from 1 to 4, with a mean of 2.23, defined as follows: 1, healthy patient; 2, mild systemic disease; 3, severe systemic disease; 4, acute life-threatening condition. There were no significant differences in group composition with regard to age, weight, sex, disease category, type and complexity of procedure, number of prior procedures, and baseline pain and anxiety levels.

Standard Intravenous Conscious Sedation
All patients were attended by a special procedures nurse and had access to patient-controlled anesthesia with delivery of 0.5 mg of midazolam and 25 µg of fentanyl per request for as many as four requests, with lockout times (when the patient could not access medication) of 5 minutes, followed by a lockout time of 15 minutes. Patients indicated the desire for medication with activation of a bell that signaled the attending nurse to deliver the drugs. Medication was withheld when the systolic pressure was less than 89 mm Hg, oxygen saturation was less than 89%, or patients developed slurred speech or became difficult to arouse.

The patient-controlled analgesia model was chosen to reduce the possibility of unblinded experimenter bias toward using more drugs in control patients and to ensure that all patients had the same access to drugs. Patient-controlled anesthesia is well suited for acute pain management during and after medical procedures and is thought to enhance comfort while providing patients with a means of control (12,13). In a pilot trial (Lang EV, unpublished observation, 1995) prior to this study, use of a patient-controlled anesthesia pump was tested but was found to be potentially hazardous. Since drug-induced cardiorespiratory emergencies are treated differently from those induced by other causes, rapid knowledge of the drug history becomes important, and entering the recording mechanism of a patient-controlled anesthesia pump could cause undue delay. Therefore, patients were given a reusable attention bell (cost, $3.50 at office supply stores) that signaled the attending nurse, rather than a machine, to deliver drugs through an indwelling intravenous access route.

To ensure that patients who would hesitate to use the bell would not undergo undue distress, rules for overriding patient-determined analgesia were defined and agreed on by the study and procedure personnel prior to the study. Overriding criteria included de novo increase in systolic blood pressure beyond 180 mm Hg, spontaneous complaints, verbal request for drugs, or significant perceived distress. In addition, all patients received 1% lidocaine for local anesthesia for all access sites—typically 10 mL for vascular access and 30–40 mL for percutaneous renal access.

Self-hypnotic Relaxation
The self-hypnotic relaxation intervention was structured in the procedure room by one of four providers (one nurse, one psychology graduate student, two medical students) and has been described in detail previously (14). It included the following standardized behaviors: matching the patient’s verbal and nonverbal communication pattern (ie, preference for modes of expression, sitting next to rather than towering over a supine patient); attentive listening; provision of control; swift response to patient requests; encouragement; use of emotionally neutral descriptors ("What are you experiencing?"); avoidance of negative descriptors ("How bad is your pain?"); and reading of a hypnotic induction script, with a provision for management of anxiety and pain, if needed. In summary, patients were instructed to roll their eyes upward, close their eyes, breathe deeply, concentrate on a sensation of floating, and immerse themselves in a safe and comfortable place (for full text, see reference 14).

The completion time of the hypnotic induction script was 5–10 minutes, and hypnosis was performed while the patient was prepared for the procedure. Since all hypnotic inductions were performed in the procedure suite, the time involved was included in the overall procedure time and, thus, in the cost analysis. All patient-provider interactions were videotaped, and 60 (25%) of 240 were randomly selected to check for adherence to the protocol. Fidelity of treatment administration was invariably high among the providers, and thus not significantly different.

Analysis of variance showed that there was no difference among providers with respect to room time; analysis was performed by using the logarithmic transformation of the procedure times because of skewness of distribution of the raw time data. To assess for theoretic differences among future providers, the reader can refer to two sensitivity analyses (described later) that would reflect the skill of the provider structuring the hypnosis: a sensitivity analysis performed for the effect of room time with hypnosis and another sensitivity analysis for the effect of undersedation with hypnosis.

Decision Analysis Model
The cost of the hypnosis treatment, compared with that of standard treatment, was assessed with a decision analysis model (Fig 1, Table 1) by using commercial software (DATA; TreeAge, Williamstown, Mass). For both treatments, with the decision analysis model the following possible outcomes were used for outpatient interventional radiologic procedures: (a) uncomplicated sedation, (b) oversedation, or (c) undersedation.


fig.ommitted Figure 1. Basic decision tree used to build the model and perform sensitivity analyses. The P values are probabilities of the event at the decision branch used in this decision model. OBS. = observation.

 

 

fig.ommitted TABLE 1. Data Used to Build the Cost Analysis Model

 

 
Uncomplicated sedation was assumed to be associated with no additional cost. Oversedation or undersedation could result in (a) no additional cost, (b) cost associated with additional intense observation, (c) cost associated with sustained observation, or (d) cost associated with hospital admission. Probabilities of occurrence and associated cost for each of these scenarios were derived from our prior experience with the 161 patients. Costs of materials administered during treatment of oversedation or undersedation were omitted because of their negligible contribution—for example, costs for oxygen tubing, emesis basins, and drugs such as nifedipine or atropine were all less than $1. The analysis was conducted from the perspective of the hospital.

Basic Decision Tree
Since the goal of this study was to provide a generalizable cost assessment for outpatient interventional radiologic procedures, input data for cost were derived from year 2000 costs at Beth Israel Deaconess Medical Center, Boston, Mass, and are listed in Table 1; sensitivity analyses were included to allow for extrapolation to cost structures at other institutions. For the basic decision analysis tree, the assumption was made that all patients would leave the hospital after a 4-hour recovery period unless extended observation or admission were required.

Room time encompassed the period from the patients’ entry into the procedure suite until their transfer to the recovery unit. Average procedure time was 78 minutes in the standard group and 61 minutes in the hypnosis group. Costs for room time included equipment amortization and personnel cost based on local salaries and fringe benefits for one physician, one nurse, one technologist, and one optional additional provider structuring the hypnotic intervention (Table 1).

The basic decision tree assumptions were that the nurse already present structured the hypnosis intervention and, thus, the cost for an optional additional hypnosis provider would be $0. To allow for the possibility of an additional hypnosis provider in a subsequent sensitivity analysis (Materials and Methods, last section), the cost of one additional health care provider, a psychologist, was included in the room time. In either event, the cost of nursing time was included for the duration of the entire procedure.

Recovery cost included four possible components (Fig 2): (a) immediate postprocedure time (eg, sheath removal, groin compression); (b) basic recovery time (eg, monitoring vital signs); (c) additional intense recovery time, when required; and (d) sustained observation time, when required. We assumed that one physician and one nurse were required for the immediate postprocedure care and that one nurse was able to monitor up to four patients during the basic recovery time. All patients required immediate postprocedure time and basic recovery time.


fig.ommitted Figure 2. Diagram of patient flow after an outpatient interventional radiologic procedure.

 

 
If over- or undersedation occurred, we assumed that patients would require additional intense recovery time and that this would have to be monitored by a nurse and physician. The following times were assumed for additional intense recovery time for complications of sedation with hypnosis: oversedation leading to sustained observation or admission, 15 or 30 minutes, respectively; undersedation leading to sustained observation or admission, 30 or 60 minutes, respectively. The following times were assumed for additional intense recovery time for complications of sedation with standard care: oversedation leading to sustained observation or admission, 30 or 60 minutes, respectively; undersedation leading to sustained observation or admission, 45 or 60 minutes, respectively.

If after the intense recovery time the patients still exhibited the effects of over- or undersedation, we allowed for an additional 30–60 minutes of sustained observation time monitored by a nurse. After the time in the interventional radiologic recovery area, all patients either were sent to the day care unit for an additional 4 hours of "outpatient" observation or, if complications necessitated, were admitted to the hospital.

To calculate admission cost for undersedation, we used the average cost weights of diagnosis-related group (DRG) 130, peripheral vascular disorders with complications (cost weight, 0.9427) and DRG 131, peripheral vascular disorders without complications (cost weight, 0.6067). The average cost weight for undersedation was 0.7747. To calculate admission cost caused by oversedation, we used the average cost weight of DRG 99, respiratory signs and symptoms with complications (cost weight, 0.6738) and DRG 100, respiratory signs and symptoms without complications (cost weight, 0.5150). The average cost weight for oversedation was 0.5944. In both instances, the Medicare blended rate paid to Beth Israel Deaconess Medical Center, Boston, in 1999 ($4,273) was assumed. The blended rate included technical but not professional fees.

The cost weight is the severity factor assigned to each DRG by the Health Care Financing Administration, or HCFA. It is multiplied by the blended rate—the standardized rate that each hospital is paid— to calculate the exact reimbursement for a specific DRG. For example, if a DRG has a cost weight of 2 and a blended rate of $5,000, the hospital would be paid $10,000 for that DRG. An average of two cost weights was used in the basic decision tree to account for institutional variations in DRG coding. Subsequently (Materials and Methods, last section), sensitivity analyses were performed to assess the effect that specific DRG coding of complications may have on our conclusions. The two cost weights for each complication defined the range of the sensitivity analyses.

Oversedation
Oversedation included all events associated with depression of cardiorespiratory or mental status. Oxygen desaturation was included only when a decrease to less than 89% persisted longer than 2 minutes and required placement of a nasal oxygen cannula.

Standard group.—Sixteen (20%) of 79 patients showed signs of oversedation. Six patients with oxygen desaturation incurred no additional cost, except for the nasal oxygen cannula, which was considered a no-cost item. Six patients required intense observation because of prolonged hypoxemia with or without associated cardiovascular depression (n = 5) and slow resolution of slurred speech (n = 1). Four patients qualified for admission—three because of drowsiness and/or unresponsiveness and one because of continued bradycardia, hypotension, and recurrent bleeding from the puncture site.

Hypnosis group.—Oversedation affected nine (11%) of 82 patients and required no treatment in five patients, except for a nasal cannula. Four patients needed intense observation—one for prolonged hypoxemia with distracting behavior during the procedure, one for transient hypoxemia in recovery, one for being poorly arousable in recovery, and one for bradycardia.

Undersedation
Undersedation included all events associated with incidents requiring staff attention, such as discomfort in recovery, persistent new hypertension, and distracting, attention-seeking patient behavior.

Standard group.—Undersedation was observed in 24 (30%) of 79 patients. One patient did not need further treatment for transient tachycardia. Twenty-one patients required intense observation for distracting behavior (n = 10), discomfort (n = 6), hypertension (n = 3), or recurrent bleeding from the puncture site (n = 2). Two patients qualified for admission because of recurrent bleeding.

Hypnosis group.—Undersedation was encountered in eight (10%) of 82 patients because of discomfort (n = 4), hypertension (n = 1), and distracting behavior (n = 3). All incidents required intense observation.

Sensitivity Analyses
Sensitivity analyses were performed to address how changes in individual input parameters would affect overall outcome and to extrapolate the applicability of these results to those of other institutions with different cost structures. Outcome was considered not sensitive to a parameter if change in the value of this parameter over a given range did not affect overall cost superiority of a treatment (ie, standard or hypnosis treatment). If outcome was sensitive to a parameter, a threshold analysis was performed to determine at what value one strategy became preferable to the other.

Sensitivity analyses were performed for the following parameters (Table 2): (a) cost of an additional hypnosis provider of $0–$10/min; (b) room time for use of hypnosis of 25–200 minutes; (c) hours of additional observation after the procedure for complications related to over- or undersedation of 0–5 hours; (d) probability of oversedation with standard treatment with P values between .00 and .50; (e) probability of undersedation with hypnosis treatment with P values between .00 and .50; (f) cost for admission caused by undersedation of $0–$10,000; (g) cost weight for admission caused by undersedation of 0.6067–0.9427; (h) cost for admission due to oversedation of $0–$10,000; (i) cost weight for admission due to oversedation of 0.5150–0.6738; (j) a blended rate of $2,500–$10,000; and (k) hourly cost of the procedure room of $2.50–$10/min.


fig.ommitted TABLE 2. Sensitivity Analyses for Several Variables Used in the Cost Analysis Model

 

 

     RESULTS

Top
ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
 
Basic Decision Tree
Figure 1 illustrates the decision analysis tree with the associated probabilities of each outcome (derived from reference 6). Average sedation cost for standard treatment was $638 and for hypnosis treatment was $300, which resulted in an average savings of $338 per case with hypnosis.

Sensitivity Analyses
Data used in the sensitivity analyses are presented in Table 2. The sensitivity analysis allowed us to calculate the effect that changing one variable would have on the total costs associated with hypnosis or standard therapy. The lower and upper boundaries correspond to the lowest and highest values assumed for each variable tested. These boundaries were chosen to reflect a reasonable range of variation that may be encountered in different clinical practices. In most cases, the range was chosen so that the baseline value was near the center of the range.

Effect of an additional hypnosis provider.—When an additional provider is included to structure the hypnosis treatment, savings realized by using hypnosis decrease to a threshold of a salary of $5.50/min; when the salary is greater than this amount, standard treatment is more cost-effective (Fig 3). The threshold of $5.50/min corresponds to $330/h, or $633,600/y plus 30% fringe benefits. When the basic decision tree is recalculated for a scenario that includes a staff psychologist at an annual salary of $70,000 plus fringe benefits, the sedation cost with hypnosis is $348. This still leaves a cost superiority of $290 ($638 minus $348) per case.


fig.ommitted Figure 3. Graph shows the effect of adding a health care provider structuring hypnosis during the procedure. Savings with adjunct hypnosis decrease with increasing reimbursement, in dollars per minute, to this additional provider up to a threshold of $5.50/min, or $330/h (dashed line), beyond which it is more costly to provide adjunct hypnosis. The expected value is the cost in dollars for standard therapy () versus that for hypnosis ().

 

 
Effect of room time and postprocedure observation time.—When sensitivity analysis was performed with room time of 25–200 minutes while keeping all other variables constant, a threshold value of 136.2 minutes resulted for adjunct hypnosis (Fig 4). Thus, as long as average room time with hypnosis does not exceed 136.2 minutes, for a case that would take 78 minutes with standard conditions, hypnosis remains less costly on average. Hypnosis was always more cost-effective over a range of postprocedure observation times of 0–5 hours because of complications of over- or undersedation.


fig.ommitted Figure 4. Graph shows the effect of room time in minutes required for an interventional radiologic procedure by using hypnosis divided by the expected value, which is the cost in dollars for standard therapy () versus that for hypnosis (). The cost of standard therapy is constant at an average procedure duration of 78 minutes. According to conditions of the basic decision tree, a procedure with hypnosis lasts, on average, 61 minutes. The threshold value (dashed line) is the room time at which the cost of hypnosis is equal to the cost of standard therapy. As long as interventional radiologic procedures performed with hypnosis require fewer than 136.2 minutes, it is more cost-effective to perform hypnosis than to perform standard therapy.

 

 
Effect of the probability of oversedation during standard treatment.—Standard treatment was always more expensive than hypnosis treatment over a range of probability between 0% and 50% of oversedation from standard therapy. When the probability of oversedation from standard therapy is 0%, standard therapy costs $189 more than hypnosis. When the probability of oversedation from standard therapy is 50%, the cost of standard therapy is $558 more than the cost of hypnosis.

Effect of the probability of undersedation with hypnosis treatment.—Standard treatment was always more expensive than hypnosis treatment over a range of probability of 0%–50% of undersedation from hypnosis therapy. When the probability of undersedation from hypnosis therapy is 0%, standard therapy costs $352 more than hypnosis. When the probability of undersedation from hypnosis therapy is 50%, the cost of standard therapy is $290 more than the cost of hypnosis.

Effect of blended rates and cost weights.—The savings with hypnosis increase with an increase in the blended rate, ranging from $250 ($550 for standard therapy minus $300 for hypnosis) at a blended rate of $2,500 and reaching $623 ($923 minus $300) at a blended rate of $10,000. We then tested whether the use of the specific DRG used to estimate the cost of complications associated with oversedation or undersedation had an effect on our results. If the cost weight for the DRG used for complications from oversedation increases from 0.5150 (DRG 100) to 0.6738 (DRG 99), the savings from the use of hypnosis increase from $321 to $356. If the cost weight for the DRG used for complications associated with undersedation increases from 0.6067 (DRG 131) to 0.9427 (DRG 130), the savings from the use of hypnosis increase from $320 to $357. Thus, as the costs of complications increase, the net savings associated with the use of hypnosis, compared with those associated with standard therapy, increase.

Effect of the hourly procedure room cost.—Our base case assumption was that each minute in the procedure room cost $4.50. As the cost of procedure room time varied between $2.50 and $10 per minute, the savings realized by using hypnosis increased from $304 per case to $431 per case.


     DISCUSSION

Top
ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
 
With use of adjunct hypnosis, the savings, on average, was $338 per case in conditions of the basic decision tree. The savings depended strongly on the Medicare blended rate of the institution, which ranged from $250 per case at a blended rate of $2,500 to $623 per case at a blended rate of $10,000. Thus, high-cost academic centers with high Medicare blended rates are expected to gain most from use of the hypnotic intervention.

The basic decision tree assumption was that hypnosis was provided by an interventional team member, such as a specially trained nurse or technologist. Members of surgical teams can be highly effective in structuring hypnosis during invasive medical procedures (3,1518) and may be superior to outside personnel (5). If an additional person were to be added to structure hypnosis, cost savings would be less, but still remain substantial at $290 per case. This latter number was derived from a decision tree by using the equivalent of a staff psychologist’s salary of $70,000/y plus 30% fringe benefits. Sensitivity analysis showed that adjunct hypnosis is less costly than standard sedation unless the additional person were to demand more than $330/h. This rate of reimbursement surpasses by far that of most nonphysician specialists and interventionalists, making even their participation in hypnosis worth their time.

If procedure personnel structure hypnosis, the cost of training and continued support should be accounted for. Typically, 24 hours of classroom instruction, supervised clinical instruction, and a second 8-hour workshop suffice for medical personnel to achieve sufficient skills in the methods (6,18). Continued supervision through a psychologist or a physician experienced in hypnosis on a biweekly basis is highly desirable.

Whether using procedure personnel is more resource-sensitive than adding a psychologist, who does not need additional training and supervision, depends on personnel turnover and recurrent training cost. The up-front costs of establishing a procedure team–based hypnosis program depend on the level of participation rate of the personnel desired. The cheapest alternative may be to have individual procedure personnel trained at a hypnosis course administered by one of the hypnosis societies (eg, Society for Clinical and Experimental Hypnosis, American Society of Clinical Hypnosis, New England Society of Hypnosis) or other accredited continuing medical education programs. Training an entire team for the procedure has the advantage of creating a supportive climate and providing team members enhanced communication skills that can also be used in nonpatient interactions.

On the basis of which model is chosen and how many persons are selected for training or whether outside trainers are invited, up-front costs are an estimated $3,000–$15,000 (estimated on the basis of the prior training cost incurred). From a hospital perspective, these costs are recuperated after using self-hypnotic relaxation in 10–50 patients.

When offered hypnosis training, personnel commonly voice concerns that inducing and maintaining hypnosis in the procedure suite is performed may prolong room time. In the case of adjunct hypnosis, as was used in this study, room time actually decreased from 78 to 61 minutes despite the fact that hypnosis was induced in the procedure suite (6). However, even if hypnosis were to add time to the procedure, it would still be less costly than standard sedation. Specifically, hypnosis could add up to an additional 58.2 minutes to the procedure time and still have a cost superiority, compared with the cost of standard treatment (Fig 4). These results should dispel concerns that introduction of the self-hypnotic intervention would reduce efficiency or be too costly.

Costs of standard conscious sedation are heavily influenced by the probability of oversedation with intravenously administered sedatives and narcotics. The average amount of sedatives and narcotics administered in standard sedation in patients in this study (1.9 drug units; with one drug unit equaling 1 mg of midazolam or 50 µg of fentanyl) is well within the range of doses commonly used for similar procedures (19) and within the customary range of drugs used in the institution of this study for these types of procedures. Higher doses risk higher probabilities of oversedation; lower doses may result in a less cooperative patient. Hypnotic adjuncts are clinically helpful in that they can provide comfort with less need for intravenous drugs (0.9 units in this study) and thus less risk of oversedation. On the other hand, individuals who are not responsive to the hypnotic intervention may either demand more drugs, and thus be exposed to the risk of oversedation, or remain undersedated. Undersedation with hypnosis also affects cost. Sensitivity analysis shows that even if the probability of undersedation were to reach 80%, hypnosis would still be less costly than standard therapy, with a savings of $86.

One potential limitation is the use of DRGs to estimate the cost of complications related to over- and undersedation. Although the DRG may not directly correspond to the actual cost of care provided by the hospital, we believe that it is a reasonable proxy. In addition, the use of DRGs incorporates the blended rate paid to each hospital. The blended rate takes into account the hospital’s patient population and regional variations in cost. Thus, by varying the severity of the blended rate, our analysis can be easily generalized to other institutions.

The superior clinical effect of hypnosis has already been described in the original article (6) from which the cost data of this study are derived. Thus, this current analysis does not aim at demonstrating the effect of hypnosis on clinical well-being (ie, its effectiveness) but merely on the effect of hypnosis on cost. Several of these events labeled as oversedation or undersedation do not qualify as complications in the sense of morbidity reporting but rather represent a highly self-critical reporting of any event in deviation of an ideal equilibrium among comfort level, dose of medication, and side effects of medication.

A second limitation is that the cost of room time for the procedure varies among institutions. However, the sensitivity analysis performed on the cost of the procedure room demonstrates that the cost superiority of hypnosis persisted at all values tested from $2.50 to $10 per minute (base case, $4.50/min).

We have previously shown that adjunct hypnosis with intravenous conscious sedation during interventional radiologic procedures is effective in reducing pain, anxiety, and procedure time. Findings of this cost analysis show substantial cost savings when adjunct hypnosis is used. Therefore, the choice between greater patient comfort and lower cost need not be made. Medical benefits of hypnosis for the patient notwithstanding, adjunct hypnosis during procedures is a clinically feasible and cost-saving practice.

 

     REFERENCES

日期:2007年5月12日 - 来自[2003年1月第226卷第2

Hypnosis for Irritable Bowel

Hypnosis for Irritable Bowel


Aug. 23, 2001 -- Relax, you're getting sleepy ... very sleepy.

That may sound like a Hollywood cliché -- the glassy-eyed subject lulled by a swinging watch -- but some researchers believe the peaceful state achieved in hypnosis can help people suffering from irritable bowel syndrome.

At a meeting this week of the World Congress of Psychosomatic Medicine, gastroenterologist Peter Whorwell, MD, will discuss more than 20 years of research showing that hypnosis can not only improve symptoms of irritable bowel syndrome, or IBS, but can even alter the underlying physical problems that cause the symptoms.

The movie version of hypnosis is not much like the real thing. Instead, says Whorwell, in his practice it is more like meditation, yoga, or guided imagery. For treating IBS, a hypnotherapist guides a patient in relaxation exercises and helps him focus on the muscles of the stomach that are so critical in IBS.

"It's a concentrated form of relaxation where the therapist is teaching the patient to control systems of their body they can't normally control," Whorwell tells WebMD.

IBS is a common disorder of the digestive system that leads to cramps and pain, gassiness, bloating, and changes in bowel habits. Some people with IBS have constipation, others have diarrhea, and some have both.

And many doctors believe there is a psychological component to IBS, in which stress, depression, or other mental states can lead to physical symptoms in the gut. Such symptoms are called "psychosomatic," and Whorwell says they are not confined to IBS. "Every disease has a psychological component," he says.

With IBS it's important for patients to have better control of the contractions of their stomach muscles and the sensitivity of their stomach to stress and other influences. That's where hypnosis can help, Whorwell says.

But it doesn't happen overnight.

"It's a skill the patient has to take the time to learn," he says. "Just as it took time to learn to control bowels as an infant, it takes time to train your body to control your gut."

At the Hypnosis Unit of University Hospitals of South Manchester, in England, where Whorwell practices, patients typically receive twelve half-hour sessions of hypnotherapy, he says.

Hypnotherapy can be used in combination with drugs that ease the pain of stomach contractions, or with changes in diet. But Whorwell believes that for some patients hypnosis can be superior.

"The beauty of hypnotherapy is that once patients are better, they stay better," he says. "Once a person stops using drugs, the symptoms can come back."

Whorwell acknowledges that finding a hypnotherapist who knows what he is doing and -- more important -- knows about IBS, can be difficult. And hypnotherapy remains somewhat outside the mainstream, he believes.

Still, a 1996 statement by the American Gastroenterological Association suggests that hypnotherapy is generally accepted as a treatment for IBS.

"Several psychological treatments have been studied in patients with IBS, including psychotherapy, ... hypnosis, relaxation, and biofeedback," according to the statement. "These seem to be effective at reducing abdominal pain and diarrhea but not constipation, and they also reduce anxiety and other psychological symptoms."

"I'm a believer," says gastroenterologist Cynthia M. Yoshida, MD, director of the Women's GI Clinic at the Digestive Health Center of Excellence at the University of Virginia, Charlottesville. "Most people in the field will tell you it's not just medicine that does it [for IBS]."

At the Women's Clinic, people with IBS may receive a range of "alternative" treatments similar to hypnosis, including guided imagery and relaxation techniques, possibly in addition to drugs and dietary changes.

"It's very individualized depending on what is going on in the patient's life and whether stress is a big part of their symptoms," she tells WebMD. "There is no cookbook for treating IBS."

日期:2006年8月16日 - 来自[alternative medicine]栏目
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Hypnosis Not a Cure-All for Extinguishing the Smoking Habit

Hypnosis Not a Cure-All for Extinguishing the Smoking Habit


June 2, 2000 -- It worked for a friend, so Debbie from Virginia tried hypnosis to break her 25-year addiction to cigarettes. It didn't work. "I have been hypnotized four times, and it didn't do a thing for me," she tells WebMD. "I'd wake up ready to smoke."

Hypnotism is one of the most hyped methods of smoking cessation with lifetime guarantees and promises of little effort necessary on the part of the smoker. While hypnotism does work for some people, too often the results don't equal expectations or the promises.

Hypnosis is a state of mind during which a person's consciousness is altered and distractions blocked. It resembles sleep, but people under hypnosis are still able to concentrate intently on a memory, a particular sensation, or any other issue. The hypnotized person is alert, yet relaxed, and this relaxed state increases the ability to respond to suggestion.

According to the Boston University Medical Center, hypnotists try to change subconscious beliefs and attitudes that may be standing in a smoker's way to quitting through suggestion. Posthypnotic suggestions are those that are carried out by the person when he or she comes out of the hypnotic state. Hypnotism will not work if the person does not want to be hypnotized.

Some people expect too much from hypnosis and in that way set themselves up for failure," Irving Kirsch, PhD, professor of psychology at the University of Connecticut, tells WebMD. "Although positive expectations can help, it also is important to understand that hypnosis won't do the job for you. You have to be motivated to quit smoking, and you have to work on ways effectively resisting the temptation to relapse."

A new study appearing in the May edition of the International Journal of Clinical and Experimental Hypnosis concluded that smokers who underwent hypnosis fared better in terms of abstaining from smoking than did smokers who attempted to quit on their own, but was not necessarily better than other treatments.

In the study, researchers Joseph Green, PhD, of Ohio State University and Steven Jay Lynn, PhD, of the State University of New York at Binghamton, looked at the results of about 60 smoking and hypnosis studies conducted over the past 30 years. Success rates varied from zero to a high of 87%. However, Green tells WebMD these figures can be misleading since periods without smoking differed for each study; in some cases there were no groups used for comparison, and methods and subjects were different.

Green believes at best, people trying to quit only have about a 50-50 chance through hypnosis. "Most licensed mental health professionals recognize that smoking is a very difficult habit to overcome," Green tells WebMD, "and that even with the best treatment approach, the chances of failure ... are greater than the chances of success."

Another study also shows just how varying success rates can be. According to the Boston University Medical Center's Community Outreach Health Information System, success rates vary widely with hypnosis. Their research shows single individual sessions have success rates of 0 to 68%. Group hypnosis has been reported to have quit rates of 8 to 88%.

Still, the American Cancer Society does promote hypnosis as one of many techniques for quitting smoking. Its research found hypnosis has helped some smokers stay off tobacco for six months or longer, and the success rate for hypnosis in smoking cessation is about equal to that of other methods used today.

For Debbie -- who declined to give her last name or city -- it has a zero success rate. She first tried it with a therapist in Virginia Beach who used a two-session program. Debbie says the first night she was hypnotized to get rid of stress, and the next morning, the focus was on smoking. "Supposedly when you went to bed that night in the morning, you would have no desire to smoke," Debbie says. "I woke up in the middle of the night with a sick child and she said that's why it didn't work."

The hypnotist did offer a guarantee. If it didn't work, a third evening visit was given for free. "I woke up and within the hour was smoking cigarettes. The $300 I paid her was also up in smoke." Debbie said she knew she was hypnotized because the hypnotist made an audiotape of what was said.

The next time she tried, it was in a large group with a licensed hypnotist. "That didn't work for me or anyone else that I know of."

Gary J. Wood, PhD, tells WebMD expectations by patients and the general public are often unrealistic. "Some patients believe that hypnosis will make them quit when they really don't want to quit yet. Patients need to be truly self-motivated to really want to quit." Wood is assistant professor in the Schools of Dentistry and Social Work at the University of Southern California.

Green, who is an associate professor of psychology, says one of the key problems in determining the effectiveness of hypnosis as a smoking cessation treatment is a lack of a standard way to conduct hypnosis. Across the studies, hypnosis treatments varied in the types of questions that were asked, the number of treatments each subject underwent, and the addition of other treatments.

"Individuals seeking smoking cessation through the use of hypnosis should temper their expectations with the knowledge that for most people, changing a habit, particularly a long-term habit like smoking, requires a lot of effort," Green tells WebMD.

It's not always the patient?s fault. Wood says some practitioners are too enthusiastic in promoting the positive outcomes and stature of hypnosis for quitting smoking. "In my view, there is a need for greater standards and controls. Unfortunately, this varies by state," he adds.

Many states allow (and sometimes even certify) the practice of hypnosis by what are termed "lay hypnotists." These may be individuals that have attended hypnosis training programs but who have no formal education and training in either medicine, dentistry, psychology, social work, marriage and family counseling, or nursing. "Without the formal mental health or health training, the ability to recognize when hypnosis [isn't appropriate] is highly questionable, and there is the potential for patient harm," Wood says.

Wood says people should seek out a practitioner that is trained and licensed in one of the health or mental health disciplines and also has taken training in hypnosis. "The practitioner should be qualified to treat the patient with or without hypnosis."

Green isn't against hypnosis as an aid for quitting smoking. He just doesn't see it as an effective cure-all. "Many of my clients value hypnosis as a means to enhance confidence, promote a general sense of well-being, decrease withdrawal urges, and to help them focus their attention on the importance of their commitment to quit smoking."

For Debbie, hypnotism proved to be a major disappointment. "I finally came to the conclusion that there is no easy way to quit."

 

日期:2006年8月16日 - 来自[alternative medicine]栏目

Hypnosis Not a Cure-All for Extinguishing the Smoking Habit

Hypnosis Not a Cure-All for Extinguishing the Smoking Habit


June 2, 2000 -- It worked for a friend, so Debbie from Virginia tried hypnosis to break her 25-year addiction to cigarettes. It didn't work. "I have been hypnotized four times, and it didn't do a thing for me," she tells WebMD. "I'd wake up ready to smoke."

Hypnotism is one of the most hyped methods of smoking cessation with lifetime guarantees and promises of little effort necessary on the part of the smoker. While hypnotism does work for some people, too often the results don't equal expectations or the promises.

Hypnosis is a state of mind during which a person's consciousness is altered and distractions blocked. It resembles sleep, but people under hypnosis are still able to concentrate intently on a memory, a particular sensation, or any other issue. The hypnotized person is alert, yet relaxed, and this relaxed state increases the ability to respond to suggestion.

According to the Boston University Medical Center, hypnotists try to change subconscious beliefs and attitudes that may be standing in a smoker's way to quitting through suggestion. Posthypnotic suggestions are those that are carried out by the person when he or she comes out of the hypnotic state. Hypnotism will not work if the person does not want to be hypnotized.

Some people expect too much from hypnosis and in that way set themselves up for failure," Irving Kirsch, PhD, professor of psychology at the University of Connecticut, tells WebMD. "Although positive expectations can help, it also is important to understand that hypnosis won't do the job for you. You have to be motivated to quit smoking, and you have to work on ways effectively resisting the temptation to relapse."

A new study appearing in the May edition of the International Journal of Clinical and Experimental Hypnosis concluded that smokers who underwent hypnosis fared better in terms of abstaining from smoking than did smokers who attempted to quit on their own, but was not necessarily better than other treatments.

In the study, researchers Joseph Green, PhD, of Ohio State University and Steven Jay Lynn, PhD, of the State University of New York at Binghamton, looked at the results of about 60 smoking and hypnosis studies conducted over the past 30 years. Success rates varied from zero to a high of 87%. However, Green tells WebMD these figures can be misleading since periods without smoking differed for each study; in some cases there were no groups used for comparison, and methods and subjects were different.

Green believes at best, people trying to quit only have about a 50-50 chance through hypnosis. "Most licensed mental health professionals recognize that smoking is a very difficult habit to overcome," Green tells WebMD, "and that even with the best treatment approach, the chances of failure ... are greater than the chances of success."

Another study also shows just how varying success rates can be. According to the Boston University Medical Center's Community Outreach Health Information System, success rates vary widely with hypnosis. Their research shows single individual sessions have success rates of 0 to 68%. Group hypnosis has been reported to have quit rates of 8 to 88%.

Still, the American Cancer Society does promote hypnosis as one of many techniques for quitting smoking. Its research found hypnosis has helped some smokers stay off tobacco for six months or longer, and the success rate for hypnosis in smoking cessation is about equal to that of other methods used today.

For Debbie -- who declined to give her last name or city -- it has a zero success rate. She first tried it with a therapist in Virginia Beach who used a two-session program. Debbie says the first night she was hypnotized to get rid of stress, and the next morning, the focus was on smoking. "Supposedly when you went to bed that night in the morning, you would have no desire to smoke," Debbie says. "I woke up in the middle of the night with a sick child and she said that's why it didn't work."

The hypnotist did offer a guarantee. If it didn't work, a third evening visit was given for free. "I woke up and within the hour was smoking cigarettes. The $300 I paid her was also up in smoke." Debbie said she knew she was hypnotized because the hypnotist made an audiotape of what was said.

The next time she tried, it was in a large group with a licensed hypnotist. "That didn't work for me or anyone else that I know of."

Gary J. Wood, PhD, tells WebMD expectations by patients and the general public are often unrealistic. "Some patients believe that hypnosis will make them quit when they really don't want to quit yet. Patients need to be truly self-motivated to really want to quit." Wood is assistant professor in the Schools of Dentistry and Social Work at the University of Southern California.

Green, who is an associate professor of psychology, says one of the key problems in determining the effectiveness of hypnosis as a smoking cessation treatment is a lack of a standard way to conduct hypnosis. Across the studies, hypnosis treatments varied in the types of questions that were asked, the number of treatments each subject underwent, and the addition of other treatments.

"Individuals seeking smoking cessation through the use of hypnosis should temper their expectations with the knowledge that for most people, changing a habit, particularly a long-term habit like smoking, requires a lot of effort," Green tells WebMD.

It's not always the patient?s fault. Wood says some practitioners are too enthusiastic in promoting the positive outcomes and stature of hypnosis for quitting smoking. "In my view, there is a need for greater standards and controls. Unfortunately, this varies by state," he adds.

Many states allow (and sometimes even certify) the practice of hypnosis by what are termed "lay hypnotists." These may be individuals that have attended hypnosis training programs but who have no formal education and training in either medicine, dentistry, psychology, social work, marriage and family counseling, or nursing. "Without the formal mental health or health training, the ability to recognize when hypnosis [isn't appropriate] is highly questionable, and there is the potential for patient harm," Wood says.

Wood says people should seek out a practitioner that is trained and licensed in one of the health or mental health disciplines and also has taken training in hypnosis. "The practitioner should be qualified to treat the patient with or without hypnosis."

Green isn't against hypnosis as an aid for quitting smoking. He just doesn't see it as an effective cure-all. "Many of my clients value hypnosis as a means to enhance confidence, promote a general sense of well-being, decrease withdrawal urges, and to help them focus their attention on the importance of their commitment to quit smoking."

For Debbie, hypnotism proved to be a major disappointment. "I finally came to the conclusion that there is no easy way to quit."

 

日期:2006年8月16日 - 来自[alternative medicine]栏目
循环ads

Hypnosis for Irritable Bowel

Hypnosis for Irritable Bowel


Aug. 23, 2001 -- Relax, you're getting sleepy ... very sleepy.

That may sound like a Hollywood cliché -- the glassy-eyed subject lulled by a swinging watch -- but some researchers believe the peaceful state achieved in hypnosis can help people suffering from irritable bowel syndrome.

At a meeting this week of the World Congress of Psychosomatic Medicine, gastroenterologist Peter Whorwell, MD, will discuss more than 20 years of research showing that hypnosis can not only improve symptoms of irritable bowel syndrome, or IBS, but can even alter the underlying physical problems that cause the symptoms.

The movie version of hypnosis is not much like the real thing. Instead, says Whorwell, in his practice it is more like meditation, yoga, or guided imagery. For treating IBS, a hypnotherapist guides a patient in relaxation exercises and helps him focus on the muscles of the stomach that are so critical in IBS.

"It's a concentrated form of relaxation where the therapist is teaching the patient to control systems of their body they can't normally control," Whorwell tells WebMD.

IBS is a common disorder of the digestive system that leads to cramps and pain, gassiness, bloating, and changes in bowel habits. Some people with IBS have constipation, others have diarrhea, and some have both.

And many doctors believe there is a psychological component to IBS, in which stress, depression, or other mental states can lead to physical symptoms in the gut. Such symptoms are called "psychosomatic," and Whorwell says they are not confined to IBS. "Every disease has a psychological component," he says.

With IBS it's important for patients to have better control of the contractions of their stomach muscles and the sensitivity of their stomach to stress and other influences. That's where hypnosis can help, Whorwell says.

But it doesn't happen overnight.

"It's a skill the patient has to take the time to learn," he says. "Just as it took time to learn to control bowels as an infant, it takes time to train your body to control your gut."

At the Hypnosis Unit of University Hospitals of South Manchester, in England, where Whorwell practices, patients typically receive twelve half-hour sessions of hypnotherapy, he says.

Hypnotherapy can be used in combination with drugs that ease the pain of stomach contractions, or with changes in diet. But Whorwell believes that for some patients hypnosis can be superior.

"The beauty of hypnotherapy is that once patients are better, they stay better," he says. "Once a person stops using drugs, the symptoms can come back."

Whorwell acknowledges that finding a hypnotherapist who knows what he is doing and -- more important -- knows about IBS, can be difficult. And hypnotherapy remains somewhat outside the mainstream, he believes.

Still, a 1996 statement by the American Gastroenterological Association suggests that hypnotherapy is generally accepted as a treatment for IBS.

"Several psychological treatments have been studied in patients with IBS, including psychotherapy, ... hypnosis, relaxation, and biofeedback," according to the statement. "These seem to be effective at reducing abdominal pain and diarrhea but not constipation, and they also reduce anxiety and other psychological symptoms."

"I'm a believer," says gastroenterologist Cynthia M. Yoshida, MD, director of the Women's GI Clinic at the Digestive Health Center of Excellence at the University of Virginia, Charlottesville. "Most people in the field will tell you it's not just medicine that does it [for IBS]."

At the Women's Clinic, people with IBS may receive a range of "alternative" treatments similar to hypnosis, including guided imagery and relaxation techniques, possibly in addition to drugs and dietary changes.

"It's very individualized depending on what is going on in the patient's life and whether stress is a big part of their symptoms," she tells WebMD. "There is no cookbook for treating IBS."

日期:2006年8月16日 - 来自[alternative medicine]栏目
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ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES

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  14. Lang EV, Lutgendorf S, Logan H, Benotsch E, Laser E, Spiegel D. Nonpharmacologic analgesia and anxiolysis for interventional radiological procedures. Semin Interv Radiol 1999; 16:113-123.

  15. Meurisse M, Defechereux T, Hamoir E, et al. Hypnosis with conscious sedation instead of general anaesthesia? Applications in cervical endocrine surgery. Acta Chir Belg 1999; 99:151-158.

  16. Esdaile J. Hypnosis in medicine and surgery 1846. Reissued (with a different title), New York, New York: Julian, 1957.

  17. Lang EV, Joyce JS, Spiegel D, Hamilton D, Lee K. Self-hypnotic relaxation during interventional radiological procedures: effects on pain perception and intravenous drug use. Int J Exp Clin Hyp 1996; 44:106-119.

  18. Lang EV, Berbaum KS. Educating interventional radiology personnel in nonpharmacologic analgesia: effect on patients’ pain perception. Acad Radiol 1997; 4:753-757.

  19. Lang EV, Chen F, Fick LJ, Berbaum KS. Determinants of intravenous conscious sedation for arteriography. J Vasc Interv Radiol 1998; 9:407-412.