Strategic integration of traditional and complementary and integrative medicine into clinical practice guidelines

Strengths of recommendations in clinical practice guidelines (CPGs) are informed by the quality of evidence of efficacy and safety, and transformed into decision making by balancing generalizability, availability, affordability, acceptability, direct and indirect costs and the values and preferences of patients, providers and policy makers. There is a paucity of evidence for many Traditional, Complementary and Integrative Medicine (TCIM) interventions and services, however their recognition in CPGs contributes to co-ordinated continuity of care across multiple healthcare settings and enhances evidence-based, person-centered clinical effectiveness and policy decisions. CPG development is a complex process that includes multidisciplinary panels of experts and stakeholder consultation. TCIM experts are required to articulate modifying factors and inform PICO questions, to accurately inform the inclusion of TCIM in CPGs. This scoping and evidence review informed the updated CPG: Deciding palliative and end of life care for people with diabetes. Method: A two phased literature search included 1. a scoping review and 2. a rapid systematic review of evidence. Electronic databases and grey literature were systematically searched to clarify modifying factors and shortlist 20 TCIMs of a rapid systematic review of efficacy. Results: 209 studies clarified seven key modifying factors including patient preferences; routine use; safe TCIMs for co-morbidities; simultaneous acting TCIMs; high quality evidence of effectiveness or ineffectiveness; risks and logistic feasibility. Evidence-based strong recommendations of the CPG included when to start or continue a TCIM intervention, refer to an appropriately qualified TCIM practitioner and when to stop a TCIM intervention or service. Conclusion: Inclusion of TCIM in CPGs requires a systematic approach to the quality of evidence, balanced against patients' values, benefits and harms, available resources, feasibility of the intervention, acceptability by stakeholders and effect on health equity. Inclusion of TCIM in CPGs can provide succinct high-level recommendations that facilitate patient centred evidence-based care and accurately inform evidence-based policy