The overall outcome of the first phase of the IIPCOS study  is confirmed in the present study on a larger group of patients and a greater number of medical practices, showing that homeopathic treatment is not inferior to conventional treatment for the treatment of acute respiratory and ear complaints. In IIPCOS-1 the response rate of homeopathically treated patients was with 82.6% significantly higher than in the conventional group. In IIPCOS-2 the response to homeopathic treatment was with 86.9% even higher, confirming the good effectiveness. However, no difference was observed between both treatment groups. This is due to a much higher response rate in the conventional group in IIPCOS-2 of 86.0% compared to 68% in IIPCOS-1. One difference between both studies is that in IIPCOS-2, only patients from Europe were analysed since those recruited at practices from the USA were excluded due to protocol deviations. In IIPCOS-1, the majority of patients included had their residence in the USA. However, despite these differences, the overall conclusion from both studies can be drawn that homeopathy is not inferior to conventional therapy. Due to the study design, the findings of IIPCOS-1 and IIPCOS-2 do not provide firm data on the comparative efficacy of homeopathic and conventional treatment in acute diseases but rather underline the potential value of homeopathy in every day clinical practice. Both studies reflect the situation in every day homeopathic practice in an international setting with average patients receiving the usual treatment of a homeopathic doctor. Furthermore, patients were recruited on the basis of chief complaints and related symptoms, rather than on the clinical diagnoses. This symptomatic approach coincides with the homeopathic nature of prescription by treating each patient individually, based on specific key symptoms and patient characteristics.
In IIPCOS-2, differences for various demographic parameters and symptom-related variables were found between both groups. Thereby the profile of typical patients seeking homeopathic therapy was confirmed [13, 14], i.e. they were more likely to be women, younger of age, less likely to smoke and to have a lower BMI. The severity of symptoms at baseline was significantly different between treatment groups as well. However the differences were small and their clinical relevance is doubtful. Indeed regression analysis had little effect on the primary outcome criterion, showing that treatment effects were only minimally affected by selection bias. Based on the unadjusted and adjusted odds ratios of the primary outcome criterion it appears that homeopathic treatment, in comparison to conventional treatment, is more beneficial for children than adults. This observation is in accordance with previous studies in which the improvements after homeopathic treatment were greater in children than in adults [11, 13].
Another possible source of bias is that the outcome criteria were assessed by the patients themselves. Since it was not possible to blind patients for their treatment, potential reporting bias from patient's expectations may have influenced the outcome. On the other hand, the patients' reports were collected by independent external study collaborators in order to minimize the influence of the patient's relationship with their physician on the treatment outcome. Although blinding of the external study coordinators was foreseen in the protocol, it cannot be ruled out that they received information from the patient revealing the nature of their medication. Therefore, blinding may not have been guaranteed in each case. Furthermore, it should be noted that at mixed centres, the choice of treatment was made by the physicians and/or following the patients' preference. The treatment decision may have been influenced by the kind or severity of the symptoms or the motivation and expectations of the patient.
Since acute respiratory and ear complaints are self-limiting conditions, it can be argued that the chosen primary outcome criterion after 14 days of treatment is not sufficiently sensitive. Patients experiencing these acute complaints may have undergone spontaneous recovery within 1 to 2 weeks. However, this outcome parameter was taken to confirm and reproduce the results of IIPCOS-1 by using a similar study design. Therefore other outcomes criteria such as the response rate after 7 days of treatment have to be considered more carefully. Moreover, the findings that the percentage of patients experiencing a first improvement within the first week was higher at all time points in the homeopathy group than in the conventional group, are at least supportive of the 14 days finding that homeopathy is not inferior to conventional medicine.
Other observational studies on the comparability of homeopathic treatment and conventional treatment of upper respiratory tract infections (URTI) have shown positive outcomes for homeopathy [15, 16]. Recently, the value of homeopathic treatment for the prevention of URTIs has been demonstrated in a controlled clinical trial . The consistent findings in IIPCOS-1 and IIPCOS-2 further contribute to the evidence that homeopathic treatment plays a beneficial role in the primary care of patients. Furthermore, the good tolerability of homeopathic treatment of acute respiratory and ear complaints was confirmed by the low number of patients that experienced adverse drug reactions.
The major limitation of the present study is that patients were not assigned randomly to their treatment group. The majority of patients in the homeopathic group had a strong treatment preference and consequently, they were not willing to be randomized. A similar reluctance towards randomisation has also been reported elsewhere for patients seeking anthroposophic therapy . These results reveal a substantial limitation to the suitability of performing large randomized controlled trials on the efficacy of homeopathy in such a primary care setting.