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Zhang Y, Wu B, Qin P, Cheng Y, Chen Y. Alternative therapies in chronic non-cancer pain management: A scoping review of randomized controlled trials. Complement Ther Med 2025; 90:103154. [PMID: 40081508 DOI: 10.1016/j.ctim.2025.103154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2025] [Revised: 02/10/2025] [Accepted: 03/04/2025] [Indexed: 03/16/2025] Open
Abstract
BACKGROUND Chronic pain is one of the most challenging health problems in modern society, placing significant burdens on individuals and healthcare systems. While pharmacological treatments remain the primary approach to pain management, their limitations often restrict choices for both clinicians and patients. In contrast, complementary therapies are gaining recognition for their potential effectiveness and safety. However, the current literature lacks a comprehensive summary of the role of complementary therapies in chronic pain management. OBJECTIVE This review aims to summarize the complementary therapies used in chronic non-cancer pain management, assess their practical applications, identify research gaps and limitations, and provide a comprehensive perspective for the development of chronic non-cancer pain management and personalized pain management strategies. METHODS This scoping review followed the PRISMA-ScR guidelines. Randomized controlled trials (RCTs) published in the last decade were retrieved from PubMed and Web of Science using the keywords "chronic pain" and "complementary therapy." Non-English studies were excluded. RESULTS A total of 848 RCTs were identified, of which 128 met the inclusion criteria. The included studies addressed chronic musculoskeletal pain (102 studies), chronic visceral pain (5 studies), chronic neuropathic pain (7 studies), and 13 studies that did not specify the pain type. The complementary therapies investigated included acupuncture, manual therapy, exercise therapy, psychological interventions, mind-body therapies, and physical modalities. CONCLUSION This review provides preliminary evidence supporting the efficacy and safety of complementary therapies in the management of chronic non-cancer pain. However, methodological and quality-related limitations were identified in the included studies. Future high-quality RCTs are needed to validate the long-term efficacy of these therapies, explore their mechanisms of action, and provide stronger evidence for their clinical application. REGISTRATION This scoping review is registered on the Open Science Framework (OSF) under the following DOI: https://doi.org/10.17605/OSF.IO/67K32.
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Affiliation(s)
- Yuxing Zhang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine/National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300381, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Bangqi Wu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine/National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300381, China.
| | - Peng Qin
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine/National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300381, China
| | - Yupei Cheng
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine/National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300381, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Yuyan Chen
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine/National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300381, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
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Trager RJ, Nichols MD, Barnett TD, Rodgers-Melnick SN, Song S, Love TE, Adan F, Dusek JA. Impact of Integrative Health and Medicine on Costs Associated with Adult Health System Beneficiaries with Musculoskeletal Conditions: A Retrospective Cohort Study. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2025; 31:36-43. [PMID: 39291351 DOI: 10.1089/jicm.2023.0812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
Objective: Owing to perceived additional costs, patients may avoid integrative health and medicine (IHM) treatments, while insurers may not cover IHM. We hypothesized that adult beneficiaries of a health system's employee insurance plan with musculoskeletal (MSK) conditions receiving covered outpatient IHM would have reduced total allowed costs over the 1-year follow-up compared with matched controls, secondarily exploring medical and pharmaceutical cost subsets. Methods: We queried medical records and claims spanning 2018-2023 for beneficiaries aged 18-89 years with a new MSK episode. Patients were divided into cohorts: (1) IHM within 3 months after MSK diagnosis and (2) no IHM after initial primary care. After inflation adjustment and trimming, propensity score matching was used to balance cohorts on demographics, comorbidity, health care utilization, and prior 12-month spend. Least-squares mean total, medical, and pharmaceutical allowed costs (United States Dollar) over the 1-year follow-up were analyzed using a linear mixed model. Findings were compared with a generalized linear model without trimming. Results: There were 251 patients per matched cohort, with adequate covariate balance. There was no meaningful between-cohort difference (IHM minus No IHM) in least-squares mean total cost (+703 [95% CI: -314, 1720]). Secondary outcomes included medical cost (+878 [95% CI: 61, 1695]) and pharmaceutical cost (+6 [95% CI: -71, 83]). A generalized linear model revealed no meaningful difference in estimated mean total medical costs (-2561 [95% CI: -7346, +2224]). Conclusions: IHM use among adult health system beneficiaries with MSK conditions was not associated with meaningful differences in 1-year follow-up total health care costs compared with matched controls. Our study was underpowered for secondary outcomes, which should be interpreted with caution. Future research should include a larger sample of patients and examine longitudinal changes in patient-reported outcomes.
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Affiliation(s)
- Robert J Trager
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland OH, USA
- Department of Family Medicine and Community Health, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Matthew D Nichols
- Population Health Data Science and Analytics, University Hospitals Accountable Care Organization, Cleveland, OH, USA
| | - Tyler D Barnett
- Population Health Data Science and Analytics, University Hospitals Accountable Care Organization, Cleveland, OH, USA
| | - Samuel N Rodgers-Melnick
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland OH, USA
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Sunah Song
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, OH, USA
| | - Thomas E Love
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Department of Medicine, MetroHealth System, Cleveland, OH, USA
- Population Health and Equity Research Institute, Case Western Reserve University/MetroHealth Medical Center, Cleveland, OH, USA
| | - Françoise Adan
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland OH, USA
| | - Jeffery A Dusek
- Department of Family Medicine and Community Health, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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Grass F, Berna C, Vogel CA, Demartines N, Agri F. Complementary and integrative medicine - Resolving situations of reduced remuneration for additional work under the SwissDRG system. Heliyon 2024; 10:e34732. [PMID: 39157326 PMCID: PMC11328068 DOI: 10.1016/j.heliyon.2024.e34732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 06/26/2024] [Accepted: 07/16/2024] [Indexed: 08/20/2024] Open
Abstract
Aim of the study Complementary and integrative medicine (CIM) has been increasingly recognized as offering promising treatment adjunctions in various clinical settings, even amongst patients with serious, chronic, or recurrent illness. Today, only few tertiary care facilities in Switzerland offer dedicated CIM services for inpatients. The aim of the present study was to evaluate whether CIM services for complex medical conditions are adequately valued by the national inpatient SwissDRG reimbursement system. Methods A simulation was performed by adding a specific code of the Swiss classification of interventions (CHOP) to the list of codes of each patient who received CIM therapies at the Lausanne University Hospital (CHUV) in 2021. This code is to be used when CIM services are provided. Hitherto, it was not entered due to a lack of specific documents justifying the resources used. The analysis focused on the impact of adding this CIM CHOP code on the Swiss Diagnosis Related Group (DRG) reimbursement. Results In total, 275 patients received a CIM therapy in 2021. The addition of the CIM CHOP code 99.BC.12 (10-25 CIM sessions per stay) resulted in a simulated loss of income of CHF 766 630 for the hospital, while the net real result is already negative by more than CHF 6 million. The DRGs positively impacted by the addition of CIM CHOP code 99.BC.12 had a mean (SD) cost weight (CW) of 1.014 (0.620), while the DRGs negatively impacted had a mean (SD) CW of 3.97 (2.764) points. Conclusion It is necessary to quickly react and improve the incentives contained in the grouping algorithm of the prospective payment system, whose effects can threaten the provision of adequate medical care to the patients despite suitable indications and potential for cost-savings.
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Affiliation(s)
- Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Chantal Berna
- Center for Integrative and Complementary Medicine, Division of Anesthesiology, Department of Interdisciplinary Centers, Lausanne University Hospital, Lausanne, Switzerland
| | - Charles-André Vogel
- Department of Administration and Finance, Lausanne University Hospital, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
- General Direction, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Fabio Agri
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
- Department of Administration and Finance, Lausanne University Hospital, Lausanne, Switzerland
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Bayes J, Palencia J, Wardle J. Complementary and Integrative Medicine Prevalence and Utilization in International Military and Veteran Settings and Communities: A Systematic Review. Mil Med 2024; 189:e1318-e1335. [PMID: 37847545 DOI: 10.1093/milmed/usad392] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/06/2023] [Accepted: 09/21/2023] [Indexed: 10/18/2023] Open
Abstract
INTRODUCTION Active duty military personnel and veterans have unique and complex health needs, with the high demands of military life often leading to chronic physical and mental health conditions. Complementary and integrative medicine (CIM) could be a possible solution to this problem. Some military health systems have started integrating CIM into health care delivery. However, there has been no systematic evaluation of the prevalence and utilization of CIM in military and veteran populations globally. MATERIALS AND METHODS A Preferred Reporting Items For Systematic Reviews and Meta-Analysis Protocols protocol was used to systematically search for original research assessing the prevalence and utilization of CIM among active serving military or veterans. CINAHL, MEDLINE, Scopus, and AMED databases were searched up to February 3, 2023. RESULTS A total of 27 studies met the inclusion criteria and were included in this review. The overall quality of evidence was high with a low risk of bias. Utilization of CIM varied. The lowest utilization demonstrated that only 1.9% of services delivered by military health system were CIM. The majority of studies found utilization rates between 30% and 80%, with some studies reporting use as high as 90%. The most commonly used CIM therapies included chiropractic care, massage, mindfulness/meditation, and acupuncture. Utilization of CIM products was high and ranged from 32% to 87%. The most frequently used products were dietary supplements, particularly multivitamins and minerals and protein supplements/amino acids. The use of herbal products was high among veterans ranging from 10% to 79%. CONCLUSIONS The high demand for CIM by military personnel and veterans has important implications for policy, funding allocation, and integration of these services into clinical practice, particularly by countries not currently doing so. Further research is needed to assess the implementation of CIM into real-world settings to explore barriers and facilitators for their use in clinical practice and, by extension, their integration into the wider health care system.
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Affiliation(s)
- Jessica Bayes
- National Centre for Naturopathic Medicine (NCNM), Faculty of Health, Southern Cross University, East Lismore, NSW 2480, Australia
| | - John Palencia
- National Centre for Naturopathic Medicine (NCNM), Faculty of Health, Southern Cross University, East Lismore, NSW 2480, Australia
| | - Jon Wardle
- National Centre for Naturopathic Medicine (NCNM), Faculty of Health, Southern Cross University, East Lismore, NSW 2480, Australia
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Falasinnu T, Nguyen T, Jiang TE, Tamang S, Chaichian Y, Darnall BD, Mackey S, Simard JF, Chen JH. The Problem of Pain in Rheumatology: Variations in Case Definitions Derived From Chronic Pain Phenotyping Algorithms Using Electronic Health Records. J Rheumatol 2024; 51:297-304. [PMID: 38101917 PMCID: PMC10922235 DOI: 10.3899/jrheum.2023-0416] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE The aim of this study was to investigate and compare different case definitions for chronic pain to provide estimates of possible misclassification when researchers are limited by available electronic health record and administrative claims data, allowing for greater precision in case definitions. METHODS We compared the prevalence of different case definitions for chronic pain (N = 3042) in patients with autoimmune rheumatic diseases. We estimated the prevalence of chronic pain based on 15 unique combinations of pain scores, diagnostic codes, analgesic medications, and pain interventions. RESULTS Chronic pain prevalence was lowest in unimodal pain phenotyping algorithms: 15% using analgesic medications, 18% using pain scores, 21% using pain diagnostic codes, and 22% using pain interventions. In comparison, the prevalence using a well-validated phenotyping algorithm was 37%. The prevalence of chronic pain also increased with the increasing number (bimodal to quadrimodal) of phenotyping algorithms that comprised the multimodal phenotyping algorithms. The highest estimated chronic pain prevalence (47%) was the multimodal phenotyping algorithm that combined pain scores, diagnostic codes, analgesic medications, and pain interventions. However, this quadrimodal phenotyping algorithm yielded a 10% overestimation of chronic pain compared to the well-validated algorithm. CONCLUSION This is the first empirical study to our knowledge that shows that established common modes of phenotyping chronic pain can lead to substantially varying estimates of the number of patients with chronic pain. These findings can be a reference for biases in case definitions for chronic pain and could be used to estimate the extent of possible misclassifications or corrections in using datasets that cannot include specific data elements.
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Affiliation(s)
- Titilola Falasinnu
- T. Falasinnu, PhD, Division of Immunology and Rheumatology, Department of Medicine, and Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine;
| | - Thy Nguyen
- T. Nguyen, BS, T. En Jiang, BS, Department of Epidemiology and Population Health, Stanford University School of Medicine
| | - Tiffany En Jiang
- T. Nguyen, BS, T. En Jiang, BS, Department of Epidemiology and Population Health, Stanford University School of Medicine
| | - Suzanne Tamang
- S. Tamang, PhD, Y. Chaichian, MD, Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine
| | - Yashaar Chaichian
- S. Tamang, PhD, Y. Chaichian, MD, Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine
| | - Beth D Darnall
- B.D. Darnall, PhD, S. Mackey, MD, PhD, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine
| | - Sean Mackey
- B.D. Darnall, PhD, S. Mackey, MD, PhD, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine
| | - Julia F Simard
- J.F. Simard, ScD, Division of Immunology and Rheumatology, Department of Medicine, and Department of Epidemiology and Population Health, Stanford University School of Medicine
| | - Jonathan H Chen
- J.H. Chen, MD, PhD, Stanford Center for Biomedical Informatics Research, and Division of Hospital Medicine, Department of Medicine, Stanford University School of Medicine, California, USA
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Real-world data and evidence in pain research: a qualitative systematic review of methods in current practice. Pain Rep 2023; 8:e1057. [PMID: 36741790 PMCID: PMC9891449 DOI: 10.1097/pr9.0000000000001057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 10/21/2022] [Accepted: 11/12/2022] [Indexed: 02/05/2023] Open
Abstract
The use of routinely collected health data (real-world data, RWD) to generate real-world evidence (RWE) for research purposes is a growing field. Computerized search methods, large electronic databases, and the development of novel statistical methods allow for valid analysis of data outside its primary clinical purpose. Here, we systematically reviewed the methodology used for RWE studies in pain research. We searched 3 databases (PubMed, EMBASE, and Web of Science) for studies using retrospective data sources comparing multiple groups or treatments. The protocol was registered under the DOI:10.17605/OSF.IO/KGVRM. A total of 65 studies were included. Of those, only 4 compared pharmacological interventions, whereas 49 investigated differences in surgical procedures, with the remaining studying alternative or psychological interventions or epidemiological factors. Most 39 studies reported significant results in their primary comparison, and an additional 12 reported comparable effectiveness. Fifty-eight studies used propensity scores to account for group differences, 38 of them using 1:1 case:control matching. Only 17 of 65 studies provided sensitivity analyses to show robustness of their findings, and only 4 studies provided links to publicly accessible protocols. RWE is a relevant construct that can provide evidence complementary to randomized controlled trials (RCTs), especially in scenarios where RCTs are difficult to conduct. The high proportion of studies reporting significant differences between groups or comparable effectiveness could imply a relevant degree of publication bias. RWD provides a potentially important resource to expand high-quality evidence beyond clinical trials, but rigorous quality standards need to be set to maximize the validity of RWE studies.
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Metri KG, Raghuram N, Narayan M, Sravan K, Sekar S, Bhargav H, Babu N, Mohanty S, Revankar R. Impact of workplace yoga on pain measures, mental health, sleep quality, and quality of life in female teachers with chronic musculoskeletal pain: A randomized controlled study. Work 2023; 76:521-531. [PMID: 36847050 DOI: 10.3233/wor-210269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Chronic pain conditions such as low back pain, knee pain and cervical pain are highly prevalent among female teachers. Chronic pain significantly affects the mental health, sleep and quality of life among teachers. OBJECTIVE This study is intended to investigate the impact of a workplace yoga intervention on musculoskeletal pain, anxiety, depression, sleep, and quality of life (QoL) among female teachers who had chronic musculoskeletal pain. METHOD Fifty female teachers aged between 25-55 years with chronic musculoskeletal pain were randomized to either the yoga group (n = 25) or the control group (n = 25). The yoga group received a 60-minute structured Integrated Yoga intervention (IY) four days a week for six consecutive weeks at school. The control group received no intervention. OUTCOME MEASURES Pain intensity, anxiety, depression, stress, fatigue, self-compassion, sleep quality, and quality of life were assessed at the baseline and six weeks. RESULTS A significant (p < 0.05) reduction in pain intensity and pain disability in the yoga group was observed after 6-week compared to baseline. Anxiety, depression, stress, sleep scores and fatigues also improved in the yoga group after six weeks. The control group showed no change. Post score comparison showed a significant difference between the groups for all the measures. CONCLUSION Workplace yoga intervention is found to be effective in improving pain, pain disability, mental health, sleep quality among female teachers with chronic musculoskeletal pain. This study strongly recommends yoga for the prevention of work-related health issues and for the promotion of wellbeing among teachers.
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Affiliation(s)
| | - Nagaratna Raghuram
- Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA University), Bangalore, India
| | - Meera Narayan
- Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA University), Bangalore, India
| | - Karthik Sravan
- Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA University), Bangalore, India
| | - Sanjana Sekar
- Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA University), Bangalore, India
| | - Hemant Bhargav
- Department of Integrative Medicine, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Natesh Babu
- Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA University), Bangalore, India
| | - Sriloy Mohanty
- Department of Integrative Medicine and Research, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Morham S, Reichardt A, Toth A, Olin G, Pohlman K, Passmore SR. Patient Characteristics and Clinical Outcomes Associated With Conservative Treatment for Spine Pain in Women Experiencing Socioeconomic Challenges. J Manipulative Physiol Ther 2022; 45:633-640. [PMID: 37294217 DOI: 10.1016/j.jmpt.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 03/21/2023] [Accepted: 04/08/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The purpose of this study was to describe patient demographics and pain changes for women over the course of care in a chiropractic program. METHODS We performed a retrospective cross-sectional analysis of a prospective quality assurance database from the Mount Carmel Clinic (MCC) in Winnipeg, Manitoba, Canada. Pain scores were reported on an 11-point Numeric Rating Scale. Baseline and discharge Numeric Rating Scale scores were compared for each spinal and extremity region through Wilcoxon signed rank tests to determine if clinically meaningful or statistically significant differences were present. RESULTS The sample population attained was 348 primarily middle-aged (mean = 43.0, SD = 14.96) women with obesity (body mass index = 31.3 kg/m2, SD = 7.89) referred to the MCC chiropractic program by their primary care physician (65.2%) for an average of 15.6 (SD = 18.49) treatments. Clinically meaningful median baseline to discharge changes in pain by spine region were observed (Cervical = -2, Thoracic = -2, Lumbar = -3, Sacroiliac = -3), each of which yielded statistical significance (P < .001). CONCLUSION This retrospective analysis found that the MCC chiropractic program serves middle-aged women with obesity experiencing socioeconomic challenges. Pain reductions were reported, regardless of the region of complaint, temporally associated with a course of chiropractic care.
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Affiliation(s)
- Sophie Morham
- Faculty of Kinesiology & Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amber Reichardt
- Faculty of Kinesiology & Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Audrey Toth
- Chiropractic Program, Mount Carmel Clinic, Winnipeg, Manitoba, Canada
| | - Gerald Olin
- Canadian Chiropractic Protective Association, Winnipeg, Manitoba, Canada
| | | | - Steven R Passmore
- Faculty of Kinesiology & Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada.
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Non-pharmacological Treatment for Chronic Pain in US Veterans Treated Within the Veterans Health Administration: Implications for Expansion in US Healthcare Systems. J Gen Intern Med 2022; 37:3937-3946. [PMID: 35048300 PMCID: PMC8769678 DOI: 10.1007/s11606-021-07370-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/16/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Consensus guidelines recommend multimodal chronic pain treatment with increased use of non-pharmacological treatment modalities (NPM), including as first-line therapies. However, with many barriers to NPM uptake in US healthcare systems, NPM use may vary across medical care settings. Military veterans are disproportionately affected by chronic pain. Many veterans receive treatment through the Veterans Health Administration (VHA), an integrated healthcare system in which specific policies promote NPM use. OBJECTIVE To examine whether veterans with chronic pain who utilize VHA healthcare were more likely to use NPM than veterans who do not utilize VHA healthcare. DESIGN Cross-sectional nationally representative study. PARTICIPANTS US military veterans (N = 2,836). MAIN MEASURES In the 2019 National Health Interview Survey, veterans were assessed for VHA treatment, chronic pain (i.e., past 3-month daily or almost daily pain), symptoms of depression and anxiety, substance use, and NPM (i.e., physical therapy, chiropractic/spinal manipulation, massage, psychotherapy, educational class/workshop, peer support groups, or yoga/tai chi). KEY RESULTS Chronic pain (45.2% vs. 26.8%) and NPM use (49.8% vs. 39.4%) were more prevalent among VHA patients than non-VHA veterans. After adjusting for sociodemographic characteristics, psychiatric symptoms, physical health indicators, and use of cigarettes or prescription opioids, VHA patients were more likely than non-VHA veterans to use any NPM (adjusted odds ratio [aOR] = 1.52, 95% CI: 1.07-2.16) and multimodal NPM (aOR = 1.80, 95% CI: 1.12-2.87) than no NPM. Among veterans with chronic pain, VHA patients were more likely to use chiropractic care (aOR = 1.90, 95% CI = 1.12-3.22), educational class/workshop (aOR = 3.02, 95% CI = 1.35-6.73), or psychotherapy (aOR = 4.28, 95% CI = 1.69-10.87). CONCLUSIONS Among veterans with chronic pain, past-year VHA use was associated with greater likelihood of receiving NPM. These findings may suggest that the VHA is an important resource and possible facilitator of NPM. VHA policies may offer guidance for expanding use of NPM in other integrated US healthcare systems.
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Kelton K, Young JR, Evans MK, Eshera YM, Blakey SM, Mann AJD, Pugh MJ, Calhoun PS, Beckham JC, Kimbrel NA. Complementary/integrative healthcare utilization in US Gulf-War era veterans: Descriptive analyses based on deployment history, combat exposure, and Gulf War Illness. Complement Ther Clin Pract 2022; 49:101644. [PMID: 35947938 PMCID: PMC9669216 DOI: 10.1016/j.ctcp.2022.101644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 06/20/2022] [Accepted: 07/23/2022] [Indexed: 11/20/2022]
Abstract
Complementary and integrative health (CIH) approaches have gained empirical support and are increasingly being utilized among veterans to treat a myriad of conditions. A cluster of medically unexplained chronic symptoms including fatigue, headaches, joint pain, indigestion, insomnia, dizziness, respiratory disorders, and memory problems, often referred to as Gulf War Illness (GWI) prominently affect US Gulf War era (GWE) veterans, yet little is known about CIH use within this population. Using data collected as part of a larger study (n = 1153), we examined the influence of demographic characteristics, military experiences, and symptom severity on CIH utilization, and utilization differences between GWE veterans with and without GWI. Over half of the sample (58.5%) used at least one CIH modality in the past six months. Women veterans, white veterans, and veterans with higher levels of education were more likely to use CIH. GWE veterans with a GWI diagnosis and higher GWI symptom severity were more likely to use at least one CIH treatment in the past six months. Over three quarters (82.7%) of veterans who endorsed using CIH to treat GWI symptoms reported that it was helpful for their symptoms. Almost three quarters (71.5%) of veterans indicated that they would use at least one CIH approach if it was available at VA. Results provide a deeper understanding of the likelihood and characteristics of veterans utilizing CIH to treat health and GWI symptoms and may inform expansion of CIH modalities for GWE veterans, particularly those with GWI.
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Affiliation(s)
- Katherine Kelton
- South Texas Veteran Health Care System, Audie L. Murphy Veteran Hospital San Antonio, TX, USA; National Center for Homelessness Among Veterans, USA.
| | - Jonathan R Young
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Durham Veterans Affairs Health Care System, Durham, NC, USA; Mid-Atlantic Mental Illness Research, Education, And Clinical Center (MIRECC), Durham, NC, USA
| | - Mariah K Evans
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Yasmine M Eshera
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Shannon M Blakey
- Durham Veterans Affairs Health Care System, Durham, NC, USA; Mid-Atlantic Mental Illness Research, Education, And Clinical Center (MIRECC), Durham, NC, USA
| | - Adam J D Mann
- Department of Psychology, University of Toledo, Toledo, OH, USA
| | - Mary Jo Pugh
- VA Salt Lake City Health Care System and IDEAS Center of Innovation, Salt Lake City UT, USA; University of Utah School of Medicine, Department of Medicine, Salt Lake City UT, USA
| | - Patrick S Calhoun
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Durham Veterans Affairs Health Care System, Durham, NC, USA; Mid-Atlantic Mental Illness Research, Education, And Clinical Center (MIRECC), Durham, NC, USA; Durham HSRD Center (ADAPT), USA
| | - Jean C Beckham
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Durham Veterans Affairs Health Care System, Durham, NC, USA; Mid-Atlantic Mental Illness Research, Education, And Clinical Center (MIRECC), Durham, NC, USA
| | - Nathan A Kimbrel
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Durham Veterans Affairs Health Care System, Durham, NC, USA; Mid-Atlantic Mental Illness Research, Education, And Clinical Center (MIRECC), Durham, NC, USA; Durham HSRD Center (ADAPT), USA
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11
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Bokhour BG, Hyde J, Kligler B, Gelman H, Gaj L, Barker AM, Douglas J, DeFaccio R, Taylor SL, Zeliadt SB. From patient outcomes to system change: Evaluating the impact of VHA's implementation of the Whole Health System of Care. Health Serv Res 2022; 57 Suppl 1:53-65. [PMID: 35243621 DOI: 10.1111/1475-6773.13938] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/22/2021] [Accepted: 01/03/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To describe how a partnered evaluation of the Whole Health (WH) system of care-comprised of the WH pathway, clinical care, and well-being programs-produced patient outcomes findings, which informed Veterans Health Administration (VA) policy and system change. DATA SOURCES Electronic health records (EHR)-based cohort of 1,368,413 patients and a longitudinal survey of Veterans receiving care at 18 WH pilot medical centers. STUDY DESIGN In partnership with VA operations, we focused the evaluation on the impact of WH services utilization on Veterans' (1) use of opioids and (2) care experiences, care engagement, and well-being. Outcomes were compared between Veterans who did and did not use WH services identified from the EHR. DATA COLLECTION Pharmacy records and WH service data were obtained from the VA EHR, including WH coaching, peer-led groups, personal health planning, and complementary, integrative health therapies. We surveyed veterans at baseline and 6 months to measure patient-reported outcomes. PRINCIPAL FINDINGS Opioid use decreased 23% (31.5-6.5) to 38% (60.3-14.4) among WH users depending on level of WH use compared to a secular 11% (12.0-9.9) decrease among Veterans using Conventional Care. Compared to Conventional Care users, WH users reported greater improvements in perceptions of care (SMD = 0.138), engagement in health care (SMD = 0.118) and self-care (SMD = 0.1), life meaning and purpose (SMD = 0.152), pain (SMD = 0.025), and perceived stress (SMD = 0.191). CONCLUSIONS Evidence developed through this partnership yielded key VA policy changes to increase Veteran access to WH services. Findings formed the foundation of a congressionally mandated report in response to the Comprehensive Addiction and Recovery Act, highlighting the value of WH and complementary, integrative health and well-being programs for Veterans with pain. Findings subsequently informed issuance of an Executive Decision Memo mandating the integration of WH into mental health and primary care across VA, now one lane of modernization for VA.
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Affiliation(s)
- Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA.,Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Justeen Hyde
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Benjamin Kligler
- Office of Patient Centered Care & Cultural Transformation, US Department of Veterans Affairs, Washington, District of Columbia, USA.,Department of Family and Community Medicine, Icahn School of Medicine at Mount Sinai, Brooklyn, New York, USA
| | - Hannah Gelman
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | - Lauren Gaj
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA
| | - Anna M Barker
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA
| | - Jamie Douglas
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | - Rian DeFaccio
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | - Stephanie L Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA.,Department of Health Policy and Management, UCLA School of Public Health, Los Angeles, California, USA
| | - Steven B Zeliadt
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, Washington, USA
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12
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Haun JN, Paykel J, Fowler CA, Lapcevic WA, Panaite V, Alman AC, Melillo C, Venkatachalam HH, French DD. Preliminary Evidence on the Association of Complementary and Integrative Health Care Program Participation and Medical Cost in Veterans. Mil Med 2022; 188:usab567. [PMID: 35064265 DOI: 10.1093/milmed/usab567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/27/2021] [Accepted: 01/13/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Transforming Health and Resilience through Integration of Values-based Experiences (THRIVE) is a complimentary and integrative health program. THRIVE is delivered through shared medical appointments where participants engage in provider-led education and group discussion on wellness-related topics. THRIVE has been associated with improved patient-reported outcomes in a female veteran cohort. This quality improvement study evaluated the association between THRIVE participation and Veterans Health Administration (VHA) healthcare costs across a 1 year period. MATERIALS AND METHODS A cohort study design (n = 184) used VHA administrative data to estimate the cost difference between 1 year pre- and post-THRIVE participation. The 1 year post-cost of the THRIVE cohort was then compared to the 1 year cost of a quasi-experimental waitlist control group (n = 156). Data sources included VHA administrative and electronic health records. RESULTS Patients were roughly 51 years old, were typically White/Caucasian, and had a service priority level representing catastrophic disability. The adjusted post-THRIVE cost was $26,291 [95% confidence interval (CI): $23,014-29,015]; $1,720 higher than the previous year's cost but was not statistically significant (P = 0.289). However, a comparison between the THRIVE cohort and a group of waitlist THRIVE patients (n = 156) the intervention group on average was $8,108 more than the waitlist group (95% CI: $3,194-14,005; P < 0.01). CONCLUSIONS In summary, data analysis of veterans' annual healthcare cost trajectories were inconclusive. This preliminary study produced mixed results requiring more research with larger samples and randomized control trial methodology. Evidence of whether the THRIVE intervention can maintain cost effectiveness while maintaining its supported evidence of healthcare quality is needed.
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Salsbury SA, Twist E, Wallace RB, Vining RD, Goertz CM, Long CR. Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a qualitative study with veteran stakeholders from a pilot trial of multimodal chiropractic care. Pilot Feasibility Stud 2022; 8:6. [PMID: 35031072 PMCID: PMC8759237 DOI: 10.1186/s40814-021-00962-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low back pain (LBP) is common among military veterans seeking treatment in Department of Veterans Affairs (VA) healthcare facilities. As chiropractic services within VA expand, well-designed pragmatic trials and implementation studies are needed to assess clinical effectiveness and program uptake. This study evaluated veteran stakeholder perceptions of the feasibility and acceptability of care delivery and research processes in a pilot trial of multimodal chiropractic care for chronic LBP. METHODS The qualitative study was completed within a mixed-method, single-arm, pragmatic, pilot clinical trial of chiropractic care for LBP conducted in VA chiropractic clinics. Study coordinators completed semi-structured, in person or telephone interviews with veterans near the end of the 10-week trial. Interviews were audiorecorded and transcribed verbatim. Qualitative content analysis using a directed approach explored salient themes related to trial implementation and delivery of chiropractic services. RESULTS Of 40 participants, 24 completed interviews (60% response; 67% male gender; mean age 51.7 years). Overall, participants considered the trial protocol and procedures feasible and reported that the chiropractic care and recruitment methods were acceptable. Findings were organized into 4 domains, 10 themes, and 21 subthemes. Chiropractic service delivery domain encompassed 3 themes/8 subthemes: scheduling process (limited clinic hours, scheduling future appointments, attendance barriers); treatment frequency (treatment sufficient for LBP complaint, more/less frequent treatments); and chiropractic clinic considerations (hire more chiropractors, including female chiropractors; chiropractic clinic environment; patient-centered treatment visits). Outcome measures domain comprised 3 themes/4 subthemes: questionnaire burden (low burden vs. time-consuming or repetitive); relevance (items relevant for LBP study); and timing and individualization of measures (questionnaire timing relative to symptoms, personalized approach to outcomes measures). The online data collection domain included 2 themes/4 subthemes: user concerns (little difficulty vs. form challenges, required computer skills); and technology issues (computer/internet access, junk mail). Clinical trial planning domain included 2 themes/5 subthemes: participant recruitment (altruistic service by veterans, awareness of chiropractic availability, financial compensation); and communication methods (preferences, potential barriers). CONCLUSIONS This qualitative study highlighted veteran stakeholders' perceptions of VA-based chiropractic services and offered important suggestions for conducting a full-scale, veteran-focused, randomized trial of multimodal chiropractic care for chronic LBP in this clinical setting. TRIAL REGISTRATION ClinicalTrials.gov NCT03254719.
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Affiliation(s)
- Stacie A. Salsbury
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 741 Brady Street, Davenport, Iowa 52803 USA
| | - Elissa Twist
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 741 Brady Street, Davenport, Iowa 52803 USA
| | - Robert B. Wallace
- Department of Epidemiology, College of Public Health, The University of Iowa, S422 CPHB, 145 N. Riverside Drive, Iowa City, Iowa 52242 USA
| | - Robert D. Vining
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 741 Brady Street, Davenport, Iowa 52803 USA
| | - Christine M. Goertz
- Department of Orthopaedic Surgery, Duke University School of Medicine, 200 Morris Street, Durham, North Carolina 27701 USA
| | - Cynthia R. Long
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 741 Brady Street, Davenport, Iowa 52803 USA
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14
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Ly VT, Coleman BC, Coulis CM, Lisi AJ. Exploring the application of the Charlson Comorbidity Index to assess the patient population seen in a Veterans Affairs chiropractic residency program. THE JOURNAL OF CHIROPRACTIC EDUCATION 2021; 35:199-204. [PMID: 33428733 PMCID: PMC8528440 DOI: 10.7899/jce-20-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 01/17/2020] [Accepted: 07/27/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Chiropractic trainees require exposure to a diverse patient base, including patients with multiple medical conditions. The Veterans Affairs (VA) Chiropractic Residency Program aims for its doctor of chiropractic (DC) residents to gain experience managing a range of multimorbid cases, yet to our knowledge there are no published data on the comorbidity characteristics of patients seen by VA DC residents. We tested 2 approaches to obtaining Charlson Comorbidity Index (CCI) scores and compared CCI scores of resident patients with those of staff DCs at 1 VA medical center. METHODS Two processes of data collection to calculate CCI scores were developed. Time differences and agreement between methods were assessed. Comparison of CCI distribution between resident DC and staff DCs was done using 100 Monte Carlo simulation iterations of Fisher's exact test. RESULTS Both methods were able to calculate CCI scores (n = 22). The automated method was faster than the manual (13 vs 78 seconds per patient). CCI scores agreement between methods was good (κ = 0.67). We failed to find a significant difference in the distribution of resident DC and staff DC patients (mean p = .377; 95% CI, .375-.379). CONCLUSION CCI scores of a VA chiropractic resident's patients are measurable with both manual and automated methods, although automated may be preferred for its time efficiency. At the facility studied, the resident and staff DCs did not see patients with significantly different distributions of CCI scores. Applying CCI may give better insight into the characteristics of DC trainee patient populations.
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15
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Haun JN, Melillo C, Cotner BA, McMahon-Grenz J, Paykel JM. Evaluating a Whole Health Approach to Enhance Veteran Care: Exploring the Staff Experience. JOURNAL OF VETERANS STUDIES 2021. [DOI: 10.21061/jvs.v7i1.201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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16
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Farmer MM, McGowan M, Yuan AH, Whitehead AM, Osawe U, Taylor SL. Complementary and Integrative Health Approaches Offered in the Veterans Health Administration: Results of a National Organizational Survey. J Altern Complement Med 2021; 27:S124-S130. [PMID: 33788607 DOI: 10.1089/acm.2020.0395] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Certain complementary and integrative health (CIH) approaches have increasingly gained attention as evidence-based nonpharmacological options for pain, mental health, and well-being. The Veterans Health Administration (VA) has been at the forefront of providing CIH approaches for years, and the 2016 Comprehensive Addiction and Recovery Act mandated the VA expand its provision of CIH approaches. Objective/Design: To conduct a national organizational survey to document aspects of CIH approach implementation from August 2017 to July 2018 at the VA. Participants: CIH program leads at VA medical centers and community-based outpatient clinics (n = 196) representing 289 sites participated. Measures: Delivery of 27 CIH and other nonpharmacologic approaches was measured, including types of departments and providers, visit format, geographic variations, and implementation challenges. Results: Respondents reported offering a total of 1,568 CIH programs nationally. Sites offered an average of five approaches (range 1-23), and 63 sites offered 10 or more approaches. Relaxation techniques, mindfulness, guided imagery, yoga, and meditation were the top five most frequently offered. The most approaches were offered in physical medicine and rehabilitation, primary care, and within integrative/whole health programs, and VA non-Doctor of Medicine clinical staff were the most common type of CIH provider. Only 13% of sites reported offering CIH approaches through telehealth at the time. Geographically, southwestern sites offered the smallest number of approaches. Implementation challenges included insufficient staffing, funding, and space, hiring/credentialing, positioning CIH as a priority, and high patient demand. Conclusions: The provision of CIH approaches was widespread at the VA in 2017-2018, with over half of responding sites offering five or more approaches. As patients seek nonpharmacologic options to address their pain, anxiety, depression, and well-being, the nation's largest integrated health care system is well-positioned to meet that demand. Providing these therapies might not only increase patient satisfaction but also their health and well-being with limited to no adverse events.
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Affiliation(s)
- Melissa M Farmer
- VA Health Services Research & Development (HSR&D), Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,VA QUERI Complementary and Integrative Health Evaluation Center, Los Angeles, CA, USA
| | - Michael McGowan
- VA Health Services Research & Development (HSR&D), Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,VA QUERI Complementary and Integrative Health Evaluation Center, Los Angeles, CA, USA
| | - Anita H Yuan
- VA Health Services Research & Development (HSR&D), Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,VA QUERI Complementary and Integrative Health Evaluation Center, Los Angeles, CA, USA
| | - Alison M Whitehead
- VA National Office of Patient Centered Care and Cultural Transformation, Washington, DC, USA
| | - Uyi Osawe
- Kaiser Permanente Southern California, Woodland Hills, CA, USA
| | - Stephanie L Taylor
- VA Health Services Research & Development (HSR&D), Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,VA QUERI Complementary and Integrative Health Evaluation Center, Los Angeles, CA, USA.,Department of Medicine, Department of Health Policy and Management, UCLA, Los Angeles, CA, USA
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17
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Correlates of Manual Therapy and Acupuncture Use Among Rural Patients Seeking Conventional Pain Management: A Cross-sectional Study. J Manipulative Physiol Ther 2021; 44:330-343. [PMID: 33896602 DOI: 10.1016/j.jmpt.2021.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/30/2020] [Accepted: 01/20/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE In this cross-sectional study, we examined correlates of manual therapy (spinal manipulation, massage therapy) and/or acupuncture use in a population engaging in conventional pain care in West Virginia. METHODS Participants were patients (aged 18+ years) from 4 Appalachian pain and rheumatology clinics. Of those eligible (N = 343), 88% completed an anonymous survey including questions regarding health history, pain distress (Short Form Global Pain Scale), prescription medications, and current use of complementary health approaches for pain management. We used age-adjusted logistic regression to assess the relation of sociodemographic, lifestyle, and health-related factors to use of manual therapies and/or acupuncture for pain (complete-case N = 253). RESULTS The majority of participants were white (92%), female (56%), and middle aged (mean age, 54.8 ± 13.4 years). Nearly all reported current chronic pain (94%), and 56% reported ≥5 comorbidities (mean, 5.6 ± 3.1). Manual therapy and/or acupuncture was used by 26% of participants for pain management (n = 66). Current or prior opioid use was reported by 37% of those using manual therapies. Manual therapy and/or acupuncture use was significantly elevated in those using other complementary health approaches (adjusted odds ratio, 3.0; 95% confidence interval, 1.5-5.8). Overall Short Form Global Pain Scale scores were not significantly associated with use of manual therapies and/or acupuncture after adjustment (adjusted odds ratio per 1-point increase, 1.01; 95% confidence interval, 1.00-1.03). CONCLUSION We found no evidence for an association of pain-related distress and use of manual therapies and/or acupuncture, but identified a strong association with use of dietary supplements and mind-body therapies. Larger studies are needed to further examine these connections in the context of clinical outcomes and cost-effectiveness in rural adults given their high pain burden and unique challenges in access to care.
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18
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Roseen EJ, Conyers FG, Atlas SJ, Mehta DH. Initial Management of Acute and Chronic Low Back Pain: Responses from Brief Interviews of Primary Care Providers. J Altern Complement Med 2021; 27:S106-S114. [PMID: 33788610 PMCID: PMC8035915 DOI: 10.1089/acm.2020.0391] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: In April 2017, the American College of Physicians (ACP) published a clinical practice guideline for low back pain (LBP) recommending nonpharmacologic treatments as first-line therapy for acute, subacute, and chronic LBP. Objective: To assess primary care provider (PCP)-reported initial treatment recommendations for LBP following guideline release. Design: Cross-sectional structured interviews. Participants: Convenience sample of 72 PCPs from 3 community-based outpatient clinics in high- or low-income neighborhoods. Approach: PCPs were interviewed about their familiarity with the ACP guideline, and how they initially manage patients with acute/subacute and chronic LBP. Treatment responses were coded as patient education, nonpharmacologic, pharmacologic, or medical specialty referral. PCPs were also asked about their comfort referring patients to nonpharmacologic treatment providers, and about barriers to referring. Responses were assessed using content analysis. Differences in responses were assessed using descriptive statistics. Key results: Interviews were completed between December 2017 and March 2018. Of 72 participating PCPs (50% male; mean years of practice = 13.8), over three-fourths indicated being familiar with the ACP guideline (76%-87% at 3 clinics). For acute LBP, PCPs typically provided advice to stay active (81%) and pharmacologic management (97%; primarily nonsteroidal anti-inflammatory drugs). For chronic LBP, PCPs were more likely to recommend nonpharmacologic treatments than for acute LBP (85% vs. 0%, p < 0.001). The most common nonpharmacologic treatments recommended for chronic LBP were physical therapy (78%), chiropractic care (21%), massage therapy (18%), and acupuncture (17%) (each compared with 0% for acute LBP, all p < 0.001). The cost of nonpharmacologic treatments was perceived as a barrier. However, PCPs working in low-income neighborhood clinics were as likely to recommend nonpharmacologic approaches as those from a high-income neighborhood clinic. Conclusions: While most PCPs indicated they were familiar with the ACP guideline for LBP, nonpharmacologic treatments were not recommended for patients with acute symptoms. Further dissemination and implementation of the ACP guideline are needed.
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Affiliation(s)
- Eric J. Roseen
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Department of Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA, USA
| | - Frank Garrett Conyers
- Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Steven J. Atlas
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Darshan H. Mehta
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Osher Center for Integrative Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, USA
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Sandbrink F, Oliva EM, McMullen TL, Aylor AR, Harvey MA, Christopher ML, Cunningham F, Minegishi T, Emmendorfer T, Perry JM. Opioid Prescribing and Opioid Risk Mitigation Strategies in the Veterans Health Administration. J Gen Intern Med 2020; 35:927-934. [PMID: 33196968 PMCID: PMC7728840 DOI: 10.1007/s11606-020-06258-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 09/18/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The Veterans Health Administration (VHA) has taken a multifaceted approach to addressing opioid safety and promoting system-wide opioid stewardship. AIM To provide a comprehensive evaluation of current opioid prescribing practices and implementation of risk mitigation strategies in VHA. SETTING VHA is the largest integrated health care system in the United States. PROGRAM DESCRIPTION VHA prescribing data in conjunction with implementation of opioid risk mitigation strategies are routinely tracked and reviewed by VHA's Pharmacy Benefits Management Services (including Academic Detailing Service) and the Pain Management Program Office. Additional data are derived from the Partnered Evidence-Based Policy Resource Center (PEPReC) and from a 2019 survey of interdisciplinary pain management teams at VHA facilities. Prescribing data are reported quarterly until first quarter fiscal year 2020 (Q1FY2020), ending December 31, 2019. PROGRAM EVALUATION VHA opioid dispensing peaked in 2012 with 679,376 Veterans receiving an opioid prescription, and when including tramadol, in 2013 with 869,956 Veterans. Since 2012, the number of Veterans dispensed an opioid decreased 56% and co-prescribed opioid/benzodiazepine decreased 83%. Veterans with high-dose opioids (≥ 100 mg morphine equivalent daily dose) decreased 77%. In Q1FY2020, among Veterans on long-term opioid therapy (LTOT), 91.1% had written informed consent, 90.8% had a urine drug screen, and 89.0% had a prescription drug monitoring program query. Naloxone was issued to 217,469 Veterans and resulted in > 1,000 documented overdose reversals. In 2019, interdisciplinary pain management teams were fully designated at 68%, partially designated at 28%, and not available at 4% of 140 VA parent facilities. Fifty percent of Veterans on opioids at very high risk for overdose/suicide received interdisciplinary team reviews. IMPLICATIONS VHA clinicians have greatly reduced their volume of opioid prescribing for pain management and expanded implementation of opioid risk mitigation strategies. IMPACTS VHA's integrated health care system provides a model for opioid stewardship and interdisciplinary pain care.
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Affiliation(s)
- Friedhelm Sandbrink
- Pain Management and Opioid Safety Program, Veterans Health Administration, Washington, DC, USA.
- Department of Neurology, Washington DC VA Medical Center, Washington, DC, USA.
- Uniformed Services University, Bethesda, MD, USA.
- George Washington University, Washington, DC, USA.
| | - Elizabeth M Oliva
- VA Program Evaluation and Resource Center, VA Office of Mental Health and Suicide Prevention, Menlo Park, CA, USA
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Tara L McMullen
- Pain Management and Opioid Safety Program, Veterans Health Administration, Washington, DC, USA
| | - Amy R Aylor
- Pain Management and Opioid Safety Program, Veterans Health Administration, Washington, DC, USA
| | - Michael A Harvey
- Patient Care Services, Pharmacy Benefits Management Service, Veterans Health Administration, Washington, DC, USA
| | - Melissa L Christopher
- Patient Care Services, Pharmacy Benefits Management Service, Veterans Health Administration, Washington, DC, USA
| | - Francesca Cunningham
- Patient Care Services, Pharmacy Benefits Management Service, Veterans Health Administration, Washington, DC, USA
| | - Taeko Minegishi
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
- Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Thomas Emmendorfer
- Patient Care Services, Pharmacy Benefits Management Service, Veterans Health Administration, Washington, DC, USA
| | - Jenie M Perry
- Pain Management and Opioid Safety Program, Veterans Health Administration, Washington, DC, USA
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Abstract
BACKGROUND Yoga interventions can improve function and reduce pain in persons with chronic low back pain (cLBP). OBJECTIVE Using data from a recent trial of yoga for military veterans with cLBP, we analyzed the incremental cost-effectiveness of yoga compared with usual care. METHODS Participants (n=150) were randomized to either 2× weekly, 60-minute yoga sessions for 12 weeks, or to delayed treatment (DT). Outcomes were measured at 12 weeks, and 6 months. Quality-adjusted life years (QALYs) were measured using the EQ-5D scale. A 30% improvement on the Roland-Morris Disability Questionnaire (primary outcome) served as an additional effectiveness measure. Intervention costs including personnel, materials, and transportation were tracked during the study. Health care costs were obtained from patient medical records. Health care organization and societal perspectives were examined with a 12-month horizon. RESULTS Incremental QALYs gained by the yoga group over 12 months were 0.043. Intervention costs to deliver yoga were $307/participant. Negligible differences in health care costs were found between groups. From the health care organization perspective, the incremental cost-effectiveness ratio to provide yoga was $4488/QALY. From the societal perspective, yoga was "dominant" providing both health benefit and cost savings. Probabilistic sensitivity analysis indicates an 89% chance of yoga being cost-effective at a willingness-to-pay of $50,000. A scenario comparing the costs of yoga and physical therapy suggest that yoga may produce similar results at a much lower cost. DISCUSSION/CONCLUSIONS Yoga is a cost-effective treatment for reducing pain and disability among military veterans with cLBP.
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Coleman BC, Fodeh S, Lisi AJ, Goulet JL, Corcoran KL, Bathulapalli H, Brandt CA. Exploring supervised machine learning approaches to predicting Veterans Health Administration chiropractic service utilization. Chiropr Man Therap 2020; 28:47. [PMID: 32680545 PMCID: PMC7368704 DOI: 10.1186/s12998-020-00335-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/02/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Chronic spinal pain conditions affect millions of US adults and carry a high healthcare cost burden, both direct and indirect. Conservative interventions for spinal pain conditions, including chiropractic care, have been associated with lower healthcare costs and improvements in pain status in different clinical populations, including veterans. Little is currently known about predicting healthcare service utilization in the domain of conservative interventions for spinal pain conditions, including the frequency of use of chiropractic services. The purpose of this retrospective cohort study was to explore the use of supervised machine learning approaches to predicting one-year chiropractic service utilization by veterans receiving VA chiropractic care. METHODS We included 19,946 veterans who entered the Musculoskeletal Diagnosis Cohort between October 1, 2003 and September 30, 2013 and utilized VA chiropractic services within one year of cohort entry. The primary outcome was one-year chiropractic service utilization following index chiropractic visit, split into quartiles represented by the following classes: 1 visit, 2 to 3 visits, 4 to 6 visits, and 7 or greater visits. We compared the performance of four multiclass classification algorithms (gradient boosted classifier, stochastic gradient descent classifier, support vector classifier, and artificial neural network) in predicting visit quartile using 158 sociodemographic and clinical features. RESULTS The selected algorithms demonstrated poor prediction capabilities. Subset accuracy was 42.1% for the gradient boosted classifier, 38.6% for the stochastic gradient descent classifier, 41.4% for the support vector classifier, and 40.3% for the artificial neural network. The micro-averaged area under the precision-recall curve for each one-versus-rest classifier was 0.43 for the gradient boosted classifier, 0.38 for the stochastic gradient descent classifier, 0.43 for the support vector classifier, and 0.42 for the artificial neural network. Performance of each model yielded only a small positive shift in prediction probability (approximately 15%) compared to naïve classification. CONCLUSIONS Using supervised machine learning to predict chiropractic service utilization remains challenging, with only a small shift in predictive probability over naïve classification and limited clinical utility. Future work should examine mechanisms to improve model performance.
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Affiliation(s)
- Brian C Coleman
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA.
- Yale School of Medicine, Yale University, New Haven, CT, USA.
| | - Samah Fodeh
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Anthony J Lisi
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Kelsey L Corcoran
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Harini Bathulapalli
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Cynthia A Brandt
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
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Zeliadt SB, Coggeshall S, Thomas E, Gelman H, Taylor SL. The APPROACH trial: Assessing pain, patient-reported outcomes, and complementary and integrative health. Clin Trials 2020; 17:351-359. [PMID: 32522024 DOI: 10.1177/1740774520928399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Electronic health record data can be used in multiple ways to facilitate real-world pragmatic studies. Electronic health record data can provide detailed information about utilization of treatment options to help identify appropriate comparison groups, access historical clinical characteristics of participants, and facilitate measuring longitudinal outcomes for the treatments being studied. An additional novel use of electronic health record data is to assess and understand referral pathways and other business practices that encourage or discourage patients from using different types of care. We describe an ongoing study utilizing access to real-time electronic health record data about changing patterns of complementary and integrative health services to demonstrate how electronic health record data can provide the foundation for a pragmatic study when randomization is not feasible. Conducting explanatory trials of the value of emerging therapies within a healthcare system poses ethical and pragmatic challenges, such as withholding access to specific services that are becoming widely available to patients. We describe how prospective examination of real-time electronic health record data can be used to construct and understand business practices as potential surrogates for direct randomization through an instrumental variables analytic approach. In this context, an example of a business practice is the internal hiring of acupuncturists who also provide yoga or Tai Chi classes and can offer these classes without additional cost compared to community acupuncturists. Here, the business practice of hiring internal acupuncturists is likely to encourage much higher rates of combined complementary and integrative health use compared to community referrals. We highlight the tradeoff in efficiency of this pragmatic approach and describe use of simulations to estimate the potential sample sizes needed for a variety of instrument strengths. While real-time monitoring of business practices from electronic health records provides insights into the validity of key independence assumptions associated with the instrumental variable approaches, we note that there may be some residual confounding by indication or selection bias and describe how alternative sources of electronic health record data can be used to assess the robustness of instrumental variable assumptions to address these challenges. Finally, we also highlight that while some clinical outcomes can be obtained directly from the electronic health record, such as longitudinal opioid utilization and pain intensity levels for the study of the value of complementary and integrative health, it is often critical to supplement clinical electronic health record-based measures with patient-reported outcomes. The experience of this example in evaluating complementary and integrative health demonstrates the use of electronic health record data in several novel ways that may be of use for designing future pragmatic trials.
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Affiliation(s)
- Steven B Zeliadt
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Health Administration, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Scott Coggeshall
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Health Administration, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Eva Thomas
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Health Administration, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Hannah Gelman
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Health Administration, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Stephanie L Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Health Administration, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Health Policy and Management, UCLA School of Public Health, Los Angeles, CA, USA
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