General CIH Use or Implementation - Whole Health
Attention A T users. To access the menus on this page please perform the following steps. 1. Please switch auto forms mode to off. 2. Hit enter to expand a main menu option (Health, Benefits, etc). 3. To enter and activate the submenu links, hit the down arrow. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links.

Whole Health

Menu
Menu

Quick Links

Veterans Crisis Line Badge
My healthevet badge
 

General CIH Use or Implementation

Library of Research Articles on Veterans and CIH Therapies

January 2021 Edition

General CIH Use or Implementation

Ashrafioun L, Allen KD, Pigeon WR. Utilization of complementary and integrative health services and opioid therapy by patients receiving Veterans Health Administration pain care. Complement Ther Med. 2018 Aug;39:8-13.

Objectives

The aims of the current study were to characterize veterans who used a complementary and integrative health (CIH) service in the Veterans Health Administration (VHA) and to assess the extent to which using a CIH-related service was associated with receiving an opioid analgesic prescription following the initiation of specialty pain service, a time at which higher intensity care is needed for patients experiencing greater psychiatric and medical complexity.

Design

This study utilized a retrospective cohort design of veterans using specialty pain services. The index visit was defined as the first specialty pain visit in Fiscal Years 2012-2015. Demographics, opioid analgesic prescriptions, psychiatric disorder diagnoses, medical comorbidity, pain severity scores, and pain conditions were extracted from VHA administrative data.

Setting: The cohort was comprised of veterans who had at least one visit with a specialty pain service as identified by a billing code.

Main outcome measures: The main outcome measures were use of a CIH-related service in the 365 days prior to the index visit and opioid analgesic prescription within 365 days after the index visit. Adjusted logistic regression analyses accounted for key covariate and potential confounding variables.

Results

Use of CIH-related services was relatively low across the cohort (1.9%). Veterans who used a CIH-related service in the 365 days prior to the index visit were more likely to be female, be younger, have less medical comorbidity, have less severe pain, and were less likely to have received an opioid prescription in the 365 days prior to the index visit. After accounting for key covariates and potential confounders, veterans who used a CIH-related service were less likely to receive an opioid analgesic prescription in the 365 days following the index visit.

Conclusion

CIH-related services were not commonly used among Veterans initiating specialty pain services. Engaging in CIH-related services prior to specialty pain services is associated with decreased opioid analgesic and non-opioid analgesic prescriptions.

Bokhour BG, Haun JN, Hyde J, Charns M, Kligler B. Transforming the Veterans Affairs to a Whole Health System of Care: Time for Action and Research. Med Care. 2020 Apr;58(4):295-300.

As part of the national movement towards value-based and accountable care, health care systems are working to incorporate patient-centered approaches to improve patients' wellness and increase engagement in self-care.1,2 In 2001, the Institute of Medicine identified patient-centered care as one of the 6 pillars of quality of care, and defined it as "providing care that is respectful of and responsive to individual preferences, needs, and values and ensuring that patient values guide all clinical decisions."3 Patient-centered care shifts away from a disease-focused care model, and changes the conversation from "What is the matter with you?" to "What matters to you?"

Bolton RE, Bokhour BG, Dvorin K, Wu J, Elwy AR, Charns M, Taylor SL. Garnering Support for Complementary and Integrative Health Implementation: A Qualitative Study of VA Healthcare Organization Leaders. J Altern Complement Med. 2021 Mar;27(S1):S81-S88.

Objectives

Healthcare organization leaders' support is critical for successful implementation of new practices, including complementary and integrative health (CIH) therapies. Yet little is known about how to garner this support and what motivates leaders to support these therapies. We examined reasons leaders provided or withheld support for CIH therapy implementation, using a multilevel lens to understand motivations influenced by individual, interpersonal, organizational, and system determinants.

Design and setting

We conducted qualitative interviews with leaders in seven Veterans Health Administration medical centers that offered at least three CIH therapies to Veterans and were identified as early adopters of CIH therapies.

Subjects: Participants included 12 executive leaders and 34 leaders of key clinical services, including primary care, mental health, physical medicine and rehabilitation, and pain. Measures: We used a thematic analysis to examine leaders' narratives of barriers and facilitators to implementation including their attitudes toward CIH therapies, perceptions of evidence, engagement in implementation, and decisions to provide concrete support for CIH therapies. Drawing from Greenhalgh's Diffusion of Innovation framework, we organized themes according to the influence of individual determinants, two levels of inner setting, and outer system context on CIH implementation.

Results

Leaders' decisions to provide or withhold support were driven by considerations across multiple levels including (1) individual attitudes/knowledge, perceptions of evidence, and personal experiences; (2) interpersonal interactions with trusted brokers, patients, and loved ones/colleagues/staff; (3) organizational concerns surrounding relative priorities, local resources, and metrics/quality/safety; and (4) system-level policy, bureaucracy, and interorganizational networks. These considerations interacted across levels, with components at organizational and system levels sometimes prevailing over individual perceptions and experiences.

Conclusions

Garnering leaders' support for CIH therapy implementation should address their considerations at multiple levels. Implementation strategies designed to shift individual attitudes alone may be insufficient for securing leaders' support without attention to broader organizational and system-level contextual issues.

Donaldson MT, Polusny MA, MacLehose RF, Goldsmith ES, Hagel Campbell EM, Miron LR, Thuras PD, Krebs EE. Patterns of conventional and complementary non-pharmacological health practice use by US military veterans: a cross-sectional latent class analysis. BMC Complement Altern Med. 2018 Sep 5;18(1):246.

Background

Non-pharmacological therapies and practices are commonly used for both health maintenance and management of chronic disease. Patterns and reasons for use of health practices may identify clinically meaningful subgroups of users. The objectives of this study were to identify classes of self-reported use of conventional and complementary non-pharmacological health practices using latent class analysis and estimate associations of participant characteristics with class membership.

Methods

A mailed survey (October 2015 to September 2016) of Minnesota National Guard Veterans from a longitudinal cohort (n = 1850) assessed current pain, self-reported overall health, mental health, substance use, personality traits, and health practice use. We developed the Health Practices Inventory, a self-report instrument assessing use of 19 common conventional and complementary non-pharmacological health-related practices. Latent class analysis was used to identify subgroups of health practice users, based on responses to the HPI. Participants were assigned to their maximum-likelihood class, which was used as the outcome in multinomial logistic regression to examine associations of participant characteristics with latent class membership.

Results

Half of the sample used non-pharmacological health practices. Six classes of users were identified. "Low use" (50%) had low rates of health practice use. "Exercise" (23%) had high exercise use. "Psychotherapy" (6%) had high use of psychotherapy and support groups. "Manual therapies" (12%) had high use of chiropractic, physical therapy, and massage. "Mindfulness" (5%) had high use of mindfulness and relaxation practice. "Multimodal" (4%) had high use of most practices. Use of manual therapies (chiropractic, acupuncture, physical therapy, massage) was associated with chronic pain and female sex. Characteristics that predict use patterns varied by class. Use of self-directed practices (e.g., aerobic exercise, yoga) was associated with the personality trait of absorption (openness to experience). Use of psychotherapy was associated with higher rates of psychological distress.

Conclusions

These observed patterns of use of non-pharmacological health practices show that functionally similar practices are being used together and suggest a meaningful classification of health practices based on self-directed/active and practitioner-delivered. Notably, there is considerable overlap in users of complementary and conventional practices.

Edmond SN, Becker WC, Driscoll MA, Decker SE, Higgins DM, Mattocks KM, Kerns RD, Haskell SG. Use of Non-Pharmacological Pain Treatment Modalities Among Veterans with Chronic Pain: Results from a Cross-Sectional Survey. J Gen Intern Med. 2018 May;33(Suppl 1):54-60. 

Background

Despite strong evidence for the effectiveness of non-pharmacological pain treatment modalities (NPMs), little is known about the prevalence or correlates of NPM use.

Objective

This study examined rates and correlates of NPM use in a sample of veterans who served during recent conflicts.

Design

We examined rates and demographic and clinical correlates of self-reported NPM use (operationalized as psychological/behavioral therapies, exercise/movement therapies, and manual therapies). We calculated descriptive statistics and examined bivariate associations and multivariable associations using logistic regression.

Participants: Participants were 460 veterans endorsing pain lasting ≥ 3 months who completed the baseline survey of the Women Veterans Cohort Study (response rate 7.7%.

Main measures: Outcome was self-reported use of NPMs in the past 12 months.

Key results

Veterans were 33.76 years old (SD = 10.72), 56.3% female, and 80.2% White. Regarding NPM use, 22.6% reported using psychological/behavioral, 50.9% used exercise/movement and 51.7% used manual therapies. Veterans with a college degree (vs. no degree; OR = 2.51, 95% CI = 1.46, 4.30, p = 0.001) or those with worse mental health symptoms (OR = 2.88, 95% CI = 2.11, 3.93, p < 0.001) were more likely to use psychological/behavioral therapies. Veterans who were female (OR = 0.63, 95% CI = 0.43, 0.93, p = 0.02) or who used non-opioid pain medications (OR = 1.82, 95% CI = 1.146, 2.84, p = 0.009) were more likely to use exercise/movement therapies. Veterans who were non-White (OR = 0.57, 95% CI = 0.5, 0.94, p = 0.03), with greater educational attainment (OR = 2.11, 95% CI = 1.42, 3.15, p < 0.001), or who used non-opioid pain medication (OR = 1.71, 95% CI = 1.09, 2.68, p = 0.02) were more likely to use manual therapies.

Conclusions

Results identified demographic and clinical characteristics among different NPMs, which may indicate differences in veteran treatment preferences or provider referral patterns. Further study of provider referral patterns and veteran treatment preferences is needed to inform interventions to increase NPM utilization. Research is also need to identify demographic and clinical correlates of clinical outcomes related to NPM use.

Elwy AR, Taylor SL. Progress of Veterans Health Administration Complementary and Integrative Health Research Along the Quality Enhancement Research Initiative Implementation Roadmap. Med Care. 2020 Sep;58 Suppl 2 9S:S75-S77. 

This special issue, The Implementation of Complementary and Integrative Health Therapies in the Veterans Health Administration, highlights how research on complementary and integrative health (CIH) therapies in the Veterans Health Administration (VA) has progressed along the Quality Enhancement Research Initiative (QUERI) Implementation Roadmap, from preimplementation, implementation, and sustainment phases. In December 2014, we served as Guest Editors of this journal's first special issue on CIH therapies among Veterans and military members, Building the Evidence Base for Complementary and Integrative Medicine Use among Veterans and Military Personnel. Since then, numerous research-related and policy efforts have propelled the state of CIH research among Veterans along this QUERI Implementation Roadmap. These efforts include the passage of the Comprehensive Addiction and Recovery Act (CARA) legislation of 2016, which requires the VA to fund research, education, and clinical activities on CIH therapies as nonpharmacological approaches to pain treatments. In addition, our QUERI partnered evaluation initiative, the Complementary and Integrative Health Evaluation Center (CIHEC), was established in 2016 with funding by the Office of Patient-Centered Care and Cultural Transformation (OPCC&CT). CIHEC conducts large-scale projects to examine the implementation of and evidence for CIH therapies in the VA, such as levels of CIH provision and Veterans' use of and interest in CIH therapies across the nation.

Evans EA, Herman PM, Washington DL, Lorenz KA, Yuan A, Upchurch DM, Marshall N, Hamilton AB, Taylor SL. Gender Differences in Use of Complementary and Integrative Health by U.S. Military Veterans with Chronic Musculoskeletal Pain. Womens Health Issues. 2018 Sep-Oct;28(5):379-386.

Aims

The Veterans Health Administration promotes evidence-based complementary and integrative health (CIH) therapies as nonpharmacologic approaches for chronic pain. We aimed to examine CIH use by gender among veterans with chronic musculoskeletal pain, and variations in gender differences by race/ethnicity and age.

Methods

We conducted a secondary analysis of electronic health records provided by all women (n = 79,537) and men (n = 389,269) veterans age 18 to 54 years with chronic musculoskeletal pain who received Veterans Health Administration-provided care between 2010 and 2013. Using gender-stratified multivariate binary logistic regression, we examined predictors of CIH use, tested a race/ethnicity-by-age interaction term, and conducted pairwise comparisons of predicted probabilities.

Results

Among veterans with chronic musculoskeletal pain, more women than men use CIH (36% vs. 26%), with rates ranging from 25% to 42% among women and 15% to 29% among men, depending on race/ethnicity and age. Among women, patients under age 44 who were Hispanic, White, or patients of other race/ethnicities are similarly likely to use CIH; in contrast, Black women, regardless of age, are least likely to use CIH. Among men, White and Black patients, and especially Black men under age 44, are less likely to use CIH than men of Hispanic or other racial/ethnic identities.

Conclusions

Women veteran patients with chronic musculoskeletal pain are more likely than men to use CIH therapies, with variations in CIH use rates by race/ethnicity and age. Tailoring CIH therapy engagement efforts to be sensitive to gender, race/ethnicity, and age could reduce differential CIH use and thereby help to diminish existing health disparities among veterans.

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 Mar;27(S1):S124-S130.

Introduction

Certain complementary and integrative health (CIH) approaches have increasingly gained attention as evidence-based non-pharmacological options for pain, mental health, and well-being. The Veteran 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-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 non-pharmacologic 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 ten 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 & rehabilitation, primary care, and within integrative/whole health programs, and VA non-MD 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 patient demand.

Conclusions

The provision of CIH approaches were widespread at the VA in 2017-2018, with over half of responding sites offering five or more approaches. As patients seek non-pharmacological 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.

Gaudet T, Kligler B. Whole Health in the Whole System of the Veterans Administration: How Will We Know We Have Reached This Future State? J Altern Complement Med. 2019 Mar;25(S1):S7-S11.

In the Office of Patient Centered Care and Cultural Transformation at the U.S. Veterans Health Administration (VA), we refer to success as the "future state" of the VA. This future state will reflect a radical reorientation from a strictly disease-oriented system to one based in "health creation." In our research and evaluation, this transformation will require us to look beyond endpoints typically measured as reductions of indications of disease to make measurement of well-being a primary outcome for the system. In fact, the declared emphasis for the entire VA system is "well-being and independence throughout [a veteran's] life journey." To reach this goal, we are rallying around a "whole health" strategy, reaching toward practices that address the whole person including family, community, and social determinants of health to achieve this "future state."

Herman PM, Yuan AH, Cefalu MS, Chu K, Zeng Q, Marshall N, Lorenz KA, Taylor SL. The use of complementary and integrative health approaches for chronic musculoskeletal pain in younger US Veterans: An economic evaluation. PLoS One. 2019 Jun 5;14(6):e0217831.

Objectives

To estimate the cost-effectiveness to the US Veterans Health Administration (VA) of the use of complementary and integrative health (CIH) approaches by younger Veterans with chronic musculoskeletal disorder (MSD) pain.

Perspective: VA healthcare system.

Methods: We used a propensity score-adjusted hierarchical linear modeling (HLM), and 2010-2013 VA administrative data to estimate differences in VA healthcare costs, pain intensity (0-10 numerical rating scale), and opioid use between CIH users and nonusers. We identified CIH use in Veterans' medical records through Current Procedural Terminology, VA workload tracking, and provider-type codes.

Results

We identified 30,634 younger Veterans with chronic MSD pain as using CIH and 195,424 with no CIH use. CIH users differed from nonusers across all baseline covariates except the Charlson comorbidity index. They also differed on annual pre-CIH-start healthcare costs ($10,729 versus $5,818), pain (4.33 versus 3.76), and opioid use (66.6% versus 54.0%). The HLM results indicated lower annual healthcare costs (-$637; 95% CI: -$1,023, -$247), lower pain (-0.34; -0.40, -0.27), and slightly higher (less than a percentage point) opioid use (0.8; 0.6, 0.9) for CIH users in the year after CIH start. Sensitivity analyses indicated similar results for three most-used CIH approaches (acupuncture, chiropractic care, and massage), but higher costs for those with eight or more CIH visits.

Conclusions

On average CIH use appears associated with lower healthcare costs and pain and slightly higher opioid use in this population of younger Veterans with chronic musculoskeletal pain. Given the VA's growing interest in the use of CIH, further, more detailed analyses of its impacts are warranted.

Khorsan R, Cohen AB, Lisi AJ, Smith MM, Delevan D, Armstrong C, Mittman BS. Mixed-Methods Research in a Complex Multisite VA Health Services Study: Variations in the Implementation and Characteristics of Chiropractic Services in VA. Evid Based Complement Alternat Med. 2013;2013:701280.

Maximizing the quality and benefits of newly established chiropractic services represents an important policy and practice goal for the US Department of Veterans Affairs' healthcare system. Understanding the implementation process and characteristics of new chiropractic clinics and the determinants and consequences of these processes and characteristics is a critical first step in guiding quality improvement. This paper reports insights and lessons learned regarding the successful application of mixed methods research approaches-insights derived from a study of chiropractic clinic implementation and characteristics, Variations in the Implementation and Characteristics of Chiropractic Services in VA (VICCS). Challenges and solutions are presented in areas ranging from selection and recruitment of sites and participants to the collection and analysis of varied data sources. The VICCS study illustrates the importance of several factors in successful mixed-methods approaches, including (1) the importance of a formal, fully developed logic model to identify and link data sources, variables, and outcomes of interest to the study's analysis plan and its data collection instruments and codebook and (2) ensuring that data collection methods, including mixed-methods, match study aims. Overall, successful application of a mixed-methods approach requires careful planning, frequent trade-offs, and complex coding and analysis.

Kligler B, Bair MJ, Banerjea R, DeBar L, Ezeji-Okoye S, Lisi A, Murphy JL, Sandbrink F, Cherkin DC. Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain. J Gen Intern Med. 2018 May;33(Suppl 1):16-23.

As a large national healthcare system, Veterans Health Administration (VHA) is ideally suited to build on its work to date and develop a safe, evidence-based, and comprehensive approach to the care of chronic musculoskeletal pain conditions that de-emphasizes opioid use and emphasizes non-pharmacological strategies. The VHA Office of Health Services Research and Development (HSR&D) held a state-of-the-art (SOTA) conference titled "Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management" in November 2016. Goals of the conference were (1) to establish consensus on the current state of evidence regarding non-pharmacological approaches to chronic musculoskeletal pain to inform VHA policy in this area and (2) to begin to identify priorities for the future VHA research agenda. Workgroups were established and asked to reach consensus recommendations on clinical and research priorities for the following treatment strategies: psychological/behavioral therapies, exercise/movement therapies, manual therapies, and models for delivering multimodal pain care. Participants in the SOTA identified nine non-pharmacological therapies with sufficient evidence to be implemented across the VHA system as part of pain care. Participants further recommended that effective integration of these non-pharmacological approaches across the VHA and especially into VHA primary care, pain care, and mental health settings should be a priority, and that these treatments should be offered early in the course of pain treatment and delivered in a team-based, multimodal treatment setting concurrently with active self-care and self-management approaches. In addition, we recommend that VHA leadership and policy makers systematically address the barriers to implementation of these approaches by expanding opportunities for clinician and veteran education on the effectiveness of these strategies; supporting and funding further research to determine optimal dosage, duration, sequencing, combination, and frequency of treatment; emphasizing multimodal care with rigorous evaluation grounded in team-based approaches to test integrated models of delivery and stepped-care approaches; and working to address socioeconomic and cultural barriers to veterans' access to non-pharmacological approaches.

Reinhard MJ, Nassif TH, Bloeser K, Dursa EK, Barth SK, Benetato B, Schneiderman A. CAM utilization among OEF/OIF veterans: findings from the National Health Study for a New Generation of US Veterans. Med Care. 2014 Dec;52(12 Suppl 5):S45-9.

Background

Complementary and alternative medicine (CAM) is increasingly seen as an adjunct to traditional plans of care. This study utilized a representative sample of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans and OEF/OIF-era veterans to explore the prevalence and characteristics of CAM users.

Research design

The National Health Study for a New Generation of US Veterans (NewGen) is a longitudinal health study of a population-based cohort of OEF/OIF (deployed) and OEF/OIF-era (nondeployed) veterans. Data from the 2009-2011 NewGen survey (n=20,563) were analyzed to determine prevalence of CAM use by demographic and military characteristics, the types of CAM modalities used, and where the modalities were sought. Results were weighted to th entire population of OEF/OIF and OEF/OIF-era veterans.

Results

There was no statistically significant association between CAM use and deployment. Those who used Department of Veterans Affairs (VA) health care after separation were more likely to be CAM users compared with those who did not use VA care; however, the majority of veterans using CAM are using it outside the VA health care system. Massage was the most prevalent CAM modality followed by chiropractic treatment; males were less likely to use CAM than women.

Conclusions

CAM modalities are being utilized by OEF/OIF veterans for health problems mainly outside the VA. Policymakers should determine appropriate use of these modalities.

Taylor SL, Bolton R, Huynh A, Dvorin K, Elwy AR, Bokhour BG, Whitehead A, Kligler B. What Should Health Care Systems Consider When Implementing Complementary and Integrative Health: Lessons from Veterans Health Administration. J Altern Complement Med. 2019 Mar;25(S1):S52-S60.

Objectives

Health care systems are increasingly interested in becoming whole health systems that include complementary and integrative health (CIH) approaches. The nation's largest health care system, the Veterans Health Administration (VA), has been transforming to such a system. However, anecdotal evidence suggested that many VA medical centers have faced challenges in implementing CIH approaches, whereas others have flourished. We report on a large-scale, research-operations partnered effort to understand the challenges faced by VA sites and the strategies used to address these to better support VAs implementation of CIH nationally.

Design

We conducted semi-structured, in-person qualitative interviews with 149 key stakeholders at 8 VA medical centers, with content based on Greenhalgh's implementation framework. For analysis, we identified a priori categories of content aligned with Greenhalgh's framework and then generated additional categories developed inductively, capturing additional implementation experiences. These categories formed a template to aid in coding data.

Results

VA sites commonly reported that nine key factors facilitated CIH implementation: (1) organizing individual CIH approaches into one program instead of spreading across several departments; (2) having CIH strategic plans and steering committees; (3) strong, professional, and enthusiastic CIH program leads and practitioners; (4) leadership support; (5) providers' positive attitudes toward CIH; (6) perceptions of patients' attitudes; (7) demonstrating evidence of CIH effectiveness; (8) champions; and (9) effectively marketing. Common challenges included are: (1) difficulties in hiring; (2) insufficient/inconsistent CIH funding; (3) appropriate patient access to CIH approaches; (4) difficulties in coding/documenting CIH use; (5) insufficient/inappropriate space; (6) insufficient staff's and provider's time; and (7) the health care cultural and geographic environments. Sites also reported several successful strategies supporting CIH implementation.

Conclusions

VA sites experience both success and challenges with implementing CIH approaches and have developed a wide range of strategies to support their implementation efforts. This information is potentially useful to other health care organizations considering how best to support CIH provision.

Taylor SL, Elwy AR. Complementary and alternative medicine for US veterans and active duty military personnel: promising steps to improve their health. Med Care. 2014 Dec;52(12 Suppl 5):S1-4.

Use and provision of CAM is common. In 2011, almost all (89%) VA medical facilities offered at least 1 of 31 types of CAM,3 whereas 29% of military treatment facilities offered 275 CAM programs in 2012.4 Studies report that per-year CAM usage among veterans or active military personnel ranges from 27% to 82%, which is similar to or slightly higher than that of the general population.5–13 CAM use could be common as some view antidepressants and opiates negatively because of their side effects, addictive nature, or modest efficaciousness. In addition, the evidence base for CAM is growing. Over 200 systematic reviews have been conducted on various CAM modalities' effectiveness on chronic pain, anxiety, posttraumatic stress disorder (PTSD), or depression, common conditions among veterans and military members.14–58 Many concluded that some CAM modalities are moderately effective for these conditions, although studies' methodological limitations often mitigate significant findings.

Taylor SL, Giannitrapani K, Ackland PE, Holliday J, Reddy KP, Drake DF, Federman DG, Kligler B. Challenges and Strategies for Implementing Battlefield Acupuncture in the Veterans Administration: A Qualitative Study of Provider Perspectives. Med Acupunct. 2018 Oct 1;30(5):252-261.

Objective

Battlefield Acupuncture (BFA) is an auricular needling protocol for pain. More than 1300 Veterans Health Administration (VHA) clinicians have been trained in BFA delivery. However, little is known about how well BFA has been implemented at the VHA. The aim of this research was to identify the challenges providers experience in implementing BFA and to look for any successful strategies used to overcome these challenges.

Materials and Methods

 Semistructured telephone interviews were conducted from June 2017 to January 2018, using an interview guide informed by the integrated Promoting Action on Research Implementation in Health Services framework to address several implementation domains: knowledge and attitudes about BFA; professional roles and training in BFA; organization of BFA delivery and resources to provide BFA; and implementation challenges and strategies to address challenges. The interviews were analyzed, using a grounded theory-informed approach. This research was conducted at 20 VHA facilities and involved 23 VHA BFA providers nationwide.

Results

Nine main implementation themes were identified: (1) providers organizing BFA delivery in various ways; (2) insufficient time to provide BFA to meet patient demand; (3) beliefs and knowledge about BFA; (4) lack of BFA indication guidelines or effectiveness data; (5) self-efficacy; (6) time delay between training and practice; (7) limited access to resources; (8) key role of leadership and administrative buy-in, and (9) written consent an unwarranted documentation burden. Providers offered some possible strategies to address these issues.

Conclusions

System- and provider-level challenges can impede BFA implementation. However, several providers discovered strategies to address some challenges that can be used within and outside the VHA, which, in turn, might improve access to this potentially promising pain-management intervention.

Taylor SL, Giannitrapani KF, Yuan A, Marshall N. What Patients and Providers Want to Know About Complementary and Integrative Health Therapies. J Altern Complement Med. 2018 Jan;24(1):85-89. doi: 10.1089/acm.2017.0074. Epub 2017 Jul 27. PMID: 28749702.

Objectives

We conducted a quality improvement project to determine (1) what information providers and patients most wanted to learn about complementary and integrative health (CIH) therapies and (2) in what format they wanted to receive this information. The overall aim was to develop educational materials to facilitate the CIH therapy decision-making processes.

Design

We used mixed methods to iteratively pilot test and revise provider and patient educational materials on yoga and meditation. We conducted semistructured interviews with 11 medical providers and held seven focus groups and used feedback forms with 52 outpatients. We iteratively developed and tested three versions of both provider and patient materials. Activities were conducted at four Veterans Administration medical facilities (two large medical centers and two outpatient clinics).

Results

Patients want educational materials with clearly stated basic information about: (1) what mindfulness and yoga are, (2) what a yoga/meditation class entails and how classes can be modified to suit different abilities, (3) key benefits to health and wellness, and (4) how to find classes at the hospital/clinic. Diverse media (videos, handouts, pocket guides) appealed to different Veterans. Videos should depict patients speaking to patients and demonstrating the CIH therapy. Written materials should be one to three pages with colors, and images and messages targeting a variety of patients. Providers wanted a concise (one-page) sheet in black and white font with no images listing the scientific evidence for CIH therapies from high-impact journals, organized by either type of CIH or health condition to use during patient encounters, and including practical information about how to refer patients.

Conclusions

Providers and patients want to learn more about CIH therapies, but want the information in succinct, targeted formats. The information learned and materials developed in this study can be used by others to educate patients and providers on CIH therapies.

Taylor SL, Herman PM, Marshall NJ, Zeng Q, Yuan A, Chu K, Shao Y, Morioka C, Lorenz KA. Use of Complementary and Integrated Health: A Retrospective Analysis of U.S. Veterans with Chronic Musculoskeletal Pain Nationally. J Altern Complement Med. 2019 Jan;25(1):32-39.

Objective

To partially address the opioid crisis, some complementary and integrative health (CIH) therapies are now recommended for chronic musculoskeletal pain, a common condition presented in primary care. As such, health care systems are increasingly offering CIH therapies, and the Veterans Health Administration (VHA), the nation's largest integrated health care system, has been at the forefront of this movement. However, little is known about the uptake of CIH among patients with chronic musculoskeletal pain. As such, we conducted the first study of the use of a variety of nonherbal CIH therapies among a large patient population having chronic musculoskeletal pain.

Materials and methods

We examined the frequency and predictors of CIH therapy use using administrative data for a large retrospective cohort of younger veterans with chronic musculoskeletal pain using the VHA between 2010 and 2013 (n = 530,216). We conducted a 2-year effort to determine use of nine types of CIH by using both natural language processing data mining methods and administrative and CPT4 codes. We defined chronic musculoskeletal pain as: (1) having 2+ visits with musculoskeletal diagnosis codes likely to represent chronic pain separated by 30-365 days or (2) 2+ visits with musculoskeletal diagnosis codes within 90 days and with 2+ numeric rating scale pain scores ≥4 at 2+ visits within 90 days.

Results

More than a quarter (27%) of younger veterans with chronic musculoskeletal pain used any CIH therapy, 15% used meditation, 7% yoga, 6% acupuncture, 5% chiropractic, 4% guided imagery, 3% biofeedback, 2% t'ai chi, 2% massage, and 0.2% hypnosis. Use of any CIH therapy was more likely among women, single patients, patients with three of the six pain conditions, or patients with any of the six pain comorbid conditions.

Conclusions

Patients appear willing to use CIH approaches, given that 27% used some type. However, low rates of some specific CIH suggest the potential to augment CIH use.

Taylor SL, Hoggatt KJ, Kligler B. Complementary and Integrated Health Approaches: What Do Veterans Use and Want. J Gen Intern Med. 2019 Jul;34(7):1192-1199. doi: 10.1007/s11606-019-04862-6. Epub 2019 Apr 22. PMID: 31011973; PMCID: PMC6614301.

Objectives

Non-pharmacological treatment options for common conditions such as chronic pain, anxiety, and depression are being given increased consideration in healthcare, especially given the recent emphasis to address the opioid crisis. One set of non-pharmacological treatment options are evidence-based complementary and integrative health (CIH) approaches, such as yoga, acupuncture, and meditation. The Veterans Health Administration (VHA), the nation's largest healthcare system, has been at the forefront of implementing CIH approaches, given their patients' high prevalence of pain, anxiety, and depression. We aimed to conduct the first national survey of veterans' interest in and use of CIH approaches.

Methods

Using a large national convenience sample of veterans who regularly use the VHA, we conducted the first national survey of veterans' interest in, frequency of and reasons for use of, and satisfaction with 26 CIH approaches (n = 3346, 37% response rate) in July 2017.

Results: In the past year, 52% used any CIH approach, with 44% using massage therapy, 37% using chiropractic, 34% using mindfulness, 24% using other meditation, and 25% using yoga. For nine CIH approaches, pain and stress reduction/relaxation were the two most frequent reasons veterans gave for using them. Overall, 84% said they were interested in trying/learning more about at least one CIH approach, with about half being interested in six individual CIH approaches (e.g., massage therapy, chiropractic, acupuncture, acupressure, reflexology, and progressive relaxation). Veterans appeared to be much more likely to use each CIH approach outside the VHA vs. within the VHA.

Conclusions

Veterans report relatively high past-year use of CIH approaches and many more report interest in CIH approaches. To address this gap between patients' level of interest in and use of CIH approaches, primary care providers might want to discuss evidence-based CIH options to their patients for relevant health conditions, given most CIH approaches are safe.

Taylor SL, Dusek JA, Elwy AR. Moving Integrative Health Research from Effectiveness to Widespread Dissemination. J Altern Complement Med. 2021 Mar;27(S1):S1-S6. doi: 10.1089/acm.2021.0080. PMID: 33788608.

This philanthropically backed JACM Special Issue on Effectiveness, Implementation and Dissemination Research in Integrative Health highlights how research on many complementary and integrative health (CIH) practices has moved beyond efficacy studies to progress further along the implementation and dissemination pipeline. This pipeline moves from "preimplementation" or effectiveness studies to implementation of evidenced-based integrative health approaches into practice, and eventually to widespread dissemination, which spurs sustainment.

Whitehead AM, Kligler B. Innovations in Care: Complementary and Integrative Health in the Veterans Health Administration Whole Health System. Med Care. 2020 Sep;58 Suppl 2 9S:S78-S79.

Consistent with its long history of innovation, the Veterans Health Administration (VA) has recently committed to a massive expansion of the provision of complementary and integrative health (CIH) approaches as part of standard care, and to an even more massive transformation to a Whole Health System of care. These shifts are being driven by several factors: mounting evidence on the effectiveness of CIH approaches for many conditions; increasing demand from Veterans; increasing need to offer nonpharmacologic pain management strategies to counter the opioid epidemic; and significant support from Congress and the VA's leadership. To-date, Veteran response and health outcomes of this shift are extremely positive.