Whole Health

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.

Auguste EJ, Weiskittle RE, Sohl SJ, Danhauer SC, Doherty K, Naik AD, Moye J. Enhancing Access to Yoga for Older Male Veterans After Cancer: Examining Beliefs About Yoga. Fed Pract. 2021 Oct;38(10):450-458. doi: 10.12788/fp.0180.

BACKGROUND

Yoga is an effective clinical intervention for cancer survivors. Most studies of the positive effects of yoga on cancer patients report on predominantly middle-aged women with breast cancer. Less is known about the use of yoga in older adults, veterans, and those from diverse racial or ethnic backgrounds.

METHODS

We examined strategies to enhance access to yoga in older veterans after cancer, focusing on education (study 1) and intervention (study 2). Study 1 included 110 participants with a median (SD) age of 64.9 (9.4) years who were mostly male (99%) cancer survivors who were interviewed 12 months after their cancer diagnosis. Study 2 included 28 participants with a median (SD) age of 69.2 (10.9) years who were mostly male (96%) cancer survivors who participated in a yoga program within 3 years of their cancer diagnosis. Standardized interviews assessed interest in and barriers to yoga while self-reporting assessed health-related quality of life and beliefs about yoga.

RESULTS

In study 1, interest in yoga increased from 5.5 to 31.8% (χ 2 = 22.25, P < .001) following education. In open-ended questions 4 themes related to negative beliefs or barriers emerged: lack of knowledge or skepticism, disinterest or dislike, physical health barriers, and logistical barriers. In study 2, beliefs were more positive following intervention for expected benefits (t = 4.44, P < .001), discomfort (t = 4.92, P < .001), and social norms (t = 4.38, P < .001) related to yoga. Physical function improved after participation in a yoga class, especially for those with higher beliefs in yoga prior to class. Age was not associated with beliefs about yoga in either sample.

CONCLUSION

A portion of older veterans who are cancer survivors were interested in yoga but faced access barriers. Implications for practice and research include increasing knowledge about yoga benefits and addressing physical health and logistical barriers to enhance access to yoga for older veterans.

Avery TJ, Schulz-Heik RJ, Friedman M, Mahoney L, Ahmed N, Bayley PJ. Clinical yoga program utilization in a large health care system. Psychol Serv. 2021 Aug;18(3):389-397. doi: 10.1037/ser0000420.

ABSTRACT

The U.S. Department of Veterans Affairs (VA) offers yoga for multiple conditions. Little information is available regarding how frequently yoga is utilized, by whom, or for which medical conditions. Here we describe referral patterns and patient adoption rates in a clinical yoga program, including telehealth yoga, at VA Palo Alto Health Care System (VAPAHCS). Referral and demographic data were extracted from the electronic medical records of 953 veterans (692 male, 261 female) referred to the outpatient clinical yoga program between 2010 and 2016. Attendance data were extracted from the same time plus 1 year. Referee demographics were compared to the overall VAPAHCS population. Twenty-two of the 187 referring providers accounted for half (50.4%) of referrals, predominantly from primary care and mental health clinics. Compared to the overall VAPAHCS patient population, referees were similar age and more likely to be female. Attendance was associated with age (older veterans were more likely to attend) but not gender. Those referred for mental health reasons were more likely to attend yoga compared to those referred for physical symptoms or for wellness (e.g., strength, health, mindfulness). Telehealth yoga follow through was lower but attendance rate similar to in-person yoga. These data provide an overview of referral and uptake in a large VA setting. Overall, referral was performed by a few providers in mental health and primary care clinics. The typical demographic of attendee was a White male from the Vietnam War era, reflective of the VA population.

Barnhill JL, Roth IJ, Faurot KR, Honvoh GD, Lynch CE, Thompson KL, Gaylord SA. Cultural Transformation in Healthcare: How Well Does the Veterans Health Administration Vision for Whole Person Care Fit the Needs of Patients at an Academic Rehabilitation Center? Glob Adv Health Med. 2022 Mar 17;11:2164957X221082994.

BACKGROUND

The Veterans Health Administration is undergoing a cultural transformation toward person-driven care referred to as the Whole Health System of Care.

OBJECTIVE

This pilot study evaluated whether the Whole Health model resonates with patients of a large public university rehabilitation clinic.

METHODS

Thirty participants completed the Veterans Health Administration's Personal Health Inventory (PHI), and six attended the course "Taking Charge of My Life and Health." Researchers analyzed PHI responses and post-course focus group transcripts. A short post-PHI survey and post-course evaluation were collected.

RESULTS

Participants agreed the PHI is a simple, useful tool. The course, while well attended, did not meet participants' expectations. Participants wanted access to integrative therapies and opportunities to contribute to healthcare transformation.

CONCLUSION

Rehabilitation patients resonated with the Whole Health vision. They expressed enthusiasm for the cultural transformation represented by the model along with frustration that standard healthcare experiences fall short of this vision.

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.

Burdick R, Corcoran KL, Zhao X, Lisi A. The rate of use of Veterans Affairs chiropractic care: a 5-year analysis. Chiropr Man Therap. 2022 Jan 21;30(1):4. doi: 10.1186/s12998-022-00413-9. PMID: 35062971; PMCID: PMC8781440.

BACKGROUND

The US Department of Veterans Affairs (VA) has initiated various approaches to provide chiropractic care to Veterans. Prior work has shown substantial increase in use of VA chiropractic care between fiscal years (FY) 2005-2016. However, the extent of the availability of these services to the Veteran population remains unclear. The purpose of this study was to analyze the rate of Veteran use of VA chiropractic services, both from on-site care at VA facilities and VA purchased care from community care providers. This study analyzed facility characteristics associated with chiropractic use by both care delivery mechanisms (on-site and in the community).

METHODS

Cross-sectional analyses of administrative data were conducted for FY 2014-2019. Data were obtained from VA's Corporate Data Warehouse. The variables extracted included number of unique Veterans receiving VA chiropractic care on-site and in the community, total Veteran population of the VA facilities, size of the VA chiropractic workforce (measured as Full-Time Equivalent, FTE), and facility characteristics (geographic region and the facility complexity). Descriptive statistics, mixed model, and multivariant models were used to analyze data.

RESULTS

Use of VA chiropractic care increased over the six-year period for both on-site and community care. National average for on-site use of the population was 1.27% in FY14 and 1.48% in FY19. Community care use was 0.29% and 1.76% for the same years. Use at individual facilities varied widely in each FY. Factors such as chiropractor FTE, geographic locations, and the complexity of the VA facility are associated with use of chiropractic services.

CONCLUSION

The VA has expanded the non-pharmacologic treatments available to Veterans by providing chiropractic services, yet chiropractic use remains low compared to other US populations. As Veterans have a high prevalence of pain and musculoskeletal conditions, continued work to assess and achieve the optimal levels of chiropractic use in this population is warranted.

Der-Martirosian C, Shin M, Upham ML, Douglas JH, Zeliadt SB, Taylor SL. Telehealth Complementary and Integrative Health Therapies During COVID-19 at the U.S. Department of Veterans Affairs. Telemed J E Health. 2022 Jul 22. doi: 10.1089/tmj.2022.0209. Epub ahead of print. PMID: 35867052.

BACKGROUND

Complementary and integrative health (CIH) therapies, such as in-person acupuncture, chiropractic care, and meditation, are evidence-based nonpharmaceutical treatment options for pain. During COVID-19, the Veterans Health Administration (VA) delivered several CIH therapies virtually. This study explores veterans' utilization, advantages/disadvantages, and delivery issues of yoga, Tai Chi, meditation/mindfulness (self-care), and massage, chiropractic, and acupuncture (practitioner-delivered care), using telephone/video at 18 VA sites during COVID-19.

METHODS

Use of virtual care was examined quantitatively with VA administrative data for six CIH therapies before and after COVID-19 onset (2019-2021). Advantages/disadvantages and health care delivery issues of these CIH therapies through virtual care were examined qualitatively using interview data (2020-2021).

RESULTS

Overall, televisits represented a substantial portion of all CIH self-care therapies delivered by VA in 2020 (53.7%) and 2021 (82.1%), as sites developed virtual group classes using VA secure online video platforms in response to COVID-19. In contrast, a small proportion of all encounters with acupuncturists, chiropractors, and massage therapists was telephone/video encounters in 2020 (17.3%) and in 2021 (5.4%). These were predominantly one-on-one care in the form of education, follow-ups, home exercises, assessments/evaluations, or acupressure. Delivery issues included technical difficulties, lack of access to needed technology, difficulty tracking virtual visits, and capacity restrictions. Advantages included increased access to self-care, increased patient receptivity to engaging in self-care, and flexibility in staffing online group classes. Disadvantages included patient preference, patient safety, and strain on staffing.

CONCLUSION

Despite delivery issues or disadvantages of tele-CIH self-care, veterans' use of teleself-care CIH therapies grew substantially during the COVID-19 pandemic.

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."

Graham SE, Coleman BC, Zhao X, Lisi AJ. Evaluating rates of chiropractic use and utilization by patient sex within the United States Veterans Health Administration: a serial cross-sectional analysis. Chiropr Man Therap. 2023 Aug 10;31(1):29.

BACKGROUND

Within the United States Veterans Health Administration (VHA), the number of patients using healthcare services has increased over the past several decades. Females make up a small proportion of overall patients within the VHA; however, this proportion is growing rapidly. Previous studies have described rates of VHA chiropractic use; however, no prior study assessed differences in use or utilization rates between male and female veterans. The purpose of this study was to assess rates of use and utilization of chiropractic care by sex among VHA patients receiving care at VHA facilities with on-station chiropractic clinics.

METHODS

A serial cross-sectional analysis of VHA national electronic health record data was conducted in Fall 2021 for fiscal year (FY) 2005-2021. The cohort population was defined as VHA facilities with on-station chiropractic clinics, and facilities were admitted to the cohort after the first FY with a minimum of 500 on-station chiropractic visits. Variables extracted included counts of unique users of any VHA on-station facility outpatient services, unique users of VHA on-station facility chiropractic services, number of chiropractic visits, and sex. To calculate use, we determined the proportion of patients of each sex who received chiropractic services to the total patients of the same sex receiving any outpatient care within each facility. To calculate utilization, we determined the number of chiropractic care visits per patient per fiscal year. A linear mixed effects model was applied to examine the difference in chiropractic care utilization by sex.

RESULTS

The percentage of female VHA on-station chiropractic patients increased from 11.7 to 17.7% from FY2005-FY2021. Among VHA facilities with on-station chiropractic care, the percentage of female VHA healthcare users who used chiropractic care (mean = 2.3%) was greater than the percentage of male VHA healthcare users who used chiropractic care (mean = 1.1%). Rates of chiropractic utilization by sex among VHA facilities with on-station chiropractic clinics were slightly higher for females (median = 4.3 visits per year, mean = 4.9) compared to males (median = 4.1 visits per year, mean = 4.6).Conclusion: We report higher use and utilization of VHA chiropractic care by females compared with males, yet for both sexes rates were lower than in the private US healthcare system. This highlights the need for further assessment of the determinants and outcomes of VHA chiropractic care.

Han L, Luther SL, Finch DK, Dobscha SK, Skanderson M, Bathulapalli H, Fodeh SJ, Hahm B, Bouayad L, Lee A, Goulet JL, Brandt CA, Kerns RD. Complementary and Integrative Health Approaches and Pain Care Quality in the Veterans Health Administration Primary Care Setting: A Quasi-Experimental Analysis. J Integr Complement Med. 2023 Jun-Jul;29(6-7):420-429.

BACKGROUND

Complementary and integrative health (CIH) approaches have been recommended in national and international clinical guidelines for chronic pain management. We set out to determine whether exposure to CIH approaches is associated with pain care quality (PCQ) in the Veterans Health Administration (VHA) primary care setting.

METHODS

We followed a cohort of 62,721 Veterans with newly diagnosed musculoskeletal disorders between October 2016 and September 2017 over 1-year. PCQ scores were derived from primary care progress notes using natural language processing. CIH exposure was defined as documentation of acupuncture, chiropractic or massage therapies by providers. Propensity scores (PSs) were used to match one control for each Veteran with CIH exposure. Generalized estimating equations were used to examine associations between CIH exposure and PCQ scores, accounting for potential selection and confounding bias.

RESULTS

CIH was documented for 14,114 (22.5%) Veterans over 16,015 primary care clinic visits during the follow-up period. The CIH exposure group and the 1:1 PS-matched control group achieved superior balance on all measured baseline covariates, with standardized differences ranging from 0.000 to 0.045. CIH exposure was associated with an adjusted rate ratio (aRR) of 1.147 (95% confidence interval [CI]: 1.142, 1.151) on PCQ total score (mean: 8.36). Sensitivity analyses using an alternative PCQ scoring algorithm (aRR: 1.155; 95% CI: 1.150-1.160) and redefining CIH exposure by chiropractic alone (aRR: 1.118; 95% CI: 1.110-1.126) derived consistent results.

DISCUSSION

Our data suggest that incorporating CIH approaches may reflect higher overall quality of care for patients with musculoskeletal pain seen in primary care settings, supporting VHA initiatives and the Declaration of Astana to build comprehensive, sustainable primary care capacity for pain management. Future investigation is warranted to better understand whether and to what degree the observed association may reflect the therapeutic benefits patients actually received or other factors such as empowering provider-patient education and communication about these approaches.

Haun JN, Alman AC, Jean-Baptiste E, Melillo C, McMahon-Grenz J, Paykel JM. Delivery of Complementary and Integrative Health Using Virtual Health Resources: A Scoping Review. J Integr Complement Med. 2022 Jul 11. doi: 10.1089/jicm.2021.0458.

INTRODUCTION

Complementary and integrative health (CIH) modalities promote overall health and well-being and can be beneficial for individuals with a range of conditions. Traditionally, CIH has been delivered in person. COVID-19 created a need to identify sustainable remote delivery options to assure access to CIH while practicing public health recommendations. This scoping review maps the opportunities and challenges to remotely delivered CIH.

MATERIALS AND METHODS

A scoping review was conducted between June 2020 and October 2020 using the following search engines: PubMed, Academic Search Premier, PsycINFO, CINAHL, Cochrane Reviews, and the Cochrane Clinical Trial Collections. Search results investigating remote CIH delivery were restricted to articles written in English, published after 1990.

RESULTS

Of the 10,884 articles identified, after review for content and methods, 330 articles were included. Most articles were randomized controlled trials (n = 170), applied mindfulness (n = 203), and targeted mental and behavioral health conditions (n = 182). Interventions were primarily delivered through mobile applications (n = 151) and web-based platforms (n = 86). Most commonly reported barriers were adherence (n = 24), resource requirements (e.g., time and space) (n = 23), and technology-related issues (n = 21). Although most studies did not report facilitators (n = 217), most commonly reported facilitators were social and technologic supports, accessibility, usability, perceptions, and rewards. Participant outcomes measured were broad and included movement (n = 88), stress (n = 68), and pain (n = 54). Intervention characteristic outcomes most often measured were satisfaction and usability (n = 5).

CONCLUSIONS

This scoping literature review identified many articles addressing remote delivery of CIH, but few reporting on the implementation of remotely delivered CIH. Findings suggest remotely delivered CIH, specifically mindfulness and meditation-based modalities, is a viable treatment option for a diverse range of health conditions. Feasibility studies and larger sample sizes are recommended to strengthen the scientific evidence.

Haun, J. N., Melillo, C., Cotner, B. A., McMahon-Grenz, J., & Paykel, J. M. (2021). Evaluating a Whole Health Approach to Enhance Veteran Care: Exploring the Staff Experience. Journal of Veterans Studies, 7(1), 163–173.

The Whole Health Initiative is a redesign of health care delivery that focuses on administering personalized veteran health plans rather than focusing on treating disease. In 2018, Whole Health launched at 36 Veteran Affairs (VA) facilities throughout the country. Flagship sites (N = 18) implemented the full Whole health system and design sites (N = 18) implemented elements of Whole Health. The project purpose was to identify efforts to improve implementation for this national initiative to improve veterans’ lives. This evaluation project used a cross-sectional design to obtain qualitative semi-structured interview data. Rapid analysis using Consolidated Framework for Implementation Research Constructs (CFIR) was used to identify themes. A snowball sample of 45 staff participants from five design sites and one flagship site participated. Participants represented management and providers among other Whole Health staff. Facilities varied in the degree to which Whole Health was implemented. The provision of leadership support and resources, the need to address national policies and procedures and the need for standardized measures used to measure Whole Health outcomes were common experiences. Implementation of Whole Health to improve veterans’ lives is a complex endeavor. Providers, clinicians, and leadership are engaged and motivated to implement this new delivery model at their facilities, understanding it changes the focus of their relationships with veterans from one of focusing on problems to one of collaboratively working with veterans to achieve individual health goals. Identified barriers limit implementation and expose issues such as lack of facility resources, hiring and training mechanisms, and leadership endorsement. Whole Health is a priority within the VA and the motivation and readiness of VA staff to move into a more collaborative relationship with the veterans they serve are foundational to success and longevity of the program. Our findings created an opportunity to promote sustainable outcomes for future Whole Health implementation efforts.

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.

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 Jul 31;49:101644.

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.

Khanna A, Dryden EM, Bolton RE, Wu J, Taylor SL, Clayman ML, Anwar C, Kasom D, McGowan M, Mullur RS, Bokhour BG, Hyde J. Promoting Whole Health and Well-Being at Home: Veteran and Provider Perspectives on the Impact of Tele-Whole Health Services. Glob Adv Health Med. 2022 Nov 25;11:2164957X221142608. doi: 10.1177/2164957X221142608. PMID: 36452292; PMCID: PMC9703484.

BACKGROUND

The Veterans Health Administration (VA) is undergoing a transformation in how healthcare is organized and provided. This transformation to a Whole Health System of Care encompasses the integration of complementary and integrative health services, education, and Whole Health coaching to develop Veterans' self-care skills. During the COVID-19 pandemic, these services were provided via telehealth (tele-WH).

OBJECTIVE

We sought to understand Veteran and provider perspectives on how tele-WH impacts Veteran engagement in Whole Health-aligned services and the impact on their well-being.

METHODS

Semi-structured interviews were conducted with 51 providers who delivered tele-WH at 10 VA Medical Centers (VAMCs) and 19 Veterans receiving tele-WH at 6 VAMCs. Participants were asked about their experiences with tele-WH, what they perceived to be the impact of tele-WH on Veterans, and their preferences moving forward. Interviews were transcribed, and a content analysis was performed using a rapid approach.

RESULTS

We identified 3 major themes that describe the perceived impact of tele-WH on Veterans. These include: (1) increased use of Whole Health-aligned services; (2) deeper engagement with Whole-Health aligned services; and (3) improvements in social, psychological, and physical well-being.

CONCLUSION

Tele-WH is perceived to be a strong complement to in-person services and is a promising mechanism for improving engagement with Whole Health-aligned services and promoting Veteran well-being. Future research is needed to measure outcomes identified in this study and to support more equitable access to telehealth for all.

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.

Kroll-Desrosiers A, Wallace KF, Higgins DM, Martino S, Mattocks KM. Musculoskeletal Pain During Pregnancy Among Veterans: Associations With Health and Health Care Utilization. Womens Health Issues. 2023 Aug 12:S1049-3867(23)00132-9.

INTRODUCTION

Musculoskeletal (MSK) pain is more likely to be diagnosed in veterans compared with the general population; however, MSK pain during pregnancy has not been studied in veterans. This study examined health and health care use differences between pregnant veterans with and without MSK pain (MSK-).

METHODS

Veterans who delivered a newborn before June 1, 2021, were identified from an existing cohort (n = 1,181). Survey and Veterans Health Administration (VA) electronic health record data were obtained on participants. Veterans meeting inclusion criteria were identified as those with MSK pain (MSK+) and were compared with MSK- participants. We examined differences between primary outcomes of VA health care engagement (including mental health diagnoses, health care visits, receipt of prescription opioids, and complementary and integrative health use) and secondary outcomes (including postpartum variables) between MSK pain groups. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were calculated.

RESULTS

There were 172 veterans (14.6%) who met MSK pain eligibility criteria. In adjusted models, MSK+ veterans were more likely to be diagnosed with major depressive disorder (aOR, 1.76; 95% CI, 1.22-2.53) and post-traumatic stress disorder (aOR, 1.79; 95% CI, 1.21-2.64) during pregnancy compared with MSK- veterans. The use of VA mental health care (aOR, 1.52; 95% CI, 1.09-2.12) and the odds of receiving an opioid prescription during pregnancy (aOR, 2.76; 95% CI, 1.53-5.00) was higher in MSK+ veterans compared with MSK- veterans. Only a small proportion (3.6%) of our entire cohort used complementary and integrative health approaches during pregnancy. MSK+ veterans were more likely to deliver by cesarean section compared with MSK- veterans (36% vs. 26%).

CONCLUSIONS

MSK+ veterans were more likely to be diagnosed with mental health conditions and to use VA mental health care during pregnancy compared with MSK- veterans. Because veterans receive their obstetrical care in the community, understanding the unique needs of pregnant MSK+ veterans in comparison with MSK- veterans is important to provide comprehensive care during the perinatal period.

Kuruvilla DE, Lindsey H, Grinberg AS, Goldman RE, Riley S, Baird S, Fenton BT, Sico JJ, Damush TM. Complementary and integrative medicine perspectives among veteran patients and VHA healthcare providers for the treatment of headache disorders: a qualitative study. BMC Complement Med Ther. 2022 Jan 25;22(1):22.

OBJECTIVE

To evaluate veteran patient and provider perceptions and preferences on complementary and integrative medicine (CIM) for headache management.

BACKGROUND

The Veterans Health Administration (VHA) has spearheaded a Whole Health system of care focusing on CIM-based care for veteran patients. Less is known about patients' and providers' CIM perceptions and preferences for chronic headache management.

METHODS

We conducted semi-structured interviews with 20 veteran patients diagnosed with headache and 43 clinical providers, across 12 VHA Headache Centers of Excellence (HCoE), from January 2019 to March 2020. We conducted thematic and case comparative analyses.

RESULTS

Veteran patients and VHA clinical providers viewed CIM favorably for the treatment of chronic headache. Specific barriers to CIM approaches included: (1) A lack of personnel specialized in specific CIM approaches for timely access, and (2) variation in patient perceptions and responses to CIM treatment efficacy for headache management.

CONCLUSION

Veteran patients and VHA clinical providers in this study viewed CIM favorably as a safe addition to mainstream headache treatments. Advantages to CIM include favorable adverse effect profiles and patient autonomy over the treatment. By adding more CIM providers and resources throughout the VHA, CIM modalities may be recommended more routinely in the management of veterans with headache.

Mannes ZL, Stohl M, Fink DS, Olfson M, Keyes KM, Martins SS, Gradus JL, Saxon AJ, Maynard C, Livne O, Gutkind S, Hasin DS. 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 Nov;37(15):3937-3946.

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.

Niemtzow RC. Implementing Battlefield Acupuncture Through a Large Medical System: Overcoming Barriers. Med Acupunct. 2020 Dec 1;32(6):377-380. doi: 10.1089/acu.2020.1470.

ABSTRACT

Developing a new and innovative acupuncture technique to deal with acute and chronic pain is a considerable undertaking in itself as many barriers must be overcome. Designing the technique and gaining acceptance is even more daunting and challenging across a large system of medical facilities such as the Department of Defense and the Veterans Administration. Such was the case of Battlefield Acupuncture (BFA), a 5-needle placement in each external ear into specific auricular points to treat acute and chronic pain. Discussion: This technique geared for military deployment is rapid, safe, and easily reproducible without side effects because it uses a choice acupuncture microsystem, namely the ear. Acquiring acupuncture practical skills is the prerequisite before designing the technique and then taking into consideration, neurophysiology data, and actual clinical experience to finally focus development is demanding. Conclusions: The benefits of BFA that was promulgated in a Joint Incentive Fund for $5.4 million resulted in thousands of trained health care providers and eventually many clinical trials to help validate the technique. Process improvement data were beneficial and important for its sustainment. There are 5 steps recommended for overcoming the barriers.

Olson J, Kligler B. Society for Acupuncture Research Turning Point: Acupuncture in the Veterans Health Administration. J Altern Complement Med. 2021 Jul;27(7):527-530. doi: 10.1089/acm.2021.0194. PMID: 34255536.

As the U.S. health care system struggles to deliver patient-centered quality care, the VHA is focused on implementing a model of care that changes the conversation from “what is the matter with you” to “what matters to you.” The Whole Health (WH) System is designed to orient care delivery around a Veteran's health goals utilizing complementary and integrative health (CIH) approaches in addition to standard biomedical care. The VHA was the first major health care system to offer acupuncture access as part of standard medical benefits. Over the past 5 years of implementation and re-evaluation, a number of lessons have been learned that may be of benefit for other private and government health care systems in the coming years.

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.

RESEEARCH 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.

Reed DE 2nd, Bokhour BG, Gaj L, Barker AM, Douglas JH, DeFaccio R, Williams RM, Engel CC, Zeliadt SB. Whole Health Use and Interest Across Veterans With Co-Occurring Chronic Pain and PTSD: An Examination of the 18 VA Medical Center Flagship Sites. Glob Adv Health Med. 2022 Feb 11;11:21649561211065374.

OBJECTIVE

Veterans Healthcare Administration (VHA) conducted a large demonstration project of a holistic Whole Health approach to care in 18 medical centers, which included making complementary and integrative health (CIH) therapies more widely available. This evaluation examines patterns of service use among Veterans with chronic pain, comparing those with and without PTSD.

METHODS

We assessed the use of Whole Health services in a cohort of Veterans with co-occurring chronic pain and PTSD (n = 1698; 28.9%), comparing them to Veterans with chronic musculoskeletal pain only (n = 4170; 71.1%). Data was gathered from VA electronic medical records and survey self-report. Whole Health services were divided into Core Whole Health services (e.g., Whole Health coaching) and CIH services (e.g., yoga). Logistic regression was used to determine whether Veterans with co-occurring chronic pain and PTSD utilized more Whole Health services compared to Veterans with chronic pain but without PTSD.

RESULTS

A total of 40.1% of Veterans with chronic pain and PTSD utilized Core Whole Health services and 53.2% utilized CIH therapies, compared to 28.3% and 40.0%, respectively, for Veterans with only chronic pain. Adjusting for demographics and additional comorbidities, Veterans with comorbid chronic pain and PTSD were 1.24 (95% CI: 1.12, 1.35, P ≤ .001) times more likely than Veterans with chronic pain only to use Core Whole Health services, and 1.23 (95% CI: 1.14, 1.31, P ≤ .001) times more likely to use CIH therapies. Survey results also showed high interest levels in Core Whole Health services and CIH therapies among Veterans who were not already using these services.

CONCLUSION

Early implementation efforts in VHA led to high rates of use of Core Whole Health and CIH therapy use among Veterans with co-occurring chronic pain and PTSD. Future assessments should examine how well these additional services are meeting the needs of Veterans in both groups.

Resnick A, Zeliadt SB, Ganz DA, Moucheraud C, Chuang E, Yano EM, Taylor SL. Changes in Use of Complementary and Integrative Health Therapies at the Veterans Affairs: Findings from a Whole Health System Pilot Program. J Integr Complement Med. 2023 Mar 16.

INTRODUCTION

The Department of Veterans Affairs (VA) launched a Whole Health System pilot program in 18 VA "Flagship" medical centers in 2018 in part to expand the provision of complementary and integrative health (CIH) therapies. Materials and methods: A longitudinal quasi-experimental design was used to examine Veterans' use of at least 1 of 12 CIH therapies 2 years after initiation of the Flagship pilot program compared with the year before the program started. The sample included Veterans with chronic musculoskeletal pain with at least one visit to a VA primary care, mental health care, or pain clinic in each of the 3 study years. A population-average logit model was used to measure changes in the percentage of Veterans using at least one the CIH therapies over time.

RESULTS

Among Veterans with chronic musculoskeletal pain receiving health care at Flagship sites, 9.7% used a CIH therapy before the Flagship program initiation, whereas 14.2% used a therapy in the second year of the program (46.0% increase). In comparison, CIH therapy use among Veterans at non-Flagship sites increased from 10.3% to 12.0% over the same period (16.5% increase). Results from the population-average logit model show that Veterans at Flagship sites were significantly more likely to be CIH therapy users in the first (p < 0.001) and second (p < 0.001) years of the implementation compared with non-Flagship sites.

DISCUSSION

The Flagship pilot program was successful in terms of increasing the use of CIH therapies among Veterans with chronic musculoskeletal pain compared with non-Flagship sites.

CONCLUSIONS

The Whole Health System implementation that included financial incentives, education, and other support to 18 VA "Flagship" medical centers helped to increase the use of CIH therapies in the VA. Future research should examine which of these efforts were most effective in expanding CIH therapy provision.

Sawyer LM, Brown LM, Lensing SY, McFadden D, Bopp MM, Ferrier I, Sullivan DH. Rapid conversion of Tai Chi classes from face-to-face to virtual during the COVID-19 pandemic: A quality improvement project. Nurs Forum. 2022 Jan 10. doi: 10.1111/nuf.12690. Epub ahead of print. PMID: 35005787.

PURPOSE

The purpose of this quality improvement project was to examine the feasibility of rapidly converting a Tai Chi program for older Veterans from face-to-face to virtual classes.

METHODS

Eighteen Veterans attending our face-to-face Tai Chi course were invited to transition to virtual classes. Feasibility was defined as the ability of program staff and participants to successfully connect and complete the initial and subsequent classes by VA Video Connect (VVC) with little to no technical difficulties, participant ability to participate in the course without safety concerns, and favorable feedback from participants and program staff.

RESULTS

Nine of 18 Veterans agreed to transition to the virtual program and attended a median (interquartile range) of 11 (4-15) classes; they were younger (62.7 + 11.5 vs. 70.5 + 7.0 years, p < .05) and more likely to have the knowledge and equipment needed to participate (78% vs. 0%, p < .01) than nonparticipants. Tai Chi instructors and participating Veterans reported being able to connect to and complete the classes virtually with only minimal technical problems. No adverse events were reported. Feedback from the instructors and Veterans was positive and included comments on ease of use and enjoyability.

CONCLUSION

Results suggest that virtual Tai Chi classes via VVC are feasible for some older Veterans.

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, 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.

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, Gelman HM, DeFaccio R, Douglas J, Hawrilenko MJ, McGinty NK, Resnick A, Tomlanovich NC, Toyama J, Whitehead AM, Kligler B, Zeliadt SB. We Built it, But Did They Come: Veterans' Use of VA Healthcare System-Provided Complementary and Integrative Health Approaches. J Gen Intern Med. 2022 Nov 30:1–8. doi: 10.1007/s11606-022-07889-4.

BACKGROUND

Interest in complementary and integrative health (CIH) approaches, such as meditation, yoga, and acupuncture, continues to grow. The evidence of effectiveness for some CIH approaches has increased in the last decade, especially for pain, with many being recommended in varying degrees in national guidelines. To offer nonpharmacological health management options and meet patient demand, the nation's largest integrated healthcare system, the Veterans Health Administration (VA), greatly expanded their provision of CIH approaches recently.

OBJECTIVE

This paper addressed the questions of how many VA patients might use CIH approaches and chiropractic care if they were available at modest to no fee, and would patients with some health conditions or characteristics be more likely than others to use these therapies.

DESIGN

Using electronic medical records, we conducted a national, three-year, retrospective analysis of VA patients' use of eleven VA-covered therapies: chiropractic care, acupuncture, Battlefield Acupuncture, biofeedback, clinical hypnosis, guided imagery, massage therapy, meditation, Tai Chi/Qigong, and yoga.

Participants: We created a national cohort of veterans using VA healthcare from October 2016-September 2019.

Key results

Veterans' use of these approaches increased 70% in three years. By 2019, use was 5.7% among all VA patients, but highest among patients with chronic musculoskeletal pain (13.9%), post-traumatic stress disorder (PTSD; 10.6%), depression (10.4%), anxiety (10.2%), or obesity (7.8%). The approach used varied by age and race/ethnicity, with women being uniformly more likely than men to use each approach. Patients having chronic musculoskeletal pain, obesity, anxiety, depression, or PTSD were more likely than others to use each of the approaches.

CONCLUSIONS

Veterans' use of some approaches rapidly grew recently and was robust, especially among patients most in need. This information might help shape federal/state health policy on the provision of evidence-based CIH approaches and guide other healthcare institutions considering providing them.

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.

Tobin J, Zeliadt SB, Upchurch DM, DeFaccio R, Douglas J, Gelman HM, Hawrilenko M, Frochen S, McGinty N, Resnick A, Tomlanovich N, Toyama J, Whitehead AM, Kligler B, Taylor SL. Racial and Ethnic Variation in Complementary and Integrative Health Therapy Use Among US Veterans. JAMA Netw Open. 2023 Jun 1;6(6):e2318020.

IMPORTANCE

White individuals are the greatest users of complementary and integrative health (CIH) therapies in the general population, but this might partially be due to differences in age, health condition, and location. Identifying the nuances in racial and ethnic differences in care is one important step to addressing them.

OBJECTIVE

To evaluate racial and ethnic differences in Veterans Affairs (VA)-covered CIH therapy use in a more nuanced manner by examining the association of 5 demographic characteristics, health conditions, and medical facility locations with those differences.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cross-sectional observational study of VA health care system users, using electronic health record and administrative data at all VA medical facilities and community-based clinics. Participants included veterans with nonmissing race and ethnicity data using VA-funded health care between October 2018 and September 2019. Data were analyzed from June 2022 to April 2023.Main outcome and measure: Any use of VA-covered acupuncture, chiropractic care, massage therapy, yoga, or meditation/mindfulness.

RESULTS

The sample consisted of 5 260 807 veterans with a mean (SD) age of 62.3 (16.4) years and was 91% male (4 788 267 veterans), 67% non-Hispanic White (3 547 140 veterans), 6% Hispanic (328 396 veterans), and 17% Black (903 699 veterans). Chiropractic care was the most used CIH therapy among non-Hispanic White veterans, Hispanic veterans, and veterans of other races and ethnicities, while acupuncture was the most commonly used therapy among Black veterans. When not accounting for the location of the VA medical facilities in which veterans used health care, Black veterans appeared more likely to use yoga and meditation than non-Hispanic White veterans and far less likely to use chiropractic care, while those of Hispanic or other race and ethnicity appeared more likely to use massage than non-Hispanic White veterans. However, those differences mostly disappeared once controlling for medical facility location, with few exceptions-after adjustment Black veterans were less likely than non-Hispanic White veterans to use yoga and more likely to use chiropractic care.

CONCUSIONS AND RELEVANCE

This large-scale, cross-sectional study found racial and ethnic differences in use of 4 of 5 CIH therapies among VA health care system users when not considering their medical facility location. Given those differences mostly disappeared once medical facilities were accounted for, the results demonstrated the importance of considering facilities and residential locations when examining racial differences in CIH therapy use. Medical facilities could be a proxy for the racial and ethnic composition of their patients, CIH therapy availability, regional patient or clinician attitudes, or therapy availability.

Wallen ES, Sippel JL, Park ME, Etingen B, Weaver FM, Hogan TP, Smith BM, Bokhour BG, Wickremasinghe IM. Utilization of whole health services among veterans with spinal cord injuries and disorders (SCI/D): Early insights from the VA SCI/D system of care. J Spinal Cord Med. 2023 May 30:1-10.

CONTEXT/OBJECTIVE

Our objective was to describe early participation in Whole Health programs across the Veterans Health Administration (VHA) Spinal Cord Injuries and Disorders (SCI/D) System of Care.

DESIGN

Retrospective analysis of VHA administrative data.Setting: The VHA SCI/D System of Care.

PARTICIPANTS

Veterans with SCI/D included in the FY2019 cumulative VHA SCI/D Registry cohort with living status during FY2017, FY2018, and FY2019.

INTERVENTIONS

N/A.Outcome measures: We assessed the number of encounters and unique Veterans with SCI/D, and the percent of Veterans with SCI/D, who utilized each Whole Health (WH) program available in VA.

RESULTS

Utilization of WH Pathway and well-being Programs increased from 62 encounters to 1703 encounters between FY2017 and FY2019 (representing 0.09% to 3.13% of Veterans with SCI/D). Utilization of chiropractic care rose from 130 encounters to 418 encounters during the same time period. Similarly, utilization of complementary and integrative health programs increased from 886 encounters to 2655 encounters (representing 1.09% to 3.11% of Veterans; FY2017 to 2019). We also report utilization of specific WH programs.Conclusion: Participation in WH services has been increasing among Veterans with SCI/D who receive health care from the VHA SCI/D System of Care. However, utilization among Veterans with SCI/D remains low overall, and targeted efforts to increase WH program reach are needed. Additional information about the relative effectiveness of different strategies to support WH implementation is also needed, to ensure strategies likely to have the most impact are prioritized.

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.