The Veterans Health Administration (VA) has expanded research and education on complementary and integrative health (CIH) programs, focusing on pain, mental health, and chronic illness. CIH programs are a part of “Whole Health,” an approach to support veterans’ health and well-being. A recent Medical Care supplement contains several articles on the effectiveness and implementation of CIH programs at the VA. As described in an accompanying editorial, the implementation roadmap for incorporating CIH into the VA system is broken down into three phases: pre-implementation, implementation, and sustainment.
Pre-implementation phase
In one article, Purcell and colleagues describe the Whole Health model’s first large pragmatic randomized controlled trial. Their formative evaluation focus on Whole Health’s potential impact on chronic pain care. They describe the different modifications needed at varying clinical care sites after describing their robust data collection from veterans, clinicians, leaders, and administrators. Their emphasis on locally tailored implementation can provide lessons for other clinical systems.
Another paper, by Giannitrapani and colleagues, uses an inductive qualitative approach to explore provider perceptions of battlefield acupuncture. They find that battlefield acupuncture may have many benefits for patients and is easy to deliver. They do note, however, that additional effectiveness research would be helpful.
Implementation phase
Twenty-two veterans participated in an 8-week long mindfulness-based care intervention for chronic pain. Eaton and colleagues reported that recruitment and retention were difficult. They also discussed several adaptations that might improve similar programs designed for veterans. As noted in a commentary, even after the pre-implementation work has been done, additional adaptation is often needed before moving on to large-scale trials.
Additional papers (here, here, and here) on the implementation phases of CIH research leveraged significant administrative data to assess implementation. This ability to use large-scale administrative data covering an entire health system is one of the VA’s strengths.
In one of the articles, Goldsmith and colleagues describe the patterns of self-reported use of non-drug and CIH therapies for pain. They combined a national survey with EMR data for people who had received at least 6 months of opioid analgesics. 80% of veterans reported using at least 1 non-drug therapy for pain in the past year. For most non-drug therapies, younger age and female sex were important correlates. Perhaps unsurprisingly, individuals with higher reported pain had lower use of movement-based therapies. The prevalence of non-drug therapies among long-term opioid users indicates that future research might be able to evaluate the outcomes of these therapies in a critical population suffering from pain.
Sustainment phase
Elwy and colleagues performed a 12-month survey study to examine the impact of CIH therapies on 119 veterans’ self-reported health and well-being. “[O]ur study showed that meditation, tai chi, and yoga appear to improve overall physical and mental health and reduced perceived stress,” according to the new research, led by Dr. A. Rani Elwy of the VA Center for Healthcare Organization and Implementation Research at the Edith Nourse Rogers Memorial Veterans Hospital.
Overall, Veterans in the study reported using 14 different CIH therapies. Yoga was the most popular, with nearly half of Veterans participating. Meditation, acupuncture, and tai chi were also popular. Three CIH therapies were associated with significant improvements in patient-reported outcomes. However, none of the CIH therapies improved veterans’ pain intensity or engagement level in their health care.
Other articles on the sustainment phase look at yoga practice among veterans with chronic pain and its cost-effectiveness.
While the special issue addresses CIH in the VA system, it holds lessons that can be more broadly applied. This collection of research shows how the use of CIH therapies is developing and, in particular, how sustained research and clinical foci can benefit patients and providers alike.
Jess Williams