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.1 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.2 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.3 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).4 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.
Our December 2014 special issue2 focused on determining the evidence base for specific CIH therapies. Now, in this September 2020 special issue, we showcase how VA researchers are addressing each part of the QUERI Implementation Roadmap to examine and facilitate CIH therapy implementation. For example, researchers are engaging stakeholders during the preimplementation phase to ensure that evidence-based CIH therapies can be adapted for routine care settings. They are also conducting research to examine both the implementation of CIH therapies through the use of selected strategies to ensure their uptake by Veterans, providers, and clinical and operational leaders, as well as sustainment of CIH therapies in usual care, focusing on the business case for VA facilities and building capacity of facility leaders to maintain CIH therapies over time.1
Purcell and colleagues describe the adaptation required for the first large, pragmatic randomized controlled trial of the Whole Health program for chronic pain among Veterans in diverse clinical settings.5 The authors used a well-known implementation science framework to guide their stakeholder engagement methods to receive initial feedback on the trial design. Purcell and colleagues then used an evidence-based quality improvement method with these stakeholders to identify implementation strategies that may be successful in overcoming barriers to trial implementation. Their work highlights the great need for using systematic, formative evaluation methods to understand how the clinical context and varying resources may impact implementation, before starting a trial.
Giannitripani and colleagues also used qualitative methods to identify providers’ perspectives of the advantages and disadvantages of using Battlefield Acupuncture (BFA) for treating Veterans’ pain.6 Using an inductive analytic process, the authors conducted 43 interviews and identified 5 disadvantages, such as insufficient clinical guidelines and the need to respond to Veterans’ requests for BFA on demand; and 4 advantages of using BFA, including the perceived utility of BFA for controlling pain and reducing opioid use, and building patient-provider trust through the use of BFA. In both studies, it remains to be seen whether or not obtaining stakeholder perspectives on CIH treatments and using these to select implementation strategies can actually overcome preidentified challenges in future implementation trials.
The study by Eaton and colleagues highlights some challenges with implementing CIH programs even when adaptations have been made for the target audience in advance.7 In this pilot study of 20 Veterans, the authors assessed the feasibility of implementing the Mindfulness-Based Care for Chronic Pain (MBCP) program, which includes meditation, gentle yoga, and psychoeducation, at one VA medical center. They found that although some Veteran participants experienced a clinically meaningful decrease in pain intensity, pain “bothersomeness,” depression, and functional impairment, retaining Veterans in the program proved harder to do. Just over half of the Veteran participants completed 5 or more of the 8 weeks of the program which had been specifically tailored for them. Thus, while earlier, preimplementation adaptations of the MBCP program appeared useful, the actual implementation efforts revealed that more adaptation work is often needed before a larger implementation trial.
The studies by Zeliadt and colleagues,8 Thomas and colleagues,9 and Goldsmith and colleagues10 all explored implementation of CIH treatments through analyzing administrative data. In a cross-sectional cohort study of 11,406 Veterans who received BFA at 57 different VA medical centers, Zeliadt and colleagues’ analyses of electronic health records indicated that over 75% of these Veterans reported immediate pain improvements following administration of BFA, and almost 60% had clinically meaningful reductions in pain intensity.8 Using this same BFA cohort, Thomas and colleagues found that Veterans who used BFA were more likely than those who did not use BFA to later utilize traditional acupuncture approaches.9 Thus, the Thomas and colleagues’ study shows that patients’ use of one CIH therapy, in this case, BFA, may be helpful to the implementation (ie, increased initiation and uptake) of other CIH therapies, such as traditional acupuncture.
The study by Goldsmith and colleagues combined data from the Evaluating Prescription Opioid Changes in Veterans study, a prospective longitudinal cohort of VA primary care patients prescribed long-term opioid therapy, with VA electronic health records, to examine whether Veterans’ participation in 1 of 10 nonpharmacological therapies (including tai chi, yoga, meditation/mindfulness, massage therapy, acupuncture, and chiropractic care) improved pain-related function.10 Of the 8891 Veterans using long-term opioid therapy in the study, 80% reported using at least 1 of 10 nondrug therapies. Higher levels of pain interference were associated with less participation in movement therapies. This finding contrasts with Zeliadt and colleagues’ study,8 which found that Veterans using opioid medication in the prior year were less likely to report reduced pain outcomes when using BFA. Future implementation research is needed to test specific strategies for increasing the uptake of CIH movement therapies for Veterans experiencing pain and to determine whether the effectiveness of these strategies differs among those using opioid treatment or not.
In our practice-based research study, we (A.R.E., S.L.T. and colleagues) examined Veterans’ use of CIH therapies as part of routine care over a 12-month period at 2 VA medical centers.11 We found that Veterans who participated in tai chi, yoga, and meditation reported significant improvements in patient-reported outcomes over time. Specifically, yoga practice was associated with decreases in perceived stress, and tai chi involvement was associated with improvements in overall physical and mental health functioning, anxiety, and increased ability to participate in social role activities. Veterans who practiced mediation reported improved physical functioning across the 12-month period. These results indicate that Veterans can sustain use of CIH therapies over time without the support of a research study, and that Veterans and providers should discuss how specific CIH therapies may be helpful for improving their health and well-being. Similarly, Donaldson and colleagues found that yoga use can be sustained by Veterans many years after they first indicated such use.12 Donaldson and colleagues used data from an ongoing survey first initiated in 2006, called the Readiness and Resilience in National Guard Soldiers, but focused on the 2015-2016 cohort examining the use of CIH and chronic pain. Data from this survey was combined with an analysis of the Essential Properties of Yoga Questionnaire,13 Short-Form version. Of the 141 Veterans in this survey wave who participated in yoga, 110 (78%) reported still participating in yoga, with many practicing yoga at home. Among yoga practitioners, 37% reported having chronic pain; this group tended to follow a gentler, independent practice. This study shows that yoga practice can be sustained over time, and become a routine practice in one’s home, as opposed to attending studio-based yoga classes.
A critical part of sustaining any evidence-based treatment is building the business case for its use. Groessl and colleagues used data from a prior trial of yoga for Veterans’ chronic low back pain to estimate the incremental cost-effectiveness of yoga compared with usual care.14 Veterans were randomized to twice-weekly, 60-minute yoga sessions over 12 weeks, tailored especially for chronic low back pain, or to a delayed treatment condition. Health care costs were estimated from electronic health records. Groessl and colleagues found that participation in yoga cost $4488 per Veteran’s quality-adjusted life year. They also found that yoga may be less costly than physical therapy for chronic low back pain, for potentially the same effectiveness.
The commentary from Alison Whitehead and Benjamin Kligler of the VA OPCC&CT describes how CIH therapies are becoming more available throughout the VA, due to: (1) the increased implementation of the Whole Health System of Care,15 which integrates allopathic and CIH care; and (2) the development of new standards for the hiring of CIH providers, the involvement of volunteers who teach CIH, and guidance for providing CIH in the community to Veterans. Conducting preimplementation, implementation, and sustainment phases of research on CIH therapies in the VA is yet another way to boost the scale-up and spread of CIH therapies across VA, to reach as many Veterans as possible. We already know that CIH therapies are effective for the treatment of Veterans’ chronic pain, posttraumatic stress, depression, and other chronic conditions.16,17 Now we need to develop, test, and use effective strategies to increase CIH use and sustainment. These strategies include creating leadership buy-in for CIH therapies, establishing a business case, and building interest and support among VA providers and Veterans by demonstrating the evidence of the effects of various CIH therapies on health outcomes. These studies found in our special issue are important steps towards these goals.
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. Accessed June 22, 2020.
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7. Eaton E, Swearingen HR, Zand Vakili A, et al. A brief report on an 8-week course of mindfulness-based care for chronic pain in the treatment of veterans with back pain: barriers encountered to treatment engagement and lessons learned. Med Care. 2020;58(suppl 2):S94–S100.
8. Zeliadt SB, Thomas ER, Olson J, et al. Patient feedback on the effectiveness of auricular acupuncture on pain in routine clinical care: the experience of 11,406 veterans. Med Care. 2020;58(suppl 2):S101–S107.
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10. Goldsmith ES, MacLehose RF, Jensen AC, et al. Complementary, integrative, and nondrug therapy use for pain among us military veterans on long-term opioids. Med Care. 2020;58(suppl 2):S116–S124.
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