Complementary and Integrative Health Approaches and Pain
Care Quality in the Veterans Health Administration
Primary Care Setting: A Quasi-Experimental AnalysisThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Integr Complement Med 2023 (Mar 27) [EPUB] ~ FULL TEXT
OPEN ACCESS Ling Han, Stephen L Luther, Dezon K Finch, Steven K Dobscha, Melissa Skanderson, Harini Bathulapalli, et. al.
Department of Internal Medicine,
Yale School of Medicine,
New Haven, CT, USA.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.
Keywords: VHA primary care; complementary and integrative health approaches (CIH); musculoskeletal disorders (MSD); natural language processing (NLP); pain care quality (PCQ); propensity score (PS).
From the Full-Text Article:
Additional filesAdditional file 1: Appendix A. The chiropractic profession a scoping review (DOCX 13 kb)
References:
Institute of Medicine (IOM)
Relieving Pain in America: A Blueprint for Transforming Prevention,
Care, Education, and Research
Washington, DC: The National Academies Press, 2011.Dahlhamer J, Lucas J, Zelaya C, et al.
Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults -
United States, 2016
MMWR Morb Mortal Wkly Rep. 2018 (Sep 14); 67 (36): 1001-1006Schappert SM, Burt CW.
Ambulatory care visits to physician offices, hospital outpatient departments,
and emergency departments: United States, 2001–02.
Vital Health Stat 13 2006;13:1–66.Gureje O, Von Korff M, Simon GE, et al.
Persistent pain and well-being.
A World Health Organization study in primary care.
JAMA 1998;280:147–151;
doi: 10.1001/jama.280.2.147Kerns RD, Otis JD, Rosenberg R.
Veterans' reports of pain and associations with ratings of health,
health risk behaviors, affective distress, and use of the healthcare system.
J Rehab Res Dev 2003;40:371–380;
doi: 10.1682/jrrd.2003.09.0371Turk DC, Dworkin RH, Allen RR, et al.
Core outcome domains for chronic pain clinical trials:
IMMPACT recommendations.
Pain 2003;106:337–345;
doi: 10.1016/j.pain.2003.08.001Veterans Health Administration.
VA Pain Management Directive (2009-053)
Department of Veterans Affairs: Washington, DC, USA; 2009.Kligler B, Bair MJ, Banerjea R, et al.
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): 16–23Pangarkar SS, Kang DG, Sandbrink F, et al.
VA/DoD clinical practice guideline: Diagnosis and treatment of low back pain.
J Gen Intern Med 2019;34(11):2620–2629;
doi: 10.1007/s11606-019-05086-4Rosland AM, Nelson K, Sun H, et al.
The patient-centered medical home in the Veterans Health Administration.
Am J Manag Care 2013;1:19(7):e263–e272.Rosenberg EI, Genao I, Chen I, et al.
Complementary and alternative medicine use by
primary care patients with chronic pain.
Pain Med 2008;9(8):1065–1072;
doi: 10.1111/j.1526-4637.2008.00477.xVeterans Health Administration.
Provision of Complementary and Integrative Health Directive (2017-1137)
Department of Veterans Affairs: Washington, DC, USA; 2017.Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, et al.
Nonpharmacologic Therapies for Low Back Pain: A Systematic Review
for an American College of Physicians Clinical Practice Guideline
Annals of Internal Medicine 2017 (Apr 4); 166 (7): 493–505Taylor SL, Herman PM, Marshall NJ, et al.
Use of Complementary and integrated health: A retrospective analysis of U.S. Veterans with chronic musculoskeletal pain nationally.
J Altern Compl Med 2019;25(1):32–39;
doi: 10.1089/acm.2018.0276Farmer MM, McGowan M, Yuan AH, et al.
Complementary and integrative health approaches offered in the Veterans
Health Administration: Results of a National Organizational Survey.
J Altern Compl Med 2021;27(S1):S124–S130;
doi: 10.1089/acm.2020.0395Furlan AD, Yazdi F, Tsertsvadze A, et al.
A systematic review and meta-analysis of efficacy, cost-effectiveness,
and safety of selected complementary and alternative
medicine for neck and low-back pain.
Evid Based Compl Altern Med 2012:953139;
doi: 10.1155/2012/953139Qaseem A, Wilt TJ, McLean RM, Forciea MA;
Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain:
A Clinical Practice Guideline From the American College of Physicians
Annals of Internal Medicine 2017 (Apr 4); 166 (7): 514–530Nahin RL, Boineau R, Khalsa PS, et al.
Evidence-based evaluation of complementary health approaches
for pain management in the United States.
Mayo Clin Proc 2016;91(9):1292–1306;
doi: 10.1016/j.mayocp.2016.06.007Ashrafioun L, Allen KD, Pigeon WR.
Utilization of complementary and integrative health services and opioid therapy
by patients receiving Veterans Health Administration pain care.
Compl Therap Med 2018;39:8–13;
doi: 10.1016/j.ctim.2018.05.008Han L, Goulet J, Skanderson M, et al.
Evaluation of complementary and integrative health approaches among
US Veterans with musculoskeletal pain using propensity score methods.
Pain Med 2019;20:90–102;
doi: 10.1093/pm/pny027Kerns RD, Philip EJ, Lee A, et al.
Implementation of the veterans health administration
national pain management strategy.
Transl Behav Med 2011;1:635–643;
doi: 10.1007/s13142-011-0094-3Luther SL, Finch DK, Bouayad L, et al.
Measuring Pain Care Quality (PCQ) in the Veterans
Health Administration (VHA) primary care setting.
Pain 2022;163(6):e715–e724;
doi: 10.1097/j.pain.0000000000002477Dorflinger LM, Gilliam WP, Lee AW, et al.
Development and application of an electronic health record information
extraction tool to assess quality of pain management in primary care.
Transl Behav Med 2014;4:184–189;
doi: 10.1007/s13142-014-0260-5Corson K, Doak MN, Denneson L, et al.
Primary care clinician adherence to guidelines for the management
of chronic musculoskeletal pain: Results from the study of the
effectiveness of a collaborative approach to pain.
Pain Med 2011;12:1490–1501;
doi: 10.1111/j.1526-4637.2011.01231.xGoulet JL, Kerns RD, Bair M, et al.
The musculoskeletal diagnosis cohort:
Examining pain and pain care among Veterans.
Pain 2016;157(8):1696–1703;
doi: 10.1097/j.pain.0000000000000567Facility Complexity Model.
VHA Office of Productivity, Efficiency and Staffing (OPES).
Available from:
http://opes.vssc.med.va.gov/Pages/Facility-Complexity-Model.aspx
[Last accessed: November 8, 2022].Rubin DB.
The design versus the analysis of observational studies for
causal effects: Parallels with the design of randomized trials.
Stat Med 2007;26:20–36;
doi: 10.1002/sim.2739Stuart EA.
Matching methods for causal inference: A review and look forward.
Stat Sci 2010;25(1):1–21; doi: 10.1214/09-STS313Sturmer T, Wyss R, Glynn RJ, et al.
Propensity scores for confounder adjustment when assessing the effects
of medical interventions using nonexperimental study designs.
J Intern Med 2014;275(6):570–580;
doi: 10.1111/joim.12197Austin PC.
The relative ability of different propensity score methods to balance
measured covariates between treated and untreated subjects
in observational studies.
Med Dec Mak 2009;29(6):661–677;
doi: 10.1177/0272989X09341755McCulloch CE, Searle SR.
Generalized, Linear and Mixed Models.
John Wiley & Sons: New York, NY, USA; 2001; pp. 220–246.Gruß I, Firemark A, McMullen CK, et al.
Satisfaction with primary care providers and health care services
among patients with chronic pain: A mixed-methods study.
J Gen Intern Med 2020;35(1):190–197;
doi: 10.1007/s11606-019-05339-2Department of Veterans Affairs.
Whole Health. 2022. Available from:
http://www.va.gov/WHOLEHEALTH
[Last accessed: July 6, 2022].Declaration of Astana:
Global Conference on Primary Health Care. 2018. Available from:
https://www.who.int/docs/defaultsource/primary-health/declaration/gcphc-declaration.pdf
[Last accessed: November 8, 2022].Beck SL, Dunton N, Berry PH, et al.
Dissemination and implementation of patient-centered indicators of pain care quality and outcomes.
Med Care 2019;57(2):159–166;
doi: 10.1097/MLR.0000000000001042AMA Pain Care Task Force.
Addressing obstacles to evidence-informed pain care.
AMA J Ethics 2020;22(1):E709–E717;
doi: 10.1001/amajethics.2020.709
Return to ALT-MED/CAM ABSTRACTS
Return to CHIROPRACTIC CARE FOR VETERANS
Since 3-28-2023
| Home Page | Visit Our Sponsors | Become a Sponsor |
Please read our DISCLAIMER |