Lead/Presenter: Rendelle Bolton,
All Authors: Bolton RE ((Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System)), Wu J (Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System) Ritter G (The Heller School for Social Policy and Management, Brandeis University) Brolin M (The Heller School for Social Policy and Management, Brandeis University) Elwy, AR (Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System) Gittell JH (The Heller School for Social Policy and Management, Brandeis University) Larson MJ (The Heller School for Social Policy and Management, Brandeis University) Bokhour BG (Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System)
Beginning in 2018, VA invested over $220 million from the Comprehensive Addiction and Recovery Act to pilot integration of complementary and integrative health (CIH) therapies into existing healthcare services at 18 Flagship Medical Centers implementing the Whole Health System of Care (WHS). Despite this investment and the incorporation of CIH into VA policy, Veterans with chronic pain under-utilize CIH therapies and considerable variation across these Flagship sites remain. We sought to examine individual and organizational factors driving suboptimal use of CIH.
We conducted a mixed-methods study analyzing medical records from 335,033 patients meeting VA/DoD/NIH chronic pain criteria, and implementation-focused qualitative interviews, tracking worksheets, and organizational documents collected quarterly between FY2018-2019 from the 18 Flagship sites. Hierarchical regression models tested the effects of WHS implementation on CIH utilization over 8 quarters, controlling for patient-level and site-level characteristics. CIH utilization was measured as any use per quarter. Implementation level was measured quarterly as a composite score combining structured ratings of 9 indicators of WHS implementation (e.g., organizational supports, CIH availability, integration into primary care, WH coaching), derived from interviews and worksheets. Using a qualitative multiple-case study and thematic analysis, we examined how organizational differences contributed to variation in CIH use in the 2 highest and 2 lowest-utilizing sites. We re-analyzed 120 previously collected qualitative interviews, site organizational documents, and implementation reports, using deductive and inductive coding to compare how sites approached implementation within their organizational context, delivered CIH, and promoted adoption. Final site syntheses facilitated between-site comparisons.
On average, 12.8% of patients with chronic pain used CIH, ranging from 3.4%-25.2% across sites. Being female, Asian, having more than one type of musculoskeletal pain, and obesity were the largest individual predictors of CIH use (all p < 0001). Implementation scores were standardized to have mean = 0, standard deviation = 1. After controlling for individual-level characteristics, patients receiving care at sites rated higher in WHS implementation were 28% more likely to utilize CIH for every 1 standard deviation increase in implementation score (p < .0001). Case-study analyses showed that high and low-utilizing sites offered similar CIH therapies but differed in organizational context, implementation approach/strategy, and WHS design. CIH therapies in high-utilizing sites were accessible via multiple pathways linked to other WHS components (e.g., WH coaching). These sites aligned implementation with chronic pain/opioid-reduction priorities and strategically aimed to transform culture through widespread training and incentives. Low-utilizing sites didnâ€™t have dedicated employees to deliver CIH, and there were few other WHS components available. Implementation was haphazard, targeted the highest risk patients in non-pain populations, and avoided disrupting culture.
WHS implementation explained variation in CIH use among patients with chronic pain beyond the availability of these therapies and individual patient characteristics. Sites that linked WHS implementation with chronic pain/opioid reduction priorities and wide-spread cultural transformation efforts created organizational contexts in which more patients were connected to CIH therapies.
Nonpharmacologic therapies for managing chronic pain are a high priority for VA and there is increasing demand for CIH. Transforming care to a WHS beyond just offering CIH therapies can better engage patients in CIH utilization.