The VA QUERI Complementary and Integrative Health Evaluation Center (CIHEC)
Guided by the VA Office of Patient Centered Care and Cultural Transformation (OPCC&CT), VA is in the midst of a healthcare transformation, shifting from a disease-oriented healthcare model to one that addresses the whole Veteran. Providing complementary and integrative health (CIH) therapies is an integral part of this Whole Health transformation. Eight CIH therapies are in the standard VA medical benefits package: acupuncture, biofeedback, clinical hypnosis, guided imagery, meditation, Tai Chi/Qigong, therapeutic massage, and yoga (VA considers chiropractic care as allopathic). Veterans often ask for non-pharmacological options, such as CIH therapies, to help manage their health. However, VAMCs often need support implementing CIH therapies. Additionally, relatively novel CIH therapies are emerging for which there is limited evidence of effectiveness.
Since 2016, CIHEC, a QUERI Partnered Evaluation Initiative conducted in collaboration with OPCC&CT, has been addressing these issues by examining the implementation of evidence-based CIH therapies and the effectiveness of novel CIH therapies for Veterans and VA employees. CIHEC includes eight investigators at six sites, who, with OPCC&CT, create a shared agenda to address VA’s most pressing evaluation needs. Much of CIHEC’s work stems from an earlier project examining the challenges that VA providers face when implementing CIH therapies and the successful strategies they used to overcome those challenges (Taylor, Bolton, Hyunh, et al., 2019). CIHEC’s work is in response to and informs Congress of progress made by VA in response to legislation such as the Comprehensive Addiction and Recovery Act, Veteran Mental Health Care Improvement Act, and Whole Veteran Act. CIHEC’s projects and dissemination strategies are summarized below.
Studying the Implementation and Provision of CIH Therapies
National Survey of Veteran Interest in, Use of, and Satisfaction with CIH Therapies. In 2016, CIHEC investigators collaborated with the VHA’s Office of Analytics and Performance Integration to conduct the first large-scale survey on Veterans’ interest in, use of, and satisfaction with 27 CIH therapies. Capitalizing on VA’s Veterans Insight Panel, CIHEC determined Veterans’ interest in and use of CIH therapies during a time of major expansion of CIH therapy provision in VA. Results showed over half of Veterans were interested in trying or learning more about six therapies (massage therapy, chiropractic, acupuncture, acupressure, reflexology, and progressive relaxation). In fact, many of these Veterans had used CIH therapies in the past year, and cited pain and stress reduction as the most frequent reasons for using CIH therapies. The majority were unaware of specific CIH therapies available at VA (Taylor, Hoggatt and Kligler, et al., 2019).
The Environmental Scan of CIH Provision at VAMCs Nationally. CIHEC next conducted the first large-scale survey to determine VAMCs’ provision of 27 CIH therapies in 2017-18. For each therapy, the survey asked 17 questions to assess the organization and provision of CIH therapies. Results showed widespread CIH therapy provision, with half the sites offering six or more therapies. Sites reported eight most frequently offered therapies: relaxation techniques, mindfulness, meditation, guided imagery, yoga, Tai Chi, Battlefield Acupuncture, and traditional acupuncture. These sites offered the majority of therapies in Mental Health, Physical Medicine and Rehabilitation Services, Primary Care, Pain clinics, and Integrative Health/Well-Being clinics (Farmer, McGowan, Yuan, et al, 2021).
CIH Data Nexus. Determining CIH therapy provision on a large scale is difficult because coding can be inconsistent and CPT4 codes are unavailable for some types of therapy. As such, CIHEC created a national cohort of VA healthcare users to determine the prevalence and effectiveness of CIH therapy use, and the demographic and health characteristics of Veteran users. CIHEC investigators routinely extract, clean, and analyze VA EHR and CHOICE community care data nationally. They produce in-depth reports for VA OPCC&CT and the public annually, with the first being the 2020 Compendium on Use of Complementary and Integrative Health Therapies and Chiropractic Care at the VA, found on OPCC&CT’s website.
Battlefield Acupuncture Implementation (BFA). BFA is a rapid protocol-based, auricular (ear) acupuncture therapy developed in 2007 to provide instantaneous pain reduction. It is intended to be delivered alongside other pain treatments and is noted for its ability to be administered with ease by a variety of BFA-trained providers without requiring intensive acupuncture training. Given anecdotal evidence of BFA’s effectiveness, VA trained over 2,400 providers to deliver BFA. CIHEC examined both BFA’s effectiveness (noted below) and implementation. To study implementation, investigators conducted interviews with BFA providers to determine their implementation challenges and strategies, and found providers were experiencing eight main implementation challenges, but had several successful strategies to overcome those challenges (Taylor, Giannitrapani, Ackland, et al., 2018).
Improving Patient and Provider Knowledge of CIH Therapies. CIHEC investigators learned from their earlier work on CIH implementation issues that most patients and providers are unfamiliar with many CIH therapies. As such, CIHEC conducted a project to determine the information providers and patients most wanted to learn about CIH therapies and in what format they wanted that information. The aim was to develop provider and patient educational materials to facilitate CIH therapy decision-making processes. Investigators used qualitative and quantitative methods to iteratively pilot-test and revise yoga and meditation education materials. Providers and Veterans were rather consistent in the specific content and format they wanted the materials to have, which differed between providers and Veterans (Taylor, Giannitrapani, Yuan, et al., 2018).
Studying the Effectiveness of CIH Therapies
Evidence Maps. As thousands of studies have been conducted on CIH therapies for many health conditions, it can be difficult to quickly grasp the state of the science for particular therapies. As such, CIHEC investigators partnered with the VA Evidence Synthesis Program to produce several “evidence maps,” which are visual depictions of the effectiveness, quality, and size of the scientific literature. These include evidence maps of acupuncture, mindfulness, Tai Chi, and CIH for pain and are on OPCC&CT’s website.
The Effectiveness of Battlefield Acupuncture for Pain. CIHEC investigators conducted four examinations of BFA effectiveness, one qualitative and three quantitative (Taylor, Giannitrapani, Ackland, et al., 2021). The first used interviews with BFA providers on their perceptions of BFA effectiveness (Giannitrapani, Ackland, Holliday, et al., 2020). They reported that BFA provided temporary pain reduction for many patients, and that pain relief subsequently led to increased provider-patient trust and communication, and increased patients’ willingness to try other “alternative” therapies for their pain. The first of three quantitative examinations of BFA effectiveness focused on a large BFA clinic (Federman, Thomas, Carbone, et al., 2018). Results showed that pain decreases were common in both group and individual settings. The second examination was among 11,431 Veterans receiving BFA at 57 VAMCs and showed that pain scores decreased 2.1 points (0-10 scale) (Zeliadt, Thomas, Olson, et al., 2020). The third used that same large sample and examined whether use of BFA led to use of traditional acupuncture, which can have a more long-lasting effect. Results showed it did lead to an increase in the use of traditional acupuncture (Thomas, Zeliadt, Coggeshall, et al., 2020).
National Tele-Whole Health Evaluation. In collaboration with the Evaluation of Patient-Centered Care QUERI PEI (PI: Bokhour), CIHEC is conducting a mixed-methods, large-scale evaluation of the effectiveness and implementation of tele-Whole Health, of which CIH therapies are a part.
CIHEC developed and manages three national CIH dissemination mechanisms that enable VA clinicians, researchers, and staff to keep abreast of research being conducted on Veterans and CIH therapies, and to foster CIH collaborations and future research. The strategies are listed below, and the documents are available on OPCC&CT’s website.
Library of Research Articles on Veterans and Complementary and Integrative Health Therapies and Chiropractic Care. CIHEC created and now maintains a publicly available, electronic library of peer-reviewed scientific papers. Updated annually, the library includes 27 CIH therapies and 9 key clinical and implementation outcomes.
Registry of Current Research on Veterans and Complementary and Integrative Health Therapies and Chiropractic Care. CIHEC created and maintains a registry of the VA-, NIH- and DoD-funded research being conducted as of 2016 among Veterans and CIH therapies. Updated biannually, the registry focuses on eight CIH therapies and six health conditions, and contains information on the PI, PI institution, project title, and funding amount.
HSR&D CIH Cyberseminars. CIHEC developed and manages this successful bi-monthly cyberseminar series for researchers from inside and outside VA to present their latest effectiveness and implementation CIH therapy research to providers, leaders and researchers across VA. OPCC&CT leadership attends each cyberseminar, providing VA program and policy information related to the presentation. Contact firstname.lastname@example.org to sign up for CIH cyberseminars.