J Gen Intern Med. 2019 (Jul); 34 (7): 1192–1199 ~ FULL TEXT
Stephanie L. Taylor, PhD, Katherine J. Hoggatt, MPH, and Benjamin Kligler, MD, MPH
Center for the Study of Healthcare Innovation,
Implementation and Policy,
Greater Los Angeles VA Healthcare System,
Los Angeles, CA, USA.
Nahin ~ Pain 2017
OBJECTIVES: Non-pharmacological treatment options for common conditions such as chronic pain, anxiety, and depression are being given increased consideration in healthcare, especially given the recent emphasis to address the opioid crisis. One set of non-pharmacological treatment options are evidence-based complementary and integrative health (CIH) approaches, such as yoga, acupuncture, and meditation. The Veterans Health Administration (VHA), the nation's largest healthcare system, has been at the forefront of implementing CIH approaches, given their patients' high prevalence of pain, anxiety, and depression. We aimed to conduct the first national survey of veterans' interest in and use of CIH approaches.
METHODS: Using a large national convenience sample of veterans who regularly use the VHA, we conducted the first national survey of veterans' interest in, frequency of and reasons for use of, and satisfaction with 26 CIH approaches (n?=?3346, 37% response rate) in July 2017.
RESULTS: In the past year, 52% used any CIH approach, with 44% using massage therapy, 37% using chiropractic, 34% using mindfulness, 24% using other meditation, and 25% using yoga. For nine CIH approaches, pain and stress reduction/relaxation were the two most frequent reasons veterans gave for using them. Overall, 84% said they were interested in trying/learning more about at least one CIH approach, with about half being interested in six individual CIH approaches (e.g., massage therapy, chiropractic, acupuncture, acupressure, reflexology, and progressive relaxation). Veterans appeared to be much more likely to use each CIH approach outside the VHA vs. within the VHA.
CONCLUSIONS: Veterans report relatively high past-year use of CIH approaches and many more report interest in CIH approaches. To address this gap between patients' level of interest in and use of CIH approaches, primary care providers might want to discuss evidence-based CIH options to their patients for relevant health conditions, given most CIH approaches are safe.
KEYWORDS: alternative medicine; chronic pain; complementary and alternative medicine; veterans
From the FULL TEXT Article:
Non-pharmacological treatment options for common conditions
such as chronic pain, anxiety, and depression are being
given increased consideration in healthcare. For example, in
part to address the opioid epidemic, the Department of Health
and Human Services’ National Pain Strategy  and the American
College of Physicians’ low back pain clinical practice
guidelines  recommend complementary and integrative health
(CIH) approaches, such as tai chi, yoga, and acupuncture
among the suggested non-pharmacological treatment options.
These recommendations are based largely on the evidence
from randomized controlled trials (RCTs) of CIH approaches.
For example, NIH researchers’ review of RCTs found evidence
supporting the effect of several CIH approaches on several types
of pain,  with similar results found in other reviews of systematic
reviews. [4–11] Recent RCTs of mindfulness approaches show they
appear to improve chronic low back pain, [12, 13] and mindfulness
and yoga may help with depressive and post-traumatic stress
disorder symptoms. [14, 15] The National Academy of Medicine
(formerly Institute of Medicine)  and others report that patients
often prefer to use CIH approaches because they prefer nonpharmacological
self-management options, experienced unwanted
side effects, or had limited response to pharmacologic and
other common treatments. [17, 18]
Given the evidence, a desire to satisfy patient demand for
non-pharmacological treatment options, and the potential to
reduce healthcare costs,  some healthcare systems have increasingly
been making CIH approaches available.
Mindfulness-based cognitive therapy is being implemented
throughout the UK’s National Health Service ; almost half
of American Hospital Association-affiliated hospitals offered
CIH therapies in 2010 ; and 93% of facilities in the nation’s
largest integrated healthcare system, the Veterans Health Administration
(VHA), offered CIH in 2011.  Currently, the
VHA is undergoing a significant expansion in the provision of
evidence-based CIH approaches to fulfill the requirements of
the 2016 Comprehensive Addiction and Recovery Act of 2016
(CARA) legislation.  According to a new policy directive as
of May 2017, the VHA considers the following evidencebased
CIH approaches as part of the standard medical benefits
package: acupuncture, therapeutic massage, guided imagery,
biofeedback, hypnotherapy, tai chi, yoga, and meditation.
Chiropractic has been part of standard VHA care since 2005
In part to guide this expansion of evidence-based CIH,
VHA leaders sought current information on veterans’ interest
in and use of various CIH approaches, both inside and outside
the VHA system because existing surveys of veterans’ use of
CIH approaches use very small or old samples. [24, 25] Veterans
represent 7% of the population and are similar to the Medicaid
population in that they tend to have less income and education,
are predominately male, and are more disabled than the general
population.  Veterans have high need for management of
chronic pain and symptoms of anxiety or depression, [27–29]
conditions for which some types of CIH might be effective.
This paper presents the results of a survey of a large sample of
veterans on their interest in, use of, and satisfaction with 26 CIH
approaches. The results are being used not only to guide national
VHA policy and operations supporting CIH delivery but also to
inform other healthcare systems as they decide which CIH
approaches to offer patients among their non-pharmacological
treatment options to improve patient health and satisfaction.
Knowing which types of treatments patients prefer, especially
for prevalent conditions like pain and stress, is a key issue for
most healthcare organizations, not only the VA. Patient satisfaction
matters more than ever because many healthcare systems
need to report on patient satisfaction for reimbursement issues or
need to respond to patient advocacy groups and councils.
A total of 3364 members of the national VHA’s
Veteran Insights Panel (VIP) were invited via email to participate
in the survey fielded July 17–25, 2017, with 1,230 completing
the survey. The survey was designed in consultation
with the VHA office overseeing CIH policy, the Office of
Patient Centered Care and Cultural Transformation, and the
VIP sponsor, the VA Survey of Healthcare Experiences of
Patients Program (SHEP) under the Office of Reporting, Analytics,
Performance, Improvement and Deployment (RAPID).
This survey received IRB approval as an operations project.
Veteran Insights Panel.
The VIP is a national online group of
veterans who regularly use VA care and is organized to enable
veterans to provide feedback on VA programs and services.
Panel members originally were identified from a sample
extracted from the VHA database and were contacted via a
recruitment email. The panel is periodically refreshed, purging
panelists with a history of non-participation and recruiting new
panelists. Panel members are not incentivized or compensated
monetarily for their participation on the VIP. For their participation
in this survey, VIP members were given a survey link
and asked to complete it within 2 weeks. To describe the full
VIP (N = 3,364) to potential VHA users, the panel are periodically
surveyed on four descriptive characteristics (although
data from this descriptive survey is unavailable to be linked
with individual surveys such as ours). In July 2017, the full
VIP panel reported the following: (1) their health status as very
good or excellent (32%), good (38%), or poor (31%); (2) their
residence as urban (63%) or rural (37%); and (3) their length
of time of using the VA as:10 or more years (39%), 5–9 years
(26%), 1–4 years (29%), less than 1 year (2%), and do not use
(4%) (although the VA attempts to survey only VA users, a
very small percent actually did not use the VA). Lastly, they
reported their level of VHA utilization as at least once/month
(28%) or every few months or less (68%), with the 4% who
were non-users not responding to this question.
We assessed veterans’ use of and interest in 26 CIH
approaches by providing brief descriptions for each (shown in
Table 3) and asking about the following:
(1) frequency of pastyear use;
(2) reasons for use (e.g., pain, stress/relaxation, sleep, post-traumatic stress disorder (PSTD), or other);
(3) how helpful it was for addressing the endorsed reasons;
(4) veterans’ knowledge of CIH approaches being offered at their VA medical center;
(5) whether it was used in or outside a VA setting or both;
(6) reasons for using it outside the VA;
(7) interest in trying or learning more about it; and
(8) reasons if any for not being interested in trying or learning more about it.
The 26 approaches were those we were aware of being provided
at some VA medical centers, although the evidence base
for some are stronger than for others. We also created a
summary variable for any use of CIH (used at least one vs.
no use). To improve access to care, the VA has recently started
contracting with community-based providers to deliver some
care (including acupuncture and chiropractic care). Our item
asking whether respondents used care within or outside the VA
setting was intentionally not designed to discern if the care was
paid for by the VA or not. For policy reasons, we cared less
about who provided the care and more about whether care was
used within the VA medical setting or in the community.
We first computed descriptive statistics for patients
who reported any use of CIH vs. no use of CIH. We then fit a
multiple-variable logistic regression model of any CIH use on
age, gender, race/ethnicity, marital status, and income, with all
terms entered simultaneously (categories for all predictors are
shown in Table 2). Using the fitted model, we computed
adjusted odds ratios (point and 95% confidence interval estimates)
to estimate the associations between patients’ demographic
characteristics and any use of CIH. We then determined,
for each CIH approach, the most frequently reported
reason for using that CIH approach and the setting of CIH use
in the past year (the proportion reporting BVA, “Somewhere
else,” or “Both”).
Reasons for using CIH approaches were
summarized by first determining, for each CIH approach, the
reasons participants reported for using that approach. We then
computed the proportion of VIP members who endorsed the
most frequently reported reason for using that CIH approach.
We also summarized frequency of use for each CIH approach
as the proportion of veterans endorsing each frequency option
(no use, a few times a year, a few times a month/about once a
month, and almost every day/a few times a week).
assessed the helpfulness of each CIH approach for the most
frequently reported reason for using that CIH approach by
computing the proportion of VIP members who reported the
approach was “Very” or “Moderately” helpful.
in trying or learning more about each CIH approach was
summarized as the proportion in each interest category (interest
in learning more at the local VA, interest in trying the
approach at the local VA, interest in trying the approach in
the Veteran’s neighborhood, or no interest in the approach).
Analyses were conducted using R (version 3.2.2).
Almost two-thirds (63%) of the veteran survey respondents
were married, 8% were single, and 29% were separated,
divorced, or widowed. A majority (86%) were Non-Hispanic
White, while 6% were Hispanic, 7% were Non-Hispanic
Black, 2% were Asian, and 5% were Native Hawaiian/
Pacific Islander or American Indian/Native American. About
half (56%) reported an annual income of less than $60,000,
and 11% reported an annual income of $100,000 or greater.
In the past year, almost half (52%) used any type of CIH
approach. Table 1 presents the descriptions of CIH users and
non-users, and presents use within and outside the VA. It
shows that patients who used CIH approaches were more
likely to be under age 65, female, and have higher incomes
than patients not using CIH approaches.
Table 2 presents the
adjusted associations between predictors of any CIH use vs. no
CIH use. It shows users were more likely to be middle-aged,
women, and non-Hispanic Native Hawaiian/Pacific Islander
or American Indian/Native American, and users were less
likely to have annual incomes of $10,000 or less or to be
Table 3 presents past-year utilization of CIH approaches by
setting of use (within the VA setting, outside the VA setting,
both within and outside the VA, and total). Massage therapy
was the most frequently used CIH approach in the past year,
with 44% using it, followed by 37% using chiropractic and
34% using mindfulness. Except for Battlefield acupuncture,
which is not readily available outside of VA or military settings,
veterans appeared to be much more likely to use each CIH
approach outside the VA vs. within the VA.
When asked about
the frequency of use, “at least weekly” use was reported by 8%
for mindfulness and 7% for animal-assisted therapy, and “a few
times amonth”/“about once a month” was reported by 12% for
massage, 11% for chiropractic, and 6% for mindfulness.
The first column in Table 4 shows veterans’ most frequently
reported reasons for using each CIH approach. For nine CIH
approaches, pain and “stress reduction/relaxation” were the
two most frequent reasons for using those approaches, followed
by “improve overall health and well-being” for five
CIH approaches and PTSD for one approach. The second
column in Table 4 shows the percent of veterans reporting that
that particular approach was “moderately helpful” or “very
helpful” for the most frequently reported reason for its use. For
example, 81.7% of people reported using acupressure for pain
and over half of those (56.6%) said it was moderately or very
helpful for pain.
It appears the most helpful approaches for
pain were chiropractic and massage therapy, and the most
helpful approaches for stress reduction/relaxation were
“hypnotherapy/hypnosis” and animal-assisted therapy.
Table 5 describes veterans’ interest in trying or learning
more about each CIH approach among those not using each
CIH approach in the past year. Overall, 84% said they would
be interested in trying/learning more about at least one CIH
approach. Of those 84%, 43% were veterans who had not used
a CIH approach in the past year (not in the table). When
considering each specific CIH approach, about half (45% or
more) said they were interested in six individual CIH
approaches (e.g., massage therapy, chiropractic, acupuncture,
acupressure, reflexology, and progressive relaxation).
Our survey of a national convenience sample of veterans who
regularly use VA care found that about half of participants had
used any of the 26 CIH approaches in the past year. The most
frequently used approaches were massage therapy, chiropractic,
mindfulness or some other type of meditation, progressive
relaxation, and yoga, with at least 20% or more of veterans
using each of these. It is interesting that these most frequently
used approaches appear somewhat split between passive,
provider-delivered and active, self-care approaches. Additionally,
about a third of veterans who had not used a particular
type of CIH were interested in trying it or learning more about
it, for all but one CIH approach (Battlefield Acupuncture). For
six CIH approaches, these levels of interest were even higher,
in some cases twice or more the percentage of veterans using
most of the CIH approaches. Pain and stress reduction/
relaxation were the two most frequent reasons given for using
CIH approaches, with improving overall health and well-being
the third. Veterans reported for all but two types of CIH that it was
moderately or very helpful for the reason for which they used it.
The prevalence of CIH utilization we found among veterans
appears much higher than that reported for the general population
in 2012.  This may reflect the shift of some CIH
approaches (e.g., meditation and yoga) to becoming more
mainstream in the last few years or it could reflect the fact
that CIH approaches are typically being provided at no or
relatively low cost to veterans using the VHA healthcare
system. It also might be that veterans who were interested in
CIH approaches were more likely than other veterans to complete
the survey, meaning that the rates of use and interest
among the wider veteran population could be lower. These
self-reported utilization rates were higher than those found in
our earlier examination of 2010–2013 medical record-reported
utilization rates among VHA users having chronic musculoskeletal
pain.  However, that examination used natural language
processing to extract CIH utilization from medical
records and most likely did not completely account for
community-based CIH utilization as we do in this examination,
so those estimates could be less reliable. Veterans’ CIH
utilization will likely increase in the near future given the
expansion of CIH provision as a non-pharmacological treatment
for pain in the VHA mandated by Congress in the 2016
Comprehensive Addiction and Recovery Act. 
The gap we found between veterans’ interest in CIH
approaches and their use of CIH approaches might point to
an opportunity for primary care providers to educate their
patients about evidence-based CIH approaches for particular
health conditions. There is a large amount of scientific evidence
for some types of CIH approaches for some types of
health conditions, while the evidence is nascent or nonexistent
for many others. As such, it can be difficult for
providers and patients to understand the array of potentially
appropriate non-pharmacological treatment options. Our earlier
research among veterans and their providers found patients
are particularly responsive to CIH-based demonstrations,
provider-delivered education, videos, and brief written
It is not surprising that pain is one of the two most frequently
reported reasons for using CIH approaches, given the high
prevalence of pain among veterans [33, 34] and the efforts among
healthcare providers to offer non-opioid alternatives for pain
management.  Half or more of veterans reported that acupressure,
acupuncture, healing touch/reiki, chiropractic, massage
therapy, movement therapy, and biofeedback helped their
pain. The evidence for some of these is stronger than others.
As such, it might be prudent to offer patients a variety of CIH
treatment options shown to have evidence of effectiveness for
their particular condition.
Our study has some limitations. First, our sample is
not representative of the veteran population in general in
that we used a large convenience sample. However, it is
the first large examination of CIH use among veterans
nationally. Second, the veteran patient population is not
generalizable to the entire population, even when considering
those of the same age,  and they may have
incurred their health conditions through active duty situations
that incur psychological as well as physical
stress not experienced by the general population. Additionally,
we achieved a 37% response rate, which is
rather standard for patient surveys. However, as noted
above, it likely resulted in overestimates of the use of
and interest in CIH approaches. Also, due to survey
length restrictions, we were unable to survey the VIP
sample on four characteristics (length of time using the
VHA, level of VHA utilization, health status, and urban/
rural residence) so we could not include these data in
the analysis. We did receive this information for the full
sample of 3,364 VIP members as a whole, but due to
privacy restrictions could not link it with the survey
responses. Also, fewer than 50 people reported using 7
of the 26 approaches we examined, which limited our
ability to explore the correlates of these approaches.
Most CIH approaches are safe non-pharmacological strategies
to improve health. We found that about half or more of
veterans thought the CIH approach they used was helpful for a
particular type of health condition. Given this, primary care
providers might consider informing their patients about some
CIH approaches as potential options to improve their health.
The authors would like to thank Alison Whitehead and Amanda Hull
at the VA Office of Patient Centered Care and Cultural Transformation;
Mark Meterko at the VA SHEP Program under the Office of Reporting,
Analytics, Performance, Improvement and Deployment (RAPID); and
the IPSOS team for input on the survey content and executing the
This work was supported by the Department of Veterans Affairs
Quality Enhancement Research Initiative Program (PEC 16-354).
Conflict of Interest:
The authors declare that they do not have a
conflict of interest.
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