Complementary and Integrative Health Approaches and Pain
Care Quality in the Veterans Health Administration
Primary Care Setting: A Quasi-Experimental Analysis

This section is compiled by Frank M. Painter, D.C.
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FROM:   J Integr Complement Med 2023 (Mar 27) [EPUB] ~ FULL TEXT


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 files

Additional file 1: Appendix A. The chiropractic profession a scoping review (DOCX 13 kb)


  1. Institute of Medicine (IOM)
    Relieving Pain in America: A Blueprint for Transforming Prevention,
    Care, Education, and Research

    Washington, DC: The National Academies Press, 2011.

  2. 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): 1001-1006

  3. Schappert 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.

  4. 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.280.2.147

  5. Kerns 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.2003.09.0371

  6. Turk 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.2003.08.001

  7. Veterans Health Administration.
    VA Pain Management Directive (2009-053)
    Department of Veterans Affairs: Washington, DC, USA; 2009.

  8. 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): 16–23

  9. Pangarkar 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/s11606-019-05086-4

  10. Rosland 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.

  11. 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.x

  12. Veterans Health Administration.
    Provision of Complementary and Integrative Health Directive (2017-1137)
    Department of Veterans Affairs: Washington, DC, USA; 2017.

  13. 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): 493–505

  14. Taylor 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.2018.0276

  15. Farmer 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.2020.0395

  16. Furlan 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: 10.1155/2012/953139

  17. Qaseem 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): 514–530

  18. Nahin 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.2016.06.007

  19. Ashrafioun 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.2018.05.008

  20. Han 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/pny027

  21. Kerns 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/s13142-011-0094-3

  22. Luther 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.0000000000002477

  23. Dorflinger 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/s13142-014-0260-5

  24. Corson 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.x

  25. Goulet 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.0000000000000567

  26. Facility Complexity Model.
    VHA Office of Productivity, Efficiency and Staffing (OPES).
    Available from:
    [Last accessed: November 8, 2022].

  27. 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.2739

  28. Stuart EA.
    Matching methods for causal inference: A review and look forward.
    Stat Sci 2010;25(1):1–21; doi: 10.1214/09-STS313

  29. Sturmer 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.12197

  30. Austin 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: 10.1177/0272989X09341755

  31. McCulloch CE, Searle SR.
    Generalized, Linear and Mixed Models.
    John Wiley & Sons: New York, NY, USA; 2001; pp. 220–246.

  32. 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/s11606-019-05339-2

  33. Department of Veterans Affairs.
    Whole Health. 2022. Available from:
    [Last accessed: July 6, 2022].

  34. Declaration of Astana:
    Global Conference on Primary Health Care. 2018. Available from:
    [Last accessed: November 8, 2022].

  35. 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.0000000000001042

  36. AMA 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



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