Complementary and Integrative Health for Pain in the VA: A National Demonstration Project

项目总结/摘要 背景超过一半的退伍军人报告肌肉骨骼（MSK）疼痛，通常伴有精神健康合并症。 补充和综合健康（CIH）疗法是重要的非药物治疗选择， 了以下条件然而，CIH在VA并不广泛使用。此外，免疫递送疗法（即， 针灸或脊椎指压疗法）是有前途的，但提供者希望病人在他们的痛苦更积极 通过使用自我护理的管理（即，冥想，太极，瑜伽），而不是依赖于冥想者提供的护理。 该领域的一个关键问题是，将自我护理CIH添加到辅助人员提供的CIH中是否更有效。 而不是单独的战略。然而，我们不知道有人在研究这一点。此外，到目前为止， 在大型VA样本中研究CIH一直很困难，因为很少有设施在其 电子健康记录，很少使用VA的标准化代码，防止多站点研究。在2016年， 国会通过了《综合成瘾和康复法案》，授权扩大CIH疗法， 弗吉尼亚作为回应，18个VA区域网络承诺每年投入500万美元，在18个地点实施CIH疗法 从2018年开始，专注于五种循证疗法：针灸，脊椎按摩，太极，正念， 还有瑜伽VA的以患者为中心的护理和文化转型办公室（OPCC&CT）将监督这一点。 这一努力包括针对18个站点中每个站点的1 000名CIH用户的数据收集工作。我们提出 通过继续与OPCC&CT的长期合作来解决上述差距，以利用1） 2018年在18个VA站点推出CIH，2）我们目前对CIH影响的两项国家/多站点研究，一项是关于 MSK疼痛和另一种将CIH患者报告的结局（PRO）测量整合到临床 在乎我们提出了一个大规模的务实的比较有效性的临床试验，以评估CIH。在UG 3 规划阶段，随着18个研究中心开始实施CIH，我们将制定和实施数据收集 我们目前正在试验的仪器和过程，以捕获CIH的使用和PRO：1）疼痛及其强度 和干扰，2）整体身心健康和3）疲劳。我们还将研究阿片类药物的使用。到 在进行衡量时，我们将采用多种战略，包括设立一个咨询委员会。在UH 3 在实施阶段，我们将采用鼓励设计进行三组务实试验， 纵向比较效果：1）针灸师提供的护理（针灸或脊椎按摩 护理）与自我护理（太极，冥想/正念或瑜伽）相结合， 3、自己照顾自己;我们将检查OPCC&CT目标样本的3个月和6个月结果， 18 000名CIH用户。我们将使用随机“轻推”（例如，教育小册子与类列表）， 每个站点都鼓励使用一种CIH的退伍军人考虑联合治疗。

PROJECT SUMMARY/ABSTRACT Background. Over half of Veterans report musculoskeletal (MSK) pain, often with mental health comorbidities. Complementary and integrative health (CIH) therapies are important non-pharmacologic treatment options for these conditions. However, CIH is not widely available at the VA. Also, practitioner-delivered therapies (i.e., acupuncture or chiropractic) are promising, but providers would like patients to be more active in their pain management by using self-care (i.e., meditation, tai chi, yoga) instead of relying on practitioner-delivered care. A critical question for the field is whether adding self-care CIH to practitioner-delivered CIH is a more effective approach than either strategy alone. However, we are unaware of anyone examining this. Also, to-date, studying CIH in large VA samples has been difficult because few facilities capture CIH use with codes in their electronic health records, and very few use the VA's standardized codes, preventing multi-site studies. In 2016, Congress passed the Comprehensive Addiction and Recovery Act mandating expansion of CIH therapies in VA. In response, 18 VA regional networks committed $5 million/yr to implement CIH therapies at 18 sites beginning in 2018, focusing on five evidence-based therapies: acupuncture, chiropractic, Tai Chi, mindfulness, and yoga. The VA's Office of Patient Centered Care and Cultural Transformation (OPCC&CT) will oversee this effort, including the data collection efforts targeting 1,000 CIH users from each of the 18 sites. We propose addressing the above gaps by continue our longstanding collaboration with OPCC&CT to capitalize on 1) the 2018 rollout of CIH in 18 VA sites and 2) our two current national/multisite studies of the effects of CIH, one on MSK pain and the other which integrates CIH patient reported outcomes (PROs) measurement into clinical care. We propose a large-scale pragmatic comparative effectiveness clinical trial to assess CIH. In the UG3 Planning Phase, as the 18 sites begin implementing CIH, we will develop and implement data collection instruments and processes that we are currently piloting to capture CIH use and PROs: 1) pain and its intensity and interference, 2) global physical and mental health and 3) fatigue. We also will examine opioid use. To inform that measurement, we will use multiple strategies, including an Advisory Board. In the UH3 Implementation Phase, we will conduct a 3-arm pragmatic trial using an encouragement design to assess the longitudinal comparative effectiveness of: 1) practitioner-delivered care (acupuncture or chiropractic care) combined with self-care (Tai Chi, meditation/mindfulness or yoga) compared to 2) practitioner-delivered care alone or 3) self-care alone. We will examine outcomes at 3 and 6 months for OPCC&CT's target sample of 18,000 CIH users. We will use randomized “nudges” (e.g., educational brochures with class listings) tailored to each site to encourage Veterans who use one type of CIH to consider a combination of therapies.