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

项目摘要/摘要 背景资料。超过一半的退伍军人报告肌肉骨骼(MSK)疼痛，通常伴有心理健康并发症。 补充和综合健康(CIH)疗法是重要的非药物治疗选择 这些条件。然而，退伍军人管理局并没有广泛提供CIH。此外，从业者提供的疗法(即， 针灸或脊椎按摩)是有希望的，但提供者希望患者在疼痛时更积极 通过自我护理(即冥想、太极、瑜伽)进行管理，而不是依赖于实践者提供的护理。 该领域的一个关键问题是，在从业者提供的CIH中增加自理CIH是否更有效 任何一种方法都比单独使用任何一种策略都要好。然而，我们不知道有任何人在检查这一点。另外，到目前为止， 在大量VA样本中研究CIH一直是困难的，因为很少有设施捕获CIH的使用并在其 电子健康记录，很少使用退伍军人管理局的标准化代码，防止了多点研究。2016年， 年，国会通过了《全面成瘾和康复法案》，要求扩大CIH疗法。 弗吉尼亚州作为回应，18个退伍军人管理局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。退伍军人事务部以患者为中心的护理和文化转型办公室(OPCC&CT)将监督这一工作 努力，包括针对18个站点中每个站点的1,000名CIH用户进行的数据收集工作。我们建议 通过继续我们与OPCC和CT的长期合作来解决上述差距，以利用1) 2018年在18个退伍军人管理局站点推出CIH，2)我们目前对CIH影响的两项全国性/多站点研究，一项是 MSK Pain和另一个将CIH患者报告结果(PROS)测量集成到临床中的应用 关心。我们提出了一项大规模实用的比较有效性临床试验来评估脑出血。在UG3中 规划阶段，随着18个站点开始实施CIH，我们将开发和实施数据收集 我们目前正在试验的用于捕捉CIH使用情况和优点的仪器和流程：1)疼痛及其强度 和干扰，2)全球身心健康和3)疲劳。我们还将检查阿片类药物的使用情况。至 在通知这一衡量标准时，我们将使用多种战略，包括咨询委员会。在UH3 实施阶段，我们将采用激励设计进行三臂务实试验，以评估 纵向比较效果：1)医生提供的护理(针灸或脊椎按摩 护理)与自我护理(太极、冥想/正念或瑜伽)相比较 单独照顾或独自照顾自己。我们将检查OPCC&CT目标样本3个月和6个月的结果 1.8万名CIH用户。我们将使用随机化的“轻推”(例如，带有课程清单的教育手册)，以满足 每个网站鼓励使用一种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.