Chronic musculoskeletal pain and some common co-morbid conditions are costly to treat and highly prevalent among OEF/OIF/OND Veterans. Provision of complementary and integrative health therapies (CIH, a main component of "whole health", or CAM) are a VHA-wide priority, are available throughout the VA and appear to be effective at treating some types of chronic musculoskeletal pain. Little is known about what CIH approaches Veterans with chronic musculoskeletal pain use and whether CIH use results in reductions in pain, opioid use, or healthcare costs.
We examined the cost effectiveness of CIH therapies in improving chronic musculoskeletal pain and six comorbid conditions among Veterans of OEF/OIF/OND wars. Aims: (1) determine the extent of CIH use; (2) determine costs associated with CIH use; (3) determine the cost effectiveness of adjunctive CIH use compared to usual care alone as well as the healthcare cost impact of CIH use with both pain and pain-comorbid conditions; and (4) obtain feedback on CIH use, CIH costs and study results using an advisory board of key VA stakeholders with expertise in CIH and pain.
We created a cohort of Veterans of OEF/OIF/OND wars with chronic musculoskeletal pain who used the VHA between 2010-2013 (n=530,216) and retrospectively examined veterans' use of nine CIH therapies. The cohort and its data on CIH use took over two years to assemble, given the complexity of the sample and using natural language processing to derive CIH use data.
Pain Outcome: We defined chronic musculoskeletal pain as either: 1) having 2+ visits with musculoskeletal diagnosis codes likely to represent chronic pain separated by 30-365 days or 2) 2+ visits with musculoskeletal diagnosis codes within 90 days and with 2+ numeric rating scale pain scores >4 at 2+ visits within 90 days. Applying either of our two chronic musculoskeletal diagnosis criteria would have produced similar results: 99% of our cohort met the first criterion and 91% met the second.
Pain Comorbid Outcomes: Traumatic brain injury (TBI), PTSD, substance abuse disorder, sleep disturbance, symptoms of anxiety, and symptoms of depression.
CIH Use: Our advisory group recommended we examine nine CIH therapies because of the evidence base and relevance to pain: acupuncture, biofeedback, guided imagery, therapeutic massage, meditation, Tai Chi, yoga, hypnosis, and chiropractic visits. To identify CIH therapy use, we conducted electronic medical record searches for 1) structured data (i.e., clinic procedure [CPT4] codes, VA administrative ["CHAR"] codes used to note CIH use in medical records, or chiropractic provider codes and 2) unstructured narrative clinical notes of CIH use. For unstructured narrative notes, we used natural language processing (NLP) text mining techniques. We defined "CIH use" as having either a structured code signifying CIH or being in an NLP "definite" or "probable" CIH use category. We defined "no CIH use" as having no structured code signifying CIH and being in the NLP "no" CIH use category.
Analysis: To examine predictors of CIH use, we excluded those with unclear use of CIH therapies based on NLP findings, reducing the analytic sample to 468,806. To examine the cost effectiveness, we used combination of multi-level regression modeling and propensity score analysis, and double robust estimation methods for comparisons. We examined the effects on pain and opioid use over a year. Costs were VHA healthcare costs. We also performed sensitivity analyses.
[From Taylor et al., 2018] Over a quarter (27%) of younger veterans with chronic musculoskeletal pain used any CIH therapy, 15% used meditation, 7% yoga, 6% acupuncture, 5% chiropractic, 4% guided imagery, 3% biofeedback, 2% tai chi, and used 2% massage. Use of any CIH therapy was more likely among females, single patients, patients with three of six pain conditions, or patients with any of six comorbid conditions. [From Evans et al., 2018]. Within gender, additional age and race/ethnicity disparities in CIH use existed. Among women, patients under age 44 or Hispanic, White, or patients of other race/ethnicities were similarly likely to use CIH; in contrast, Black women, regardless of age, were least likely to use CIH. Among men, White and Black patients, and especially Black men under age 44, were less likely to use CIH than other men. [From Herman et al., 2019] CIH users differed from nonusers across all baseline covariates except the Charlson comorbidity index. They also differed on annual pre-CIH-start healthcare costs ($989 versus $637 for inpatient, $8,551 versus $4,370 for outpatient, and $1,161 versus $787 for pharmacy) ), pain (4.33 versus 3.76), and opioid use (66.6% versus 54.0%). The multi-level regression modeling results indicated lower annual healthcare costs (-$637; 95% CI: $1,023, $247), lower pain (-0.34; -0.40, -0.27), and slightly higher (< a percentage point) opioid use (0.76; 0.59, 0.93) for CIH users in the year after CIH start. Sensitivity analyses indicated similar results for three most-used CIH approaches (acupuncture, chiropractic, and massage), but a cost increase for Veterans with 8+ CIH visits. Also, our use of an Advisory Board guided us on which CIH to assess; how to define musculoskeletal pain; what CIH code words to use in natural language process searches, to examine only VA healthcare costs (which included CIH provision costs and excluded non-VA costs); and the implications of our findings for the VA (that CIH approaches hold promise for pain reduction and, as such, potentially opioid prevention, providing further evidence of the need to support their implementation).
This was the first VA widespread study of individual-level CIH use among Veterans with musculoskeletal pain and the impact of CIH use on pain, healthcare utilization and costs. Patients appear willing to use CIH therapies, given 27% used them. However, low rates of use for some specific CIH suggest the potential to increase CIH use. Furthermore, given that gender, race/ethnicity and age disparities in CIH use existed, it seems important to tailor CIH engagement efforts to reduce that differential CIH use. Finally, given that CIH use appears associated with subsequent lower healthcare costs and pain and slightly higher opioid use and given the VA's growing interest in CIH use, more detailed analyses of CIH's impacts are warranted.
- Herman PM, Yuan AH, Cefalu MS, Chu K, Zeng Q, Marshall N, Lorenz KA, Taylor SL. The use of complementary and integrative health approaches for chronic musculoskeletal pain in younger US Veterans: An economic evaluation. PLoS ONE. 2019 Jun 5; 14(6):e0217831.
- Taylor SL, Herman PM, Marshall NJ, Zeng Q, Yuan A, Chu K, Shao Y, Morioka C, Lorenz KA. Use of Complementary and Integrated Health: A Retrospective Analysis of U.S. Veterans with Chronic Musculoskeletal Pain Nationally. Journal of alternative and complementary medicine (New York, N.Y.). 2019 Jan 1; 25(1):32-39.
- Evans EA, Herman PM, Washington DL, Lorenz KA, Yuan A, Upchurch DM, Marshall N, Hamilton AB, Taylor SL. Gender Differences in Use of Complementary and Integrative Health by U.S. Military Veterans with Chronic Musculoskeletal Pain. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2018 Sep 1; 28(5):379-386.
Online News Media Articles
- Taylor SL. Veterans with pain increasingly using complementary and integrative therapies. VAntage Point: Official Blog of the US Department of Veteran Affairs [Internet]. 2017 Jul 27. Available from: https://www.blogs.va.gov/VAntage/39929/veterans-pain-increasingly-using-complementary-integrative-therapies/.
HSR&D or QUERI Articles
- Taylor SL, Lorenz K. A VA Priority: Complementary and Integrative Health Approaches to Addressing Pain. VA HSR&D Forum. 2016 May 1; 2016(Spring): 6-8.
- Evans EA, Taylor SL. Gender Disparities in the Use of Complementary and Integrative Health by U.S. Military Veterans with Chronic Musculoskeletal Pain. Spotlight on Women's Health [Cyberseminar]. VA HSR&D. 2018 Nov 29.
- Taylor S, Herman P. The Cost-Effectiveness of Complementary and Alternative Treatments to Reduce Pain: A Work in Progress. Health Economic Resource Center (HERC) [Cyberseminar]. HSR&D. 2017 Feb 15.
- Taylor SL, Herman P, Lorenz K. The Use of Complementary and Integrative Health in the OEF/OIF/OND Veteran Population. Spotlight on Pain Management [Cyberseminar]. HSR&D. 2017 Jan 10.