Providers' and Administrators' Perceptions of Complementary and Integrative Health Practices Across the Veterans Health Administration.

OBJECTIVES: Use of complementary and integrative health (CIH) therapies is being promoted by the Veterans Health Administration (VA), but promotion may not equate to adoption. The purpose of this study was to explore whether perceptions regarding CIH at one VA medical center (VAMC) were similar to perceptions from a sample of other VAMCs. DESIGN: This article reports a subset of qualitative findings from a mixed-methods study. SETTING/PARTICIPANTS: Sites were recruited through a VA-wide CIH listserver. On the basis of site description (e.g., therapies offered, interest in CIH), sustained site interest, and geographic location, recorded interviews of 22 persons were conducted at 6 sites across the country. OUTCOME MEASURES: Interviewees were asked the same questions as the single-site VAMC study respondents. RESULTS: Variable access to CIH services across the VA created the need for workarounds. Multiple barriers (e.g., limited space and challenging credentialing) and facilitators (e.g., strong champion and high veteran demand) were cited. Respondents described nonpharmacologic pain control, the usefulness in treating mental health and/or post-traumatic stress disorder issues, and improvement of staff morale as additional reasons to promote CIH. Findings confirmed those from the earlier single-site VAMC phase of the study. Even the highest-performing sites reported struggling to meet veterans' demands for delivery of CIH. CONCLUSIONS: Almost half of active-duty military personnel report the use of at least one type of CIH therapy. As active-duty personnel transition to veteran status, both their physical and mental healthcare needs can potentially benefit from CIH therapies. The VA must actively support local enthusiastic CIH proponents and receive congressional support if it is to actually meet its stated goal of providing personalized, proactive, patient-driven healthcare through the promotion of comprehensive CIH services to veterans.

Perceptions of other integrative health therapies by Veterans with pain who are receiving massage.

Veterans are increasingly using complementary and integrative health (CIH) therapies to manage chronic pain and other troubling symptoms that significantly impair health and quality of life. The Department of Veterans Affairs (VA) is exploring ways to meet the demand for access to CIH, but little is known about Veterans' perceptions of the VA's efforts. To address this knowledge gap, we conducted interviews of 15 inpatients, 8 receiving palliative care, and 15 outpatients receiving CIH in the VA. Pain was the precipitating factor in all participants' experience. Participants were asked about their experience in the VA and their opinions about which therapies would most benefit other Veterans. Participants reported that massage was well-received and resulted in decreased pain, increased mobility, and decreased opioid use. Major challenges were the high ratio of patients to CIH providers, the difficulty in receiving CIH from fee-based CIH providers outside of the VA, cost issues, and the role of administrative decisions in the uneven deployment of CIH across the VA. If the VA is to meet its goal of offering personalized, proactive, patient-centered care nationwide then it must receive support from Congress while considering Veterans' goals and concerns to ensure that the expanded provision of CIH improves outcomes.

Perceptions of providers and administrators in the Veterans Health Administration regarding complementary and alternative medicine.

BACKGROUND: The integration of complementary and alternative medicine (CAM) therapies into a large organization such as the Veterans Health Administration (VHA) requires cultural change and deliberate planning to ensure feasibility and buy-in from staff and patients. At present, there is limited knowledge of VHA patient care providers' and administrators' viewpoints regarding CAM therapies and their implementation. OBJECTIVES: Our purpose was to qualitatively examine knowledge, attitudes, perceived value and perceived barriers, and/or facilitators to CAM program implementation among VHA providers and administrators at a large VHA facility. RESEARCH DESIGN: We are reporting the qualitative interview portion of a mixed-methods study. SUBJECTS: Twenty-eight participants (patient care providers or administrators) were purposely chosen to represent a spectrum of positions and services. Participants' experience with and exposure to CAM therapies varied. MEASURES: Individual interviews were conducted using a semi-structured format and were digitally recorded, transcribed, and coded for themes. RESULTS: Recurrent themes included: a range of knowledge about CAM; benefits for patients and staff; and factors that can be facilitators or barriers including evidence-based practice or perceived lack thereof, prevailing culture, leadership at all levels, and lack of position descriptions for CAM therapists. Participants rated massage, meditation, acupuncture, and yoga as priorities for promotion across the VHA. CONCLUSIONS: Despite perceived challenges, providers and administrators recognized the value of CAM and potential for expansion of CAM within the VHA. Interview results could inform the process of incorporating CAM into a plan for meeting VHA Strategic Goal One of personalized, proactive, patient-driven health care across the VHA.

Management of chronic noncancer pain by VA primary care providers: when is pain control a priority?

OBJECTIVE: To examine how primary care providers (PCPs) prioritize management of chronic pain in patients with multiple chronic conditions and to determine PCP perspectives on chronic pain management and pain treatment resources. STUDY DESIGN: Survey mailed to a random sample of 500 Department of Veterans Affairs (VA) PCPs at VA medical centers and community-based outpatient clinics. METHODS: After reading a vignette describing a patient with multiple chronic conditions and chronic pain, PCPs were asked to identify the 3 most important issues to address during the visit. The survey also asked about the availability of services, and level of confidence and satisfaction with chronic pain management. RESULTS: A total of 279 eligible PCPs (57%) responded to the survey, 77% of whom identified pain control among the top 3 treatment priorities. PCPs who did not choose pain control were more likely to indicate that chronic pain patients should see a specialist (54% vs 35%, P = .006) and were less confident about using opioid analgesics (52% vs 72%, P = .002). Of the respondents, 86% reported psychology or mental health clinics were available at their clinic site; 71%, physical therapy; and 20%, multidisciplinary pain clinics. Most PCPs (74%) were satisfied with the quality of care they provide for patients with chronic pain but only 30% were satisfied with access to pain specialty services. CONCLUSION: Additional training opportunities for PCPs and more effective use of ancillary services may be needed for further improvements in care for chronic pain patients.

Social connectedness and patient recovery after major operations.

BACKGROUND: Social connectedness is thought to play an important role in overall health and well being. We hypothesized that social network size and other measures of social connectedness would predict perceived pain intensity, unpleasantness, and anxiety in veterans recovering after major thoracic or abdominal operations and influence postoperative complications and length of stay. STUDY DESIGN: Six hundred five patients from two Veterans Affairs' medical centers who participated in a randomized controlled trial of massage as adjuvant treatment for postoperative pain were the subjects of this study. Subjects' social networks were assessed by the numbers of friends or relatives an individual had and how frequently contact was made with members of their social network. Subjective outcomes were rated with visual analogue scales for 5 postoperative days. Daily opiate use, postoperative complications, and length of stay were also recorded. RESULTS: Mean (+/-SD) age was 63.8 years (+/-10.2 years) and 98.5% of participants were men. Those reporting a greater social network were older and had lower preoperative pain intensity, unpleasantness, and state and trait anxiety (p < 0.001). Considerably less pain intensity, unpleasantness, and opiate use were associated with increasing social network size during the first 5 postoperative days. After adjusting for preoperative values of pain and anxiety, these relationships were no longer statistically significant. Smaller social network size was associated with the likelihood of length of stay >or= 7 days (p = 0.03). CONCLUSIONS: These findings suggest that the effect of social networks on surgical outcomes can be mediated by their effect on levels of preoperative pain and anxiety. Patients should be screened preoperatively for pain and anxiety because these are strong predictors of a more difficult postoperative recovery.

Acute postoperative pain management using massage as an adjuvant therapy: a randomized trial.

HYPOTHESIS: Adjuvant massage therapy improves pain management and postoperative anxiety among many patients who experience unrelieved postoperative pain. Pharmacologic interventions alone may not address all of the factors involved in the experience of pain. DESIGN: Randomized controlled trial. SETTING: Department of Veterans Affairs hospitals in Ann Arbor, Michigan, and Indianapolis, Indiana. PATIENTS: Six hundred five veterans (mean age, 64 years) undergoing major surgery from February 1, 2003, through January 31, 2005. INTERVENTIONS: Patients were assigned to the following 3 groups: (1) control (routine care), (2) individualized attention from a massage therapist (20 minutes), or (3) back massage by a massage therapist each evening for up to 5 postoperative days. Main Outcome Measure Short- and long-term (> 4 days) pain intensity, pain unpleasantness, and anxiety measured by visual analog scales. RESULTS: Compared with the control group, patients in the massage group experienced short-term (preintervention vs postintervention) decreases in pain intensity (P = .001), pain unpleasantness (P < .001), and anxiety (P = .007). In addition, patients in the massage group experienced a faster rate of decrease in pain intensity (P = .02) and unpleasantness (P = .01) during the first 4 postoperative days compared with the control group. There were no differences in the rates of decrease in long-term anxiety, length of stay, opiate use, or complications across the 3 groups. CONCLUSION: Massage is an effective and safe adjuvant therapy for the relief of acute postoperative pain in patients undergoing major operations.