Evolving use of Evolving use of CComplementary omplementary and and AAlternative lternative MMedicine edicine

(CAM) (CAM) and Integrative Health and Integrative Health

in the VAHCSin the VAHCS

Sandra J W Smeeding PhD, CNS, FNP-BCAssociate Director Integrative Health

VA Salt Lake City

ObjectivesObjectives

1. Describe the scientific model of healthcare and the emergence of new models that include CAM.

2. Learn about VAHCS surveys reveal about CAM use and practice.

3. Describe VAHCS CAM initiative opportunities.

4. Describe VAHCS CAM initiative challenges and barriers.

Scientific Disease ModelScientific Disease Model

• Medical Scientific modelMedical Scientific model: pathophysiology of disease, cellular and molecular, mechanistic knowledge.

• Multiple specialties and subspecialtiesMultiple specialties and subspecialties, all necessary; focus attention on parts with pharmaceuticals to fix the parts.

• Increase in Chronic DiseaseIncrease in Chronic Disease: 33% have one, nearly 65% >65 yrs. have > one chronic illness, decreasing quality of

life, increasing health care utilization and expenditures.

- 41% of soldiers < 30 yrs. from Iraq and Afghanistan have HTN, MH concerns PTSD, depression, anxiety, back pain.

• CostCost:: Chronic care > $1.5 trillion/yr or 75% of all medical expenses. US highest in healthcare cost - 37th in national health (1).

Chronic Illness Chronic Illness

• Multiple medicationsMultiple medications, many specialists, a “pill for every ill.”

• Non AdherenceNon Adherence/ADR’s/Side effects/Drug recalls/ADR’s/Side effects/Drug recalls:

- 6% hospital admissions traced to non adherence (2-3).

- 40-50% Diabetics, 40% HTN don’t follow medication Rx.

- 40% Depression stop taking medication in 3 months and another 50% in 4 months.

• Chronic complex problemsChronic complex problems involve the mental, emotional, social, environmental and physical.

• Science and technology, the pathophysiological model alone are insufficient to shape healthcare.

Emergence of Complementary and Emergence of Complementary and Alternative Medicine (CAM) and Alternative Medicine (CAM) and

Integrative HealthIntegrative Health• CAM useCAM use: JAMA (1998) more than 42% of surveyed adults

used complementary therapies.(4).

- 629 million visits to alternative practitioners . - $21 Billion spent with $12 billion out of pocket.

• 2007 National Health Interview Survey (NHIS),2007 National Health Interview Survey (NHIS), approximately 38 percent of Americans, adults use CAM.

• Integrative Health is a bridgeIntegrative Health is a bridge between conventional and CAM assisting in epidemic of chronic diseases related to patient centered, self-management and prevention focus (5).

Why use CAM?Why use CAM?• Pursuit of well-being.

• Maintain improve health and health related quality of life, disease prevention.

• New method/relief from suffering from chronic illness.

• Uninsured-limited access to care.

• Cost effective, not high tech.

• Concerns about pharmaceuticals safety: multiple medications, safety recalls, side effects.

Klemm analysis Assessment of Current VHA Practices and Future

Opportunities(1999)• A benchmark study: CAM Literature review, site visits

VHA provider survey and expert opinions .

• Every VA site reported some CAM therapies use.

• Providers insufficient knowledge of CAM to use or refer and varying belief’s within each facility.

• Internal communication about CAM minimal, Education and communication critical barriers.

• Veterans have chronic conditions not responding well to conventional treatments, a large proportion are using CAM for management of chronic conditions (6).

Klemm Analysis (con’t)Klemm Analysis (con’t)

• Systematically understand Veterans CAM use.

• Extend scientific literature review for CAM.

• Expand research on safety, efficacy and cost effectiveness in prevalent chronic conditions.

• Consider expanding CAM for diseases that conventional treatments are not optimally effective.

• Adopt quality standards for CAM substances sold at VA retail concessions.

White House commission on White House commission on Complementary and Alternative Complementary and Alternative

Medicine (2002)Medicine (2002)• Ensure public policy maximizes potential benefits of CAM (7). • Four main areas of focus:

-Coordination of research to increase knowledge. -Education and training of CAM healthcare providers.-Reliable and useful information about CAM practices. -Guidance for appropriate access to and delivery of CAM.

• Emphasis of Report: Whole person care, individualization, evidence of safety and efficacy, partnership, prevention, wellness/health promotion and self-care as guiding principles.

• 19 of 29 white House commission recommendations applicable to VA.

1.1. Research reviewResearch review: evidence on safe and effective.

2. Credentialing of VA CAM ProvidersCredentialing of VA CAM Providers to ensure safety.

-- Establish standards for training, credentialing, scope of practice for CAM practitioners-guidelines completed(2010).

- - Identify therapies & practices to be integrated into VA care.

- - Implementation strategies: therapies, resources, timelines.

3.3. Research and FundingResearch and Funding: Assist ORD.

4.4. Education and TrainingEducation and Training of CAM Providers and Community of Practice. Clearing house for information.

A. VAHCS CAM SurveyA. VAHCS CAM Survey: CAM Use & Practices- (2002) and repeat survey (2010).

National VA CAM Field AdvisoryNational VA CAM Field Advisory(2002)(2002)

VA Hospital Survey: VA Hospital Survey: CAM Use and Practices (HAIG-2002CAM Use and Practices (HAIG-2002) • 98% response response (8).

• 84% VA’s provided or referred out for CAM therapies VA’s provided or referred out for CAM therapies. 16% (23 locations) did not.

• CAM therapiesCAM therapies (21): Acupressure, acupuncture, aromatherapy, biofeedback, herbal/nutritional supplements, energy healing, Guided Imagery, hypnotherapy, massage, meditation, music therapy, Native Am. Healing, chiropractic, stress management, relaxation therapy, Tai chi/Qigong, yoga.

• Therapies at VA sitesTherapies at VA sites: Stress management, relaxation (86), Biofeedback (66), Guided Imagery (65), Hypnosis (48), Music (38), Meditation (36), Acupuncture (32), Massage (32).

VA Hospital Survey: VA Hospital Survey: CAM Use and Practices (HAIG-2002)CAM Use and Practices (HAIG-2002)

• Chronic diseaseChronic disease: #1 Stress management, Pain, Anxiety, Back pain, Headache/migraine, Depression.

• Clinical privileging of CAM Therapies & Clinical privileging of CAM Therapies & ProvidersProviders: Clinical Executive Board (45), Professional Standards Board (74), provider supervisor (54), other (28) and no process (21).

• Providers offering CAMProviders offering CAM: Psychologist (310), Nursing (NP,CNS,RN) (106), MD/DO (85), PT/OT (68), LCSW (66), Clergy (32).

• SummarySummary: Wide use of CAM, Limited evidence, additional research; need for integrative models

Complementary and Alternative Complementary and Alternative Medicine use by VeteransMedicine use by Veterans

Primary Care Survey, VA Southern Arizona.

-50% reported CAM50% reported CAM use use for chronic pain & illness as well as prevention/health promotion (9).

- Mind-body therapies, energy medicine, TCM, nutritional and spiritual modalities.

- Veterans generally satisfied with conventional care (10).

- Dissatisfied: reliance on pharmaceuticals, lack of whole person approach, inadequate

information nutrition, exercise, social and spiritual aspects of health.

Complementary and Alternative Complementary and Alternative Medicine use by VeteransMedicine use by Veterans

• Oncology & Chronic Pain SurveyOncology & Chronic Pain Survey, VA Bedford, Mass (11).

• 6 selected CAM treatments: herbs/dietary supplements, homeopathy chiropractic, massage, acupuncture.

• 27% Veterans reported CAM use Veterans reported CAM use in the past 12-months. No

difference in use between groups.

• 76% of CAM non-users would usewould use it if offered at the VA.

Complementary and Alternative Complementary and Alternative Medicine and VA ProvidersMedicine and VA Providers

• VA Integrative & CAMVA Integrative & CAM (icam) list serve: >159 VA staff; Elizabeth.Hakas@va.gov (need VA e-mail address).

• VA AcupunctureVA Acupuncture list serve: > 80 VA staff; Elizabeth.Hakas@va.gov (need VA e-mail address).

• VASLCVASLC experience and assistance experience and assistance to VA sites and providers in over 27 states on the integration of CAM (12). Sandra.Smeeding@va.gov .

• Samueli/VA webinarsSamueli/VA webinars: Integrative health business plan; PTSD and acupuncture research.

• Innovation in Practice AwardsInnovation in Practice Awards.

The Patient Protection and The Patient Protection and Affordable Care Act (PPACA)Affordable Care Act (PPACA)

• TitleTitle IVIV—Prevention—Prevention of chronic disease and improving public health, modernizing disease prevention (subtitle A).

• Federal Coordination Federal Coordination CouncilCouncil and leadership of prevention, wellness, health promotion.

• Evidence-based, innovative, transformative models for prevention, integrative healthintegrative health, on individual and community level.

• Advisory GroupAdvisory Group including integrative health practitioners addressing health promotion, prevention and lifestyle.

CAM Effectiveness ConsiderationsCAM Effectiveness Considerations

• Evidence base, research methods.Evidence base, research methods.• Clinical effectiveness evaluationClinical effectiveness evaluation modelmodel - health outcomes.

- Have final approval from government regulatory bodies.- The scientific evidence on the effect on health outcomes.- Must improve the net health outcome.- Must be beneficial as any current, established treatment.- Improvement must be attainable outside the

investigational research setting in clinical settings.

• Medicare: reasonable and necessary:Medicare: reasonable and necessary: - Safe and effective.- Not experimental or investigational.- Appropriate.

Educational and Cost Effectiveness Educational and Cost Effectiveness ConsiderationsConsiderations

• Inconsistent CAM provider standards and scope of practice: credentialing, licensing, and regulations across state lines.

Acupuncturist in 35 states (11 states have introduced legislature), massage in 27 states, naturopathic in 14 states, homeopathic in 4 states.

- Practice of CAM without sufficient CAM training or credentials.

• Cost driven HCS, need CAM studies on cost-effectiveness.

- Need for uniform or consistent insurance coverage criteria for eval. and comparative analyses of CAM and conventional tx.

- Cost & outcomes of CAM providers: MD CAM & non MD CAM.

VA CAM initiative VA CAM initiative Opportunities and strengthsOpportunities and strengths

• Chronic conditionsChronic conditions not responsive to convention treatment may be responsive to CAM.

• VHA centralized, regional and local mechanismsVHA centralized, regional and local mechanisms enabling overall uniform consistent standards and criteria.

• Regional & localRegional & local phased implementation tailored to local conditions.

• Collaborative relationshipsCollaborative relationships: academic and research .

• Opportunity to conductOpportunity to conduct outcomes researchoutcomes research contributing to scientific literature.

• Offer patient servicesOffer patient services used by a large and growing percent of U.S population.

VA VA Integration of CAMIntegration of CAM Considerations and Challenges Considerations and Challenges

• AcceptanceAcceptance VA providers, administration, management, staff.

• Clinical effectiveness & Research:Clinical effectiveness & Research: objective eval. methods (13,14).

• StandardizationStandardization of education, training, licensure, certification providers.

• Cost effectivenessCost effectiveness of modalities and provider classifications.

• Operational and Implementation stepsOperational and Implementation steps clearly articulated goals.

• Definition of successDefinition of success realistic and clear from the beginning.

• EducationEducation on CAM on CAM use, methods, diagnosis, communication!

Integration of Conventional and Integration of Conventional and CAM BenefitsCAM Benefits

• CombinedCombined - addresses the physical, emotional and spiritual aspects of health and disease, health promotion and prevention.

• Whole personWhole person, CAM long hx. of use in world cultures.

• Can reduce sufferingreduce suffering, , improve health related Quality of Lifeimprove health related Quality of Life.

• Promotes Promotes patient self-management & empowerment & empowerment.

• Veteran/consumer and provider demandVeteran/consumer and provider demand..

• May reduce cost: May reduce cost: self management, decreased utilization of chronic care long term.

References

1. Center for Disease Control and Prevention Chronic disease prevention (2009).

2. Sullivan SD, Kreling DH, Hazlet TK. Noncompliance with medication regimens and subsequent hospitalizations: literature analysis and cost of hospitalization estimate. Res Pharm Ec. 1990;2(2):19-33.

3. Nagasaw, Smith MC, Barnes JH, Fincham JE. Meta-analysis of correlates of diabetes patients' compliance with prescribed medications. Diabetes Educ. 1990;16(3):192-200.

4. Eisenberg DM, Davis RB, Etner SL, et al. Trends in alternative medicine use in the United States, 1990-1997. JAMA. 1998;280:1569-1575.

5. Maizes V, Rakel D., Niemiee J., Integrative Health and patient centered care. Explore J Science and Healing (2009)5(5):277-289

References

6. Klemm Analysis Group: Alternative Medicine Therapy: Assessment of Current VHA Practices and Opportunities.(1999) Washington, DC.

7. White House Commission on Complementary and Alternative Medicine Policy, Final Report (2002) www.whccamp.hhs.gov

8. Rick C, Feldman J, et al Survey of complementary and alternative medicine (CAM) (2002). Washington, DC: Department of Veterans Affairs Health Administration. Office of Policy and Planning, Healthcare Analysis and Information Group.

9. Baldwin C, Long K, Kroesen K. A profile of military veterans in the southwestern US who use complementary and alternative medicine: Implications for integrated care Arch. Intern. Med.(2002) 12:1697-1704.

10. Kroesen K, Baldwin C. et al: U.S. military veterans’ perceptions of the conventional medical care system and their use of CAM. Family Pract. (2002),19:57-64.

References

11. McEachrane-Gross, Liebschutz J Berlowitz D., Use of selected complementary and alternative medicine (CAM) treatments in veterans with cancer or chronic pain: a cross-sectional survey BMC Comple & Alt Med.. (2006) (6)34:1-7.

12. Smeeding S, Osguthorpe S., Development of an Integrative Healthcare Model in the Salt Lake City Veterans Affairs. Healthcare System. Altern Ther Health Med. (2005) 11:46-51.

13. Smeeding S, Bradshaw D, et al Outcome evaluation of the Veterans Affairs Salt Lake City Integrative Health Clinic for Chronic Pain and Stress related depression, anxiety and Post Traumatic Stress Disorder. J. Alt and Compl. Med.,Aug. (2010) .

14. Smeeding S, Bradshaw D, et al: Outcome evaluation of the Veterans Affairs Salt Lake City Integrative Health Clinic for chronic nonmalignant pain Clin. J. Pain Fall (2010)