Cost Savings from Reducing Pain Through the Delivery of Integrative Medicine Program to Hospitalized Patients

Health Resource Utilization and Cost Impact of Integrative Medicine Services for Newly Diagnosed Chronic Pain Patients

Background: Integrative medicine (IM) is the healing-oriented practice of medicine that emphasizes the relationship between practitioner and patient. It considers the whole person, their environment, lifestyle, and social and cultural factors. It is evidence based and makes use of all appropriate therapies, conventional and complimentary. Objective: To evaluate the impact of IM services on health outcomes and care costs of chronic pain management patients compared with standard care. Methods: This article uses University of New Mexico hospital billing data from 10/2016 to 09/2019 to identify patients with nervous system or musculoskeletal pain. A total of 1,304 patients were matched using propensity scores into IM services (treatment: 652) and standard care (control: 652) cohorts for difference-in-differences analysis. The patients were matched based on age, sex, race, zip code, insurance type, ICD-10s, prescriptions, health care events, and medical claim costs. Results: Patients who used IM services had better health outcomes and lower costs at 3-month, 6-month, and 12-month follow-up. At the 12-month follow-up, the IM group showed a 19% decrease in utilization of inpatient care, a 37% decrease in Emergency Department utilization, and an 11.3% reduction in claim costs compared with the control group. Conclusion: Patients who utilize IM services as part of chronic pain management have overall lower health care costs and better health outcomes. Unfortunately, in the health system studied, less than 3% of patients utilize these services. Promotion of and education about IM services should be aimed at both patients and their providers.

Implementing paper-based patient-reported outcome collection within outpatient integrative health and medicine

OBJECTIVE

To investigate the feasibility of pre- and post-encounter patient-reported outcome (PRO) measure collection within an outpatient integrative health and medicine (IHM) clinic and to characterize factors associated with successful completion.

METHODS

We conducted a retrospective review of 27,464 outpatient IHM encounters including 9,520 chiropractic; 8,237 acupuncture; 5,847 massage; 2,345 IHM consultation; and 1,515 osteopathic manipulation treatment encounters at four clinics offering IHM over 18 months. Patients were asked to complete paper questionnaires rating pain, anxiety, and stress from 0-10 immediately pre- and post-encounter. Generalized linear mixed effect regression models were used to examine the relationship between demographic, clinical, and operational covariates and completing (1) pre-encounter and (2) paired (i.e., pre and post) PROs.

RESULTS

Patients (N = 5587, mean age 49 years, 74% white, 77% female) generally presented for musculoskeletal conditions (81.7%), with a chief complaint of pain (55.1%). 21,852 (79.6%) encounters were among patients who completed pre-encounter PROs; 11,709/21,852 (53.6%) completed subsequent post-encounter PROs. Odds of PRO completion were more impacted by provider, operational, and clinical-level factors than patient factors. Covariates associated with increased odds of pre-encounter PRO completion included being female, having additional IHM encounters, and having a pain or anxiety complaint. Covariates associated with increased odds of paired PRO completion included being aged 31-40 vs. 51-60 years and having additional IHM encounters.

CONCLUSION

Implementing a paper-based PRO collection system in outpatient IHM is feasible; however, collecting post-encounter PROs was challenging. Future endeavors should leverage the electronic health record and patient portals to optimize PRO collection and engage patients and clinical providers.

Mindfulness-Based Interventions for Perioperative Pain Management and Opioid Risk Reduction Following Surgery: A Stepped Care Approach

Surgical procedures often improve health and function but can sometimes also result in iatrogenic effects, including chronic pain and opioid misuse. Due to the known risks of opioids and the physical, emotional, and financial suffering that often accompanies chronic pain, there has been a call for greater use of complementary non-pharmacological treatments like mindfulness-based interventions. Mindfulness can be broadly described as an attentional state involving moment-by-moment meta-awareness of thoughts, emotions, and body sensations. An expanding number of randomized clinical trials have found strong evidence for the value of mindfulness techniques in alleviating clinical symptomology relevant to surgical contexts. The purpose of this review is to examine the empirical evidence for the perioperative use of mindfulness interventions. We present a mindfulness-based stepped care approach that first involves brief mindfulness to treat preoperative pain and anxiety and prevent development of postoperative chronic pain or opioid misuse. More extensive mindfulness-based interventions are then provided to patients who continue to experience high pain levels or prolonged opioid use after surgery. Finally, we review psychophysiological mechanisms of action that may be integral to the analgesic and opioid sparing effects of mindfulness.

The Impact of Inpatient Acupuncture on a Mixed Hospital Floor: A Pragmatic 3-Month Cost-Effectiveness Retrospective Evaluation

Objective

Viability of inpatient acupuncture is limited by current hospital reimbursement structuring. Research has primarily focused on length of stay (LOS) instead of cost of stay (COS). This study evaluated acupuncture as an option for inpatient pain control, determined if acupuncture influenced patient satisfaction during hospitalization, and examined any effects on LOS and COS.

Materials and Methods

In a quasiexperimental pilot research study, acupuncture was offered free of charge for 3 months on a single floor of an urban medical center. Pre- and postintervention scores, number of treatments, and diagnosis related groups (DRGs) of patients receiving acupuncture were tracked and then compared to a nonintervention, DRGs-matched group with overlapping hospital-floor and admission dates. LOS, COS, and patient satisfaction scores during the months of intervention were compared to the months before and after the intervention.

Results

Patients' pain significantly decreased each time they were treated. Consumer Assessment of Healthcare Providers and Systems scores increased to 85, 99, and 97 during the months of intervention and then returned to the lower, preacupuncture levels after acupuncture was no longer available. LOS was higher in the intervention group (+7.8 days), but acupuncture saved the hospital an anticipated $125,770 in the projected COS during that 3-month time alone.

Conclusions

Acupuncture was a potent pain-relief alternative for hospitalized patients, providing more satisfaction. Acupuncture resulted in longer LOS, but the aggregate COS was 86% less than expected. Acupuncture may be a financially viable, clinically impactful adjunct to hospital care.

Effectiveness of Medical Music Therapy Practice: Integrative Research Using the Electronic Health Record: Rationale, Design, and Population Characteristics

Background: Several clinical trials support the efficacy of music therapy (MT) for improving outcomes in hospitalized patients, but few studies have evaluated the real-world delivery and integration of MT across multiple medical centers. This article describes the rationale, design, and population characteristics of a retrospective study examining the delivery and integration of MT within a large health system. Methods: A retrospective electronic health record (EHR) review was conducted of hospitalized patients seen by and/or referred to MT between January 2017 and July 2020. MT was provided across ten medical centers, including an academic medical center, a freestanding cancer center, and eight community hospitals. Discrete demographic, clinical, and MT treatment and referral characteristics were extracted from the EHR, cleaned, and organized using regular expressions functions, and they were summarized using descriptive statistics. Results: The MT team (average 11.6 clinical fulltime equivalent staff/year) provided 14,261 sessions to 7378 patients across 9091 hospitalizations. Patients were predominantly female (63.7%), White (54.3%) or Black/African American (44.0%), 63.7 ± 18.5 years of age at admission, and insured under Medicare (51.1%), Medicaid (18.1%), or private insurance (14.2%). Patients' hospitalizations (median length of stay: 5 days) were primarily for cardiovascular (11.8%), respiratory (9.9%), or musculoskeletal (8.9%) conditions. Overall, 39.4% of patients' hospital admissions included a mental health diagnosis, and 15.4% were referred to palliative care. Patients were referred by physicians (34.7%), nurses (29.4%), or advanced practice providers (24.7%) for coping (32.0%), anxiety reduction (20.4%), or pain management (10.1%). Therapists provided sessions to patients discharged from medical/surgical (74.5%), oncology (18.4%), or intensive care (5.8%) units. Conclusions: This retrospective study indicates that MT can be integrated across a large health system for addressing the needs of socioeconomically diverse patients. However, future research is needed to assess MT's impact on health care utilization (i.e., length of stay and rates of readmission) and immediate patient-reported outcomes.

Immediate Effects of Integrative Health and Medicine Modalities Among Outpatients With Moderate-To-Severe Symptoms

Background

Patients seeking integrative health and medicine (IHM) modalities often present with multiple physical and psychological concerns. Research supports IHM's effectiveness for addressing symptoms over longer time periods. However, few studies have evaluated immediate outpatient effects.

Objective

This study describes pre-encounter patient-reported outcome (PRO) clusters and examines the immediate clinical effectiveness of IHM modalities on pain, stress, and anxiety among outpatients with moderate-to-severe symptoms.

Methods

A retrospective review was conducted of encounters among adults presenting to outpatient acupuncture, chiropractic, massage, integrative medicine consultation, or osteopathic manipulation treatment between January 2019 and July 2020. Encounters were included if patients reported pre-encounter pain, stress, or anxiety ≥4 on a numeric rating scale (NRS). Outcome analyses included random effects for patient and provider using a mixed model.

Results

Across 7335 clinical encounters among 2530 unique patients (mean age: 49.14 years; 81.0% female; 75.9% White; 15.8% Black/African American), the most common pre-encounter PRO clusters were pain, stress, and anxiety ≥4 (32.4%); pain ≥4 only (31.3%); and stress and anxiety ≥4 (15.6%). Clinically meaningful single-encounter mean [95% CI] changes were observed across all modalities in pain (-2.50 [-2.83, -2.17]), stress (-3.22 [-3.62, -2.82]), and anxiety (-3.05 [-3.37, -2.73]).

Conclusion

Patients presenting to outpatient IHM with moderate-to-severe symptoms most often presented with pain, stress, and anxiety ≥4 on the NRS. Multiple IHM modalities yielded clinically meaningful (≥2 unit) immediate reductions in these symptoms. Future research measuring immediate and longitudinal effectiveness is needed to optimize the triage and coordination of IHM modalities to meet patients' needs.

Integrative approach for women with fibromyalgia in a Veterans Affairs Medical Center: An observational study

Fibromyalgia, a complex condition characterized by widespread musculoskeletal pain, presents a significant burden on individuals and healthcare systems. This observational study aims to explore the potential of an outpatient integrative care model for the management of fibromyalgia in women, focusing on personalized goals, patient education, non-pharmaceutical treatments, and lifestyle modifications. The primary objective is to assess patient satisfaction and its correlation with pain, quality of life, depression, and post-traumatic stress disorder (PTSD) symptoms. This pilot study seeks to determine the effectiveness of this model in the alleviation of fibromyalgia-related pain and the improvement of overall well-being. Twenty-five women diagnosed with fibromyalgia participated in a 14-week outpatient treatment program at a Veterans Affairs Medical Center, involving weekly patient-directed, integrative group visits and health coaching. Pre- and post-evaluation questionnaires were administered to assess patient satisfaction, patients' subjective sense of empowerment in the management of fibromyalgia, and symptom improvement (i.e., pain, quality of life, depression, and PTSD). In addition, the study evaluated the correlation of patient empowerment with symptom improvement. The integrative care model received high patient satisfaction, with a mean score of 8.04 out of 10. Significant pain reduction was observed based on the Numeric Rating Scale (n = 22, P < .001). Quality of life showed significant improvement according to the Fibromyalgia Impact Questionnaire (n = 24, P = .01). Furthermore, depression symptoms improved significantly, as assessed by Patient Health Questionnaire (n = 24, P = .04). However, there was no statistically significant change in PTSD scores (n = 22, P = .3). Patient empowerment was strongly correlated with pain reduction (n = 25, r = .78, P < .001), quality of life (n = 25, r = .57, P < .001), and improvement in depression symptoms (n = 22, r = .50, P = .004). Pairwise deletion was used for each outcome. This integrative care model demonstrated promising results in effectively managing fibromyalgia-related pain and enhancing quality of life and depression symptoms in women. This model presents a feasible and potentially effective treatment approach for fibromyalgia. Further research with larger sample sizes and control groups is warranted to validate these findings and encourage broader implementation.

Complementary and Integrative Medicine: a plea for a better resource allocation by the SwissDRG grouping algorithm

No abstract available.

Retrospective Outcomes of a New Acupuncture Service at a Comprehensive Cancer Center

Introduction: Among cancer centers, patients' interest in acupuncture is growing, in addition to clinical research in the intervention. Their National Cancer Institute-designated comprehensive cancer center piloted an acupuncture service. Their aim was to assess whether acupuncture impacted patient self-reported symptoms as delivered clinically and discuss their implementation strategy. Methods: Patients undergoing acupuncture at a comprehensive cancer center from June 2019 to March 2020 were asked to complete a modified Edmonton Symptom Assessment Scale (ESAS) before and after each session. The authors evaluated symptom changes after acupuncture in both outpatient and inpatient settings. A change of ≥1 U, on the 0-10 scale, was considered clinically significant. Results: Three hundred and nine outpatient and 394 inpatient acupuncture sessions were provided to patients at the comprehensive cancer center during this period, of which surveys from 186 outpatient (34 patients) and 124 inpatient (57 patients) sessions were available for analysis. The highest pretreatment symptoms reported by outpatients were neuropathy (5.78), pain (5.58), and tiredness (5.59). Outpatients receiving acupuncture reported clinically significant improvements in pain (ESAS score change of -2.97), neuropathy (-2.68), decreased lack of well-being (-2.60), tiredness (-1.85), nausea (-1.83), anxiety (-1.56), activities of daily living issues (-1.32), depression (-1.23), anorexia (-1.19), insomnia (-1.14), and shortness of breath (-1.14). The most severe pretreatment symptoms reported by inpatients were pain (6.90), insomnia (6.16), and constipation (5.44). Inpatients receiving acupuncture reported clinically significant improvements in anxiety (-3.69), nausea (-3.61), insomnia (-3.26), depression (-2.98), pain (-2.77), neuropathy (-2.68), anorexia (-2.20), constipation (-1.95), and diarrhea (-1.26). Conclusion: Both outpatient and inpatient participants in this pilot acupuncture program reported clinically significant improvements in symptoms after a single acupuncture treatment. Some differences between the outpatient and inpatient settings warrant further investigation.

Integrative Medicine: An Opportunity for Improving Quality of Care in the Inpatient Setting

As medicine shifts to a value-based focus, health care providers in inpatient settings are actively seeking approaches to providing high-quality patient care without exacerbating prevailing cost burden. Complementary and integrative medicine may offer one potential solution for this challenge. Although the benefits of utilizing integrative practices in the inpatient setting have not been explored extensively thus far, early evidence demonstrates great promise of using integrative modalities to improve symptom burden in the inpatient setting while increasing patient pain satisfaction and reducing overall costs of care. Currently, social, educational, and financial barriers exist, limiting the widespread incorporation of complementary and integrative medicine into the inpatient setting. Nonetheless, a more robust body of literature demonstrating the effectiveness of complementary and integrative medicine in reducing costs of care and improving patient outcomes may help address these limitations and lead to the acceptance of integrative practices as the standard of high-value inpatient care.

The invisible cost of pain management by the current International Classification of Diseases coding system: a study in a tertiary care inpatient setting

ABSTRACT

The International Classification of Diseases ( ICD ) is applied worldwide for public health data collection among other use cases. However, the current version of the ICD ( ICD-10 ), to which the reimbursement system is linked in many countries, does not represent chronic pain properly. This study aims to compare the ICD-10 with the ICD-11 in hospitalized patients in terms of specificity, clinical utility, and reimbursement for pain management. The medical records of hospitalized patients consulted for pain management at Siriraj Hospital, Thailand, were reviewed, and all pain-related diagnoses were coded into ICD-10 and ICD-11 . The data of 397 patients showed unspecified pain was coded 78% in the ICD-10 and only 0.5% in the ICD-11 version. The difference gap in the proportion of unspecified pain between the 2 versions is wider than in the outpatient setting. The 3 most common codes for ICD-10 were other chronic pain, low back pain, and pain in limb. The 3 most common codes for ICD-11 were chronic cancer pain, chronic peripheral neuropathic pain, and chronic secondary musculoskeletal pain. As in many other countries, no pain-related ICD-10 codes were coded for routine reimbursement. The simulated reimbursement fee remained the same when adding 397 pain-related codings, even if the cost of pain management, such as cost of labor, existed. Compared with the ICD-10 version, the ICD-11 is more specific and makes pain diagnoses more visible. Thus, shifting from ICD-10 to ICD-11 has the potential to improve both the quality of care and the reimbursement for pain management.

Integrative medicine utilization among infertility patients

BACKGROUND

Previous research suggests that some women are using integrative and complementary holistic approaches to optimize their own health and treat infertility. We aimed to determine patterns of integrative medicine use among those seeking fertility optimization by 1) Characterizing patterns of integrative medicine use to increase fertility; 2) Identifying demographic predictors associated with such integrative medicine use; and 3) Exploring cultural and religious influences on use of integrative medicine.

METHODS

Cross-sectional self-reported survey data were collected from 1460 patients presenting to an academic fertility center in Chicago, Illinois. Variables were described with univariate frequencies and proportions, unadjusted bivariate comparisons were made between patient-level factors and reported integrative modality use, and multivariable logistic regression evaluated the strength of covariate-adjusted predictors of reported integrative medicine utilization.

RESULTS

80.4% of respondents reported using at least one integrative medicine modality to treat infertility (Acupuncture: 38.5%, Yoga: 27.6%, Massage: 25.8%, Meditation: 16.7%, and Herbal supplements: 18.5%). Diet therapy was the most frequently utilized modality (74.0%) followed by body therapy (45.2%), traditional alternative medicine (42.0%), mind therapy (32.1%), and senses therapy (23.0%). Any integrative medicine modality use was 4.03 times more likely among Hindu respondents compared to participants that identified as not religious (95% CI 1.2-13.7, p < 0.026). Significant differences in specific modality use were observed by race, religious affiliation, age, income, and insurance coverage.

CONCLUSION

Most infertility patients in our study reported using at least one integrative medicine modality to help them conceive. Utilization was associated with age of participant, religious affiliation, annual income, and insurance coverage. Further research is needed to assess the impact of integrative medicine utilization on patient quality of life and outcomes.

Documentation of Complementary and Integrative Health Therapies in the Electronic Health Record: A Scoping Review

Introduction: Complementary and integrative health (CIH) therapies refers to massage therapy, acupuncture, aromatherapy, and guided imagery. These therapies have gained increased attention in recent years, particularly for their potential to help manage chronic pain and other conditions. National organizations not only recommend the use of CIH therapies but also the documentation of these therapies within electronic health records (EHRs). Yet, how CIH therapies are documented in the EHR is not well understood. The purpose of this scoping review of the literature was to examine and describe research that focused on CIH therapy clinical documentation in the EHR. Methods: The authors conducted a literature search using six electronic databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid MEDLINE, Scopus, Google Scholar, Embase, and PubMed. Predefined search terms included "informatics," "documentation," "complementary and integrative health therapies," "non-pharmacological approaches," and "electronic health records" using AND/OR statements. No restrictions were placed on publication date. The inclusion criteria were as follows: (1) Original peer-reviewed full article in English, (2) focus on CIH therapies, and (3) CIH therapy documentation practice used in the research. Results: The authors identified 1684 articles, of which 33 met the criteria for a full review. A majority of the studies were conducted in the United States (20) and hospitals (19). The most common study design was retrospective (9), and 26 studies used EHR data as a data source for analysis. Documentation practices varied widely across all studies, ranging from the feasibility of documenting integrative therapies (i.e., homeopathy) to create changes in the EHR to support documentation (i.e., flowsheet). Discussion: This scoping review identified varying EHR clinical documentation trends for CIH therapies. Pain was the most frequent reason for use of CIH therapies across all included studies and a broad range of CIH therapies were used. Data standards and templates were suggested as informatics methods to support CIH documentation. A systems approach is needed to enhance and support the current technology infrastructure that will enable consistent CIH therapy documentation in EHRs.

Optimizing Patient-Reported Outcome Collection and Documentation in Medical Music Therapy: Process-Improvement Study

BACKGROUND

To measure the effectiveness of nonpharmacologic interventions delivered during clinical care, investigators need to ensure robust and routine data collection without disrupting individualized patient care or adding unnecessary documentation burden.

OBJECTIVE

A process-improvement study was undertaken to improve documentation consistency and increase the capture of patient-reported outcomes (PROs; ie, stress, pain, anxiety, and coping) within a medical music therapy (MT) team.

METHODS

We used 2 Plan-Do-Study-Act (PDSA) cycles to improve documentation processes among an MT team (13.3 clinical full-time equivalent staff). Trainings focused on providing skills and resources for optimizing pre- and postsession PRO collection, specific guidelines for entering session data in the electronic health record, and opportunities for the team to provide feedback. Two comparisons of therapists' PRO collection rates were conducted: (1) between the 6 months before PDSA Cycle 1 (T0) and PDSA Cycle 1 (T1), and (2) between T1 and PDSA Cycle 2 (T2).

RESULTS

Music therapists' rates of capturing any PRO within MT sessions increased significantly (P<.001) from T0 to T1 and from T1 to T2 for all domains, including stress (4/2758, 0.1% at T0; 1012/2786, 36.3% at T1; and 393/775, 50.7% at T2), pain (820/2758, 29.7% at T0; 1444/2786, 51.8% at T1; and 476/775, 61.4% at T2), anxiety (499/2758, 18.1% at T0; 950/2786, 34.1% at T1; and 400/775, 51.6% at T2), and coping (0/2758, 0% at T0; 571/2786, 20.5% at T1; and 319/775, 41.2% at T2). Music therapists' feedback and findings from a retrospective analysis were used to create an improved electronic health record documentation template.

CONCLUSIONS

Rates of PRO data collection improved within the medical MT team. Although the process improvement in this study was applied to a nonpharmacologic MT intervention, the principles are applicable to numerous inpatient clinical providers. As hospitals continue to implement nonpharmacologic therapies in response to the Joint Commission's recommendations, routine PRO collection will provide future researchers with the ability to evaluate the impact of these therapies on pain relief and opioid use.

Integrative Oncology and the Clinical Care Network: Challenges and Opportunities

Integrative oncology is a new and growing field of cancer care. Integrative oncology is a patient-centered, evidence-based field of comprehensive cancer care that utilizes integrative therapies such as mind-body practices, acupuncture, massage, music therapy, nutrition, and exercise in collaboration with conventional cancer treatments. Patient interest and utilization has been growing over the past two decades. Clinical research has shown the benefits of these approaches to improving symptom management and quality of life, and is now being incorporated into national guidelines from the National Comprehensive Cancer Network (NCCN) and American Society for Clinical Oncology (ASCO). The availability of these services at cancer centers is growing, although the structure and implementation of integrative oncology remains highly variable. This article discusses the benefits of integrative oncology and provides an overview of the current state of integrative oncology programs nationwide. Current challenges and opportunities for cancer centers to provide integrative services is reviewed in the areas of programmatic structure, clinical service, education, and research.

The Benefits of Integrative Medicine for Pain Management in Oncology: A Narrative Review of the Current Evidence

The aim of this evidence-based study is to narrate and evaluate the current evidence on recommendations for practicing physicians and other healthcare providers regarding integrative approaches to managing pain in patients with cancer. This review will assess the guideline recommendations and analyze the role of integrative medicine in addressing cancer pain in patients. The literature search highlights relevant studies that will inform evidence-based recommendations for practicing physicians, highlighting their relevance and weaknesses. Acupuncture, massage, and hypnosis have intermediate-strength evidence quality and are moderately recommended for various types of cancer pain. Most of the evidence points to acupuncture being recommended for aromatase inhibitor-related joint pain, hypnosis for procedural pain, and massage for palliative care pain. Other practices with lower-quality evidence include yoga and guided imagery with progressive muscle relaxation, mostly recommended for general cancer pain or musculoskeletal pain. Additionally, music therapy is recommended for procedural or surgical pain. Low-quality or inconclusive evidence was found for other mind-body interventions or natural products. Similarly, there is insufficient evidence to provide recommendations for pediatric patients. Further research is required to enhance our understanding of the role of integrative medicine interventions in caring for cancer patients.

The Effect of Aromatherapy with Citrus aurantium Aroma on Pain after Orthopedic Surgery: A Randomized Clinical Trial

Introduction

Postoperative pain is one of the most common physiological and psychological stress in patients that disrupts body function and can endanger patients' health. This study aims to determine the effect of aromatherapy with Citrus aurantium essential on pain after orthopedic surgery.

Methods

This randomized clinical trial was performed on 60 candidates for orthopedic surgery. Patients were selected through convenience sampling and divided into intervention and control groups through randomized block allocation. If the visual analogue scale (VAS) score was above 3, patients in the intervention group received aromatherapy with C. aurantium essential and the patients in the control group received a placebo (almond oil). VAS was used to measure pain. Data analysis was performed using independent t test, paired t test, and analysis of variance with repeated measures using SPSS software version 13.

Results

Mean (SD) of pain intensity after intervention in experimental and control groups within 4, 8, and 12 hours after surgery was 7.30 (1.23) vs. 7.90 (0.99), 5.30 (0.98) versus 5.53 (0.68) and 2.53 (0.9) vs. 3.60 (0.77) respectively. The findings indicated that there was a significant difference in mean pain intensity between the experimental and control groups at 4 and 12 hours after surgery. Use of analysis of variance with repeated measures test with taking into account the interaction of time and group also showed a significant difference in mean pain intensity between the two experimental and control groups.

Conclusion

Aromatherapy with Citrus aurantium essential can be effective in reducing mild to moderate pain after orthopedic surgery. Further studies are recommended to confirm this finding.

Effectiveness of music therapy within community hospitals: an EMMPIRE retrospective study

Introduction

Given the challenges health systems face in providing effective nonpharmacologic treatment for pain and psychological distress, clinical effectiveness studies of evidence-based strategies such as music therapy (MT) are needed.

Objectives

This study examined changes in patient-reported outcomes (PROs) after MT and explored variables associated with pain reduction of ≥2 units on a 0 to 10 numeric rating scale (NRS).

Methods

A retrospective review was conducted on initial MT interventions provided to adults receiving community hospital care between January 2017 and July 2020. Sessions were included if participants reported pre-session pain, anxiety, and/or stress scores of ≥4 on the NRS. Data analysis included a bootstrap analysis of single-session changes in PROs and a logistic regression exploring variables associated with pain reduction (ie, ≥2 units vs <2 units).

Results

Patients (n = 1056; mean age: 63.83 years; 76.1% female; 57.1% White; 41.1% Black/African American) reported clinically significant mean reductions in pain (2.04 units), anxiety (2.80 units), and stress (3.48 units). After adjusting for demographic, clinical, and operational characteristics in the model (c-statistic = 0.668), patients receiving an MT session in which pain management was a goal were 4.32 times more likely (95% confidence interval 2.26, 8.66) to report pain reduction of ≥2 units than patients receiving an MT session in which pain management was not a session goal.

Conclusion

This retrospective study supports the clinical effectiveness of MT for symptom management in community hospitals. However, additional research is needed to determine which characteristics of MT interventions and patients influence pain change.

Enhancing Intradermal Delivery of Lidocaine by Dissolving Microneedles: Comparison between Hyaluronic Acid and Poly(Vinyl Pyrrolidone) Backbone Polymers

Lidocaine hydrochloride (LiH), an amide-type local anesthetic agent, is commonly used in dermatological procedures. LiH is categorized as a BCS (biopharmaceutics classification system) class III group, which has high solubility and poor permeability. It should be noted that, in this context, LiH is intended as a local anesthetic, so the level of LiH in systemic circulation should be minimized to avoid toxicity and unwanted side effects such as hypotension and bradycardia. This study aimed to formulate and evaluate LiH-loaded dissolving microneedles (DMNs) with different polymer bases. Moreover, an in vitro permeation study using Franz diffusion cells and in vivo study were also performed. LiH-loaded DMNs were prepared using polymer groups of poly(vinyl pyrrolidone) (PVP-K30) and hyaluronic acid (HA). DMNs were created using the micro-molding method with centrifugation. The formulations selected based on the evaluation were F3 (HA 10%) and F5 (PVP-K30 25%). Based on the in vitro permeation study, the amount of drug permeated and deposited in the skin at F3 (HA 10%) was 247.1 ± 41.85 and 98.35 ± 12.86 μg, respectively. On the other hand, the amount of drug permeated and deposited in the skin at F5 (PVP-K30 25%) was 277.7 ± 55.88 and 59.46 ± 9.25 μg, respectively. Our in vivo drug-permeation study showed that only one rat from the PVP-K30 polymer group-with a concentration of 150.32 ng/mL-was detected on rat plasma. Therefore, LiH can be formulated into a DMN and can be deposited in the skin with a safe concentration of the drug permeating into systemic circulation.

Patients Receiving Integrative Medicine Effectiveness Registry (PRIMIER) of the BraveNet practice-based research network: Outcomes of the PRIMIER cohort

OBJECTIVE

To evaluate the real-world effectiveness of integrative medicine treatment on quality of life using the Patients Receiving Integrative Medicine Effectiveness Registry (PRIMIER).

DESIGN

A prospective, longitudinal, observational evaluation of patient reported outcomes for quality of life.

SETTING

Participants were patients from 17 integrative medicine clinics who received personalized, integrative medicine treatments between August 2013 and October 2017.

MAIN OUTCOME MEASURES

Participants completed the Patient Reported Outcomes Measurement Information System (PROMIS)- 29, Perceived Stress Scale-4 (PSS-4), and the Patient Activation Measure (PAM) at index (baseline) visit and at 2, 4, 6, and 12 month follow-up assessments. Electronic health record data included diagnostic and billing codes/descriptions. A linear mixed-effects model was used to test whether outcomes changed from index through 12 months RESULTS: During enrollment, 4883 participants began the assessment, 3658 completed the index measures, and 2374 (65 %) completed at least 1 follow-up assessment, had electronic health record data and at least 1 integrative medicine visit. Most participants (mean age=51.4 years) were white (88.4 %), female (79.7 %), and college-educated (78.5 %). Significant improvements (p < 0.001) were observed at 12-months on all PROMIS-29 measures, PSS-4, and PAM. At 12 months, clinically meaningful improvements were found for 38 % and 28 % on PROMIS-29 Mental and Physical Health Summary scores respectively.

CONCLUSIONS

PRIMIER is the largest study to assess the real-world effectiveness of integrative medicine. Results indicate a statistical and clinical improvement across all measures at 12 months. Future research could explore whether dosing, timing or combinations of integrative medicine interventions have differential impacts on quality of life.

Improving acute pain management of trauma patients on medication-assisted therapy

BACKGROUND

Approximately 9,500,000 people in the United States misused opioids in 2020. Many people manage their opioid use disorder (OUD) with medication-assisted treatment (MAT). Using MAT to address OUD adds to the complexities and challenges of adequate acute pain control.

LOCAL PROBLEM

Chart review indicated only 20% of trauma patients on MAT achieved adequate pain control on the trauma service at the University of Louisville Hospital. This quality initiative aimed to increase patient pain control to 50% in 90 days.

METHODS

A rapid cycle quality improvement project with four plan-do-study-act (PDSA) cycles was conducted over 8 weeks. Four core interventions were implemented concurrently, with tests of change biweekly. Qualitative and qualitative data analyses were completed at each cycle.

INTERVENTIONS

The core interventions included a risk assessment tool, shared decision-making (SDM) tool, provider checklist, and a team engagement plan.

RESULTS

The number of patients with a pain score of ≤5 (scale 0-10) increased to 78% from 20%. The mean pain score decreased from 8 to 4.6. The fourth PDSA cycle results showed a 92% patient engagement with SDM and 100% utilization of the provider checklist. Team engagement scores greater than 4 on a 5-point Likert scale were 86%.

CONCLUSIONS

Effective patient-centered acute pain control for trauma patients on MAT is achievable. The combined use of an SDM tool and a provider checklist was an efficient way to provide effective and patient-centered care and positively affected patient outcomes.

The Critical Role of Nutrition Care to Improve Pain Management: A Global Call to Action for Physical Therapist Practice

Physical therapists have unique education in the comprehensive biopsychosocial assessment and treatment of chronic pain and its mechanisms. Recently, physical therapists have raised awareness regarding the impact of nutrition on promoting health and managing noncommunicable diseases. Robust evidence supports the implementation of nutrition in physical therapist education and practice. Of particular interest for the physical therapist are investigations that use dietary interventions for the treatment of chronic pain. Yet physical therapists have received little guidance regarding their role in nutrition care for pain management and may pass on opportunities to counsel their patients on the connection between nutrition and pain. Therefore, a clinical paradigm shift and unified voice within the profession is called on to encourage physical therapists to develop tailored multimodal lifestyle interventions that include nutrition care for the management of chronic pain. This Perspective describes evidence supporting the implementation of nutrition care in physical therapist practice, supports the role of nutritional pain management for physical therapists, and encourages the use of nutrition care for primary, secondary, tertiary, prevention, health promotion, and wellness related to chronic pain. To achieve these aims, this Perspective offers suggestions for how physical therapists can (1) enhance clinical decision making; (2) expand professional, jurisdictional, and personal scope of practice; (3) evolve entry-level education; and (4) stimulate new investigations in nutrition care and pain science research. In doing so, physical therapists can assert their role throughout the pain management continuum, champion innovative research initiatives, and enhance public health by reducing the impact of chronic pain.

IMPACT

The nutrition care process for pain management is defined as the basic duty to provide adequate and appropriate nutrition education and counseling to people living with pain. Including the nutrition care process as part of a multimodal approach to pain management provides an opportunity for physical therapists to assert their role throughout the pain management continuum. This includes championing innovative research initiatives and enhancing public health by reducing the impact of chronic pain for over 50 million Americans.

Effect of Inpatient Integrative Medicine Consultation on 30-Day Readmission Rates: A Retrospective Observational Study at a Major U.S. Academic Hospital

Objectives: The prevalence of inpatient integrative medicine (IM) consult services is increasing among academic health care institutions. The diversity of services between institutions, as well as the novel nature of such interventions, makes it challenging for health care administrators to determine the cost/benefit of adding such a program to their institution. The main purpose of this study was to examine the performance of the new University of California, Los Angeles (UCLA) East-West (EW) consult service as measured by 30-day readmission rates and lengths of stay. Design: This is a retrospective observational case-control study with participants matched to themselves. Setting: UCLA Santa Monica Hospital, a 281-bed academic tertiary care hospital near Los Angeles, California. Subjects: Patients who had received an EW consultation during the inaugural 20 months of the program (2018-2020), and who had been hospitalized in the prior 2 years from the date of their first EW consult. Intervention: Inpatient East-West consultation, which may include counseling, acupuncture and/or trigger point injections depending on medical necessity. Outcome Measures: Thirty-day readmission rates and lengths of hospital admission were compared between the hospitalization that included an EW consult (which included the use of acupuncture and/or trigger point injections when appropriate) and any prior admissions during the 2 years before that EW consult. Secondary outcomes included quantitative analysis of average number of treatments and qualitative assessment of integrative treatment(s) received, conditions treated, and reasons that EW treatment may have been deferred during a consult. Results: One hundred sixty-five unique patients met the study criteria. The EW consultation was associated with clinically relevant, statistically significant decreased 30-day readmission rates (33.0% vs. 4.6%, p < 0.001, odds ratio [OR] 0.10, 95% confidence interval [CI] 0.06-0.17). This effect was similar when limiting the analysis to pain-related admissions (32.3% vs. 3.4%, p < 0.001, OR = 0.07, 95% CI 0.03-0.16). Hospital admissions with EW consults were found to have a statistically significant increased length of stay (7.03 days vs. 5.40 days, p < 0.001). Conclusion: The EW medicine, an example of IM, correlates with a reduced risk of 30-day readmission and with modestly increased lengths of stay.

Preliminary Evidence on the Association of Complementary and Integrative Health Care Program Participation and Medical Cost in Veterans

INTRODUCTION

Transforming Health and Resilience through Integration of Values-based Experiences (THRIVE) is a complimentary and integrative health program. THRIVE is delivered through shared medical appointments where participants engage in provider-led education and group discussion on wellness-related topics. THRIVE has been associated with improved patient-reported outcomes in a female veteran cohort. This quality improvement study evaluated the association between THRIVE participation and Veterans Health Administration (VHA) healthcare costs across a 1 year period.

MATERIALS AND METHODS

A cohort study design (n = 184) used VHA administrative data to estimate the cost difference between 1 year pre- and post-THRIVE participation. The 1 year post-cost of the THRIVE cohort was then compared to the 1 year cost of a quasi-experimental waitlist control group (n = 156). Data sources included VHA administrative and electronic health records.

RESULTS

Patients were roughly 51 years old, were typically White/Caucasian, and had a service priority level representing catastrophic disability. The adjusted post-THRIVE cost was $26,291 [95% confidence interval (CI): $23,014-29,015]; $1,720 higher than the previous year's cost but was not statistically significant (P = 0.289). However, a comparison between the THRIVE cohort and a group of waitlist THRIVE patients (n = 156) the intervention group on average was $8,108 more than the waitlist group (95% CI: $3,194-14,005; P < 0.01).

CONCLUSIONS

In summary, data analysis of veterans' annual healthcare cost trajectories were inconclusive. This preliminary study produced mixed results requiring more research with larger samples and randomized control trial methodology. Evidence of whether the THRIVE intervention can maintain cost effectiveness while maintaining its supported evidence of healthcare quality is needed.

Health costs of women with chronic overlapping pain conditions by opioid and complementary and integrative health use

OBJECTIVE

To estimate differences in average annual health care expenditures of adult women with chronic overlapping pain conditions (COPCs) by pain treatment modality as follows: (1) no long-term opioid or complementary and integrative health (CIH) use; (2) CIH only use; (3) long-term opioid only use; and (4) long-term opioid and CIH use.

DATA SOURCE

Cross-sectional Medical Expenditure Panel Survey data (2012-2016).

STUDY DESIGN

We estimated differences between average annual expenditures of adult women with COPCs by their use of long-term opioids and CIH modalities. Generalized linear regression with a log link function was used to estimate adjusted marginal effects in annual expenditures. The distribution family was chosen based on Modified Park Tests. We controlled for pain severity, patient demographic characteristics, physical limitations, comorbidities, mental health, insurance status, physical therapy use, and census region. We also employed propensity-score based marginal mean weighting through stratification to balance our treatment groups on observed covariates.

DATA COLLECTION/EXTRACTION METHODS

We identified adult women (>17 years) with one or more self-reported COPC using 3-digit International Classification of Diseases (ICD)-9/10-Clinical Modification (CM) codes (N = 9169) and categorized their use of CIH and long-term opioids.

PRINCIPAL FINDINGS

Compared to women without long-term opioid or CIH use, CIH only use was significantly associated with lower inpatient expenditures (-$947 [-$1699, -$196]; p-value < 0.01), higher office-based expenditures ($1345 [$944, $1746]; p-value < 0.001), and higher patient out-of-pocket expenditures ($628 [$409, $848]; p-value < 0.001). Long-term opioid use, alone or in combination with CIH, was significantly associated with higher expenditures (p-value < 0.05) in total and across all utilization categories compared to women without any long-term opioid or CIH use.

CONCLUSIONS

Our results indicate that CIH treatment approaches for chronic pain have the potential to be utilized without increasing overall costs. Future research should further examine the role of CIH modalities in achieving cost-effective pain management that reduces avoidable opioid use.

Effects of Intensive Outpatient Integrative Medicine on Health Care Utilization on High Utilizer Patients at a Major Academic Health System

Objective: To determine if integrative medicine (IM) involvement can reduce acute care utilization for patients with complex medical conditions and high health care utilization. Design: Prospective single-center cohort study. Interventions: Twenty-nine complex high utilizer patients were treated by the University of California, Los Angeles (UCLA) East-West Extensivist IM specialty clinic with acupuncture, trigger point injections, and Traditional Chinese Medicine dietary modifications. Number of hospitalizations, hospitalization days, and emergency room visits were tracked for 6 months. Results: There was a statistically significant decrease in number of hospitalizations (-31.4%, p = 0.021) and hospitalization days (-38.0%, p = 0.038) after 6 months. Subgroup analysis suggested greater improvement with more frequent visits. Conclusion: IM specialty care correlates with reduced hospitalization frequency and total hospitalization days among high utilizers of care.

Integrative pediatric pain management: Impact & implications of a novel interdisciplinary curriculum

OBJECTIVES

Objectives of this paper are to: 1) Describe a novel interdisciplinary, integrative pain curriculum for pediatric residents. 2) Describe changes in residents' understanding of pain epidemiology, physiology, and management; application of the biopsychosocial model in pain management; and understanding and application of non-pharmacologic approaches to pain management.

DESIGN, SETTING

This study was done in a pediatric residency program within an urban pediatric teaching hospital. It employed both anonymous, Likert-scale surveys administered via Qualtrics, as well as open-ended, free response questions.

INTERVENTIONS

We provided a multidisciplinary pain education curriculum to pediatric residents with a focus on pain neuroscience, a history of pain management, the biopsychosocial model of care, and exposure to non-pharmacologic interventions to pain management over six hours of instruction conducted in two blocks of three hours each.

OUTCOME MEASURES

Self-identified changes via survey measuring resident physician knowledge, comfort, approach, and management of pediatric pain through an interdisciplinary pain curriculum.

RESULTS

Prior to this training, many residents were not confident in their understanding of pain neuroscience, the biopsychosocial model of care, and non-pharmacologic interventions. At completion of training, residents indicated positive changes in knowledge of, and comfort with, all of the domains taught. Ninety percent of residents indicated that the curriculum changed the way they conceptualized, approached, and/or managed pain, and reported thinking more holistically about pain management. Nearly all residents indicated they would like to have more training (98 %, N = 57) in integrative modalities.

CONCLUSIONS

Pediatric resident physicians are receptive to training in an interdisciplinary, integrative, pediatric pain management education intervention, and subsequently show positive changes in knowledge and comfort levels. There is a need and desire for additional pain education in resident training programs.

Adaptations to Acupuncture and Pain Counseling Implementation in a Multisite Pragmatic Randomized Clinical Trial

Objectives: As part of a pragmatic effectiveness trial of integrative pain management among inpatients with cancer, the authors sought to understand the clinical context and adaptations to implementation of two study interventions, acupuncture and pain counseling (i.e., pain education and coping skills). Design: The larger study uses a 2 × 2 factorial design with inpatients randomized to: (1) usual care (UC), (2) UC with acupuncture, (3) UC with pain counseling, and (4) UC with acupuncture and pain counseling. The study is being conducted in two hospitals (one academic and one public) and three languages (Cantonese, English, and Spanish). The authors conducted a process evaluation by interviewing study interventionists. Analysis included deductive coding to describe context, intervention, implementation, and inductive thematic coding related to intervention delivery. Results: Interviewees included seven acupuncturists and four pain counselors. Qualitative themes covered adaptations and recognizing site-specific differences that affected implementation. Interventionists adhered closely to protocols and made patient-centered adaptations that were then standardized in broader implementation (e.g., including caregivers in pain counseling sessions; working in culturally nuanced ways with non-English-speaking patients). The public hospital included more patients with recent diagnoses and advanced disease, more ethnically and linguistically diverse patients, less continuity of staffing, and shared patient rooms. At the academic medical center, more patients were familiar with integrative therapies and all were located in single rooms. Providing acupuncture to hospital staff was a key strategy to establish trust, experientially explain the intervention, and create camaraderie and staff buy-in. Conclusions: Providing nonpharmacologic interventions for a pragmatic trial requires adapting to a range of clinical factors. Site-specific factors included greater coordination and resources needed for successful implementation in the public hospital. The authors conclude that adaptation to context and individual patient needs can be done without compromising intervention fidelity and that intervention design should apply principles such as centering at the margins to reduce participation barriers for diverse patient populations.

Significant Pain Reduction in Hospitalized Patients Receiving Integrative Medicine Interventions by Clinical Population and Accounting for Pain Medication

Background: Prior research has reported that integrative medicine (IM) therapies reduce pain in inpatients, but without controlling for important variables. Here, the authors extend prior research by assessing pain reduction while accounting for each patient's pain medication status and clinical population. Methods: The initial data set consisted of 7,106 inpatient admissions, aged ≥18 years, between July 16, 2012, and December 15, 2014. Patients' electronic health records were used to obtain data on demographic, clinical measures, and pain medication status during IM. Results: The final data set included first IM therapies delivered during 3,635 admissions. Unadjusted average pre-IM pain was 5.33 (95% confidence interval [CI]: 5.26 to 5.41) and post-IM pain was 3.31 (95% CI: 3.23 to 3.40) on a 0-10 scale. Pain change adjusted for severity of illness, clinical population, sex, treatment, and pain medication status during IM was significant and clinically meaningful with an average reduction of -1.97 points (95% CI: -2.06 to -1.86) following IM. Adjusted average pain was reduced in all clinical populations, with largest and smallest pain reductions in maternity care (-2.34 points [95% CI: -2.56 to -2.14]) and orthopedic (-1.71 points [95% CI: -1.98 to -1.44]) populations. Pain medication status did not have a statistically significant association on pain change. Decreases were observed regardless of whether patients were taking narcotic medications and/or nonsteroidal anti-inflammatory drugs versus no pain medications. Conclusions: For the first time, inpatients receiving IM reported significant and clinically meaningful pain reductions during a first IM session while accounting for pain medications and across clinical populations. Future implementation research should be conducted to optimize identification/referral/delivery of IM therapies within hospitals. Clinical Trials.gov #NCT02190240.

Pain Management in Clinical Practice Research Using Electronic Health Records

BACKGROUND

The use of electronic health record (EHR) systems encourages and facilitates the use of data for the development and surveillance of quality indicators, including pain management.

AIM

to conduct an integrative review on pain management research using data extracted from EHR in order to synthesize and analyze the following elements: pain management (assessments, interventions, and outcomes) and study results with potential clinical implications, data source, clinical sample characteristics, and method description.

DESIGN

An integrative review of the literature was undertaken to identify exemplars of scientific research studies that explore pain management using data from EHR, using Cooper's framework.

RESULTS

Our search of 1,061 records from PubMed, Scopus, and Cinahl was narrowed down to 28 eligible articles to be analyzed.

CONCLUSION

Results of this integrative review will make a critical contribution, assisting others in developing research proposals and sound research methods, as well as providing an overview of such studies over the past 10 years. Through this review it is therefore possible to guide new research on clinical pain management using EHR.

Interest and Willingness to Pay for Integrative Therapies of Patients With Cancer and Caregivers

PURPOSE

Complementary and integrative medicine (CIM) services are more prevalent in cancer centers but continue to be underutilized by patients. This study examines perspectives from patients and caregivers about these services being offered at a comprehensive cancer center.

METHODS

Patients and caregivers were surveyed about their familiarity, interest, and experience with five CIM therapies: acupuncture, massage, meditation, music therapy, and yoga. Respondents were also asked about their interest when recommended by their medical team and when offered in a clinical trial as well as their willingness to pay for these services. Respondents were also asked about perceived barriers to accessing these services. Chi-squared tests were performed to explore associations between past experience, interest levels, and willingness to pay.

RESULTS

A total of 576 surveys were obtained (464 patients and 112 caregivers). Most respondents identified as White or Caucasian (65.6%), female (57.2%), had been a patient for < 3 years (74.2%), had some college education (73.8%), and made > $40,000 in US dollars as their annual household income (69.1%). Respondents were most familiar with therapeutic massage (34.2%) and least familiar with acupuncture (20.0%). The average interest in these services increased from 53.3% to 64.1% when recommended by a medical professional. Respondents were most willing to pay $1-60 for therapeutic massage (62.3%) and least willing to pay for meditation (43.7%). The main barriers to accessing CIM services were cost (56.0%) and lack of knowledge (52.1%).

CONCLUSION

Overall, a significant proportion of patients and caregivers were unfamiliar with these five integrative therapies. Increasing education, decreasing cost, and a recommendation by medical professionals would improve CIM usage.

The effect of osteopathic medicine on pain in musicians with nonspecific chronic neck pain: a randomized controlled trial

Background:

Nonspecific chronic neck pain (cNP) is common in adult violinists and violists and is often treated with osteopathic medicine (OM), although the effectiveness of this treatment has not been determined to date. This study aimed to evaluate the effectiveness and safety of OM in adult violinists and violists with cNP.

Methods:

In a two-armed randomized controlled single-center open trial, adult violinists and violists, including music students, with cNP (⩾12 weeks) were randomized to either five individualized OM sessions (OM group) or to no intervention (control group, CG) in the outpatient clinic for integrative medicine, Charité - Universitätsmedizin Berlin, Germany. All patients received a musicians’ medicine consultation and paracetamol on demand. The primary outcome parameter was the neck pain intensity on a visual analog scale (VAS, 0–100 mm, 0 = no pain, 100 = worst imaginable pain) after 12 weeks. Secondary outcomes included neck pain disability (Neck Disability Index, NDI, 0–100%) after 12 weeks. The last follow-up visit was after 52 weeks. Statistical analysis included analysis of covariance adjusted for respective baseline value.

Results:

Altogether, 62 outpatients were included [OM group (n = 28), CG (n = 34); 81% female; mean age, 41.6 ± 11.1 years; mean baseline neck pain, 55.9 ± 11.6 mm]. After 12 weeks, OM was associated with an improvement in the OM group versus the CG in neck pain on the VAS [14.6 mm (95% confidence interval 8.0; 21.2) versus 40.8 mm (34.7; 46.9), p < 0.001, Cohen’s d = 1.4], and neck pain disability as determined by the NDI [8.8% (6.7; 10.8) versus 17.2% (15.3; 19.1), p < 0.001]. Some improvements were maintained until 52 weeks of follow-up. No serious adverse events were observed.

Conclusions:

The results of this study suggest that OM might be effective in reducing pain intensity in adult violinists and violists with nonspecific cNP. Further studies should investigate the efficacy of OM in comparison with a sham procedure and with other effective therapy methods in high-quality multicenter trials.

Trial registration:

WHO Trial Registration https://apps.who.int/trialsearch/NoAccess.aspx?aspxerrorpath=/trialsearch/Trial2.aspx by German Clinical Trials Register DRKS00009258, Universal Trial Number (UTN): U1111-1173-5943.

Non-Opioid Perioperative Pain Strategies for the Clinician: A Narrative Review

Alternative and non-opioid options for pain management are necessary in perioperative patient care. Opioids are no longer touted as cure-all medications, and furthermore, there have been tremendous advances in alternative therapies such as in interventional pain, physical therapy, exercise, and nutritional counseling that have proven benefits to combat pain. The center for disease control now strongly recommends the use of multimodal analgesia and multidisciplinary approaches based on the individual needs of patients: personalized medicine. In this manuscript, the specifics of non-opioid pharmacological and non-pharmacological analgesic approaches will be discussed as well as their possible indications and uses to reduce the need for excessive use of opioids for adequate pain control.

Optimizing delivery to meet demand for integrative medicine services in an academic hospital setting: A pilot study

CONTEXT

A rapidly growing body of evidence shows the positive benefits of integrative medicine (IM) services for patients in hospital-based settings. IM therapies, such as acupuncture, massage, meditation and relaxation, and animal-assisted therapy, reduce symptom burden of pain, anxiety, and stress and increase sense of well-being and satisfaction in hospitalized patients. Current challenges facing hospitals are to move beyond proof-of-concept studies and to provide hospital-based IM therapies.

OBJECTIVE

The aim of our quality improvement project was to develop, implement, and evaluate a feasible, scalable, hospital-based "best practice" model for increasing demand for IM services and optimizing their delivery.

DESIGN

A multidisciplinary team convened to use quality improvement tools to outline a process for providing IM services.

SETTING

A large academic medical center in the Midwestern United States.

PARTICIPANTS

IM leadership staff, IM providers, nurses, hospital team members, support staff, and quality improvement staff.

INTERVENTIONS

After determining baseline levels of demand and service delivery, we sought to (1) increase nursing staff awareness of available IM services; (2) improve communication between IM providers and nurses; and (3) reinforce communication at the level of nurse supervisors, patients, and family members.

MAIN OUTCOME MEASURES

We recorded the numbers and types of IM services ordered at baseline and postimplementation and determined the new delivery rate of requested services.

RESULTS

We noted an increase in the number of IM orders, percentage of delivered IM services, and percentage of patients who reported that IM services improved their hospital stay.

Patient-reported quality of care in anthroposophic and integrative medicine: A scoping review

OBJECTIVE

To investigate how, and to what extent, patient-reported quality of care is measured in Anthroposophic and Integrative Medicine (AM/IM).

METHODS

Scoping review of evaluation studies of patient-reported quality of care and development studies of PREMs and/or PROMs in AM/IM, using five stages of Arksey's methodological framework.

SEARCH STRATEGY

Literature search in twelve relevant databases.

DATA EXTRACTION

Basic information, added categories: Focus; PREMs/PROMs; Evaluation measures; Patient involvement; Use of results.

RESULTS

Sixty-four included studies: 30 quantitative, 20 qualitative and 14 mixed-methods studies. Quantitative studies showed a wide variety of instruments and qualitative studies showed a meaningful list of evaluation themes. Most prevalent themes: Agency & Empowerment; Patient-provider relationship; Perceived effectiveness; Coping & Psychological functioning; Inner awareness; Meaning; and General wellbeing. Seven studies report concrete, coherent, patient-derived evaluation measures with emphasis on PROMs and/or PREMs.

CONCLUSION

Patient-reported quality of care was not measured in a standardised way. Knowledge gap: in general, quantitative studies lack patient-derived measures and qualitative studies lack development of concrete evaluation measures. Many AM/IM evaluation aspects connect with patient-centred care.

PRACTICE IMPLICATION

The international field of AM/IM would benefit from the development of a core set of validated PROMs and PREMs to further enhance its scientific underpinning.

Patient-Reported Outcomes in Integrative Oncology: Bridging Clinical Care With Research

There is growing interest in the value of routine collection and monitoring of patient-reported outcomes as part of high-quality, patient-centered, oncology care. Integrative oncology, with its focus on providing symptom and lifestyle support for patients throughout the cancer care continuum, serves a diverse patient population with a complex, changing symptom burden. Monitoring of patient-reported outcomes can contribute significantly to the successful comprehensive evaluation and management of patients receiving integrative oncology care. Data collected as part of an integrative oncology evaluation can also support real-world clinical research efforts to help learn more about the effects of integrative oncology interventions on patient symptoms, quality of life, and treatment outcomes.

A Replicable and Sustainable Whole Person Care Model for Chronic Pain

Background: Integrative health is an expanding field that is increasingly called upon by conventional medicine to provide care for patients with chronic pain and disease. Although evidence has mounted for delivering integrative therapies individually, there is little consensus on how best to deliver these therapies in tandem as part of whole person care. While many models exist, few are financially sustainable.

Methods and results: This article describes a conceptual and logistical model for providing integrative outpatient health care within an academic medical center or hospital system to patients with chronic pain and disease. In hopes that the model will be replicated, administrative details are provided to explain how the model operates and has been maintained over nine years. The details include the intentional building of a particular work culture.

Conclusion: This whole person care model that addresses chronic pain and disease in an outpatient integrative clinic has been successful, sustainable and can be replicated in other academic medical centers or hospital clinics.

Integrative Medicine as a Vital Component of Patient Care

The landscape of medicine in the United States has been slowly progressing toward a more holistic and individualized approach to healing. Part of this progress has been the integration between western and alternative forms of medicine, a concept that has been described as “integrative medicine.” This approach to healthcare incorporates a patient’s mind, spirituality, and sense of community into the healing process. Integrative medicine has been typically well received and the demand has been steadily increasing in primary US hospitals. Here we cover a number of topics that include the definition of integrative medicine, its potential benefits, current examples of successful implementations, and potential barriers to its expansion. The aim was to give a primary on integrative medicine and its current state for healthcare providers.

Chiropractic Integration into Private Sector Medical Facilities: A Multisite Qualitative Case Study

OBJECTIVES

Chiropractic care may have value in improving patient outcomes and decreasing opioid use, but little is known about the impetus for or process of incorporating these services into conventional medical settings. The purpose of this qualitative study was to describe organizational structures, care processes, and perceived value of chiropractic integration within U.S. private sector medical facilities.

DESIGN

Multisite, comparative organizational case study.

SETTINGS

Nine U.S. private sector medical facilities with on-site chiropractic care, including five hospitals and four clinics.

PARTICIPANTS

One hundred and thirty-five key facility stakeholders including doctors of chiropractic (DCs), non-DC clinicians, support staff, administrators, and patients.

METHODS

Researchers conducted 2-day site visits to all settings. Qualitative data were collected from audio-recorded, semi-structured, role-specified, individual interviews; standardized organizational data tables; and archival document review. A three-member, interdisciplinary team conducted thematic content analysis of verbatim transcripts using an existing conceptual framework and emergent codes.

RESULTS

These nine medical facilities had unique organizational structures and reasons for initiating chiropractic care in their settings. Across sites, DCs were sought to take an evidence-based approach to patient care, work collaboratively within a multidisciplinary team, engage in interprofessional case management, and adopt organizational mission and values. Chiropractic clinics were implemented within existing human resources, physical plant, information technology, and administrative support systems, and often expanded over time to address patient demand. DCs usually were co-located with medical providers and integrated into the collaborative management of patients with musculoskeletal and co-morbid conditions. Delivery of chiropractic services was perceived to have high value among patients, medical providers, and administration. Patient clinical outcomes, patient satisfaction, provider productivity, and cost offset were identified as markers of clinic success.

CONCLUSION

A diverse group of U.S. private sector medical facilities have implemented chiropractic clinics, and a wide variety of facility stakeholders report high satisfaction with the care provided.