A Popula)on Health Approach to Examining Yoga s Impact: The VA PRIMIER Study A. Rani Elwy, PhD
I know I m depressed, but I m not geing treatment because I don t want that kind of treatment. I don t want drugs, and I don t want to talk to anyone. I want yoga. I want medita)on. Why won t the VA give me that?
VA Healthcare Analysis & Informa)on Group (HAIG) FY15 Survey CIM was available in 131 (93%) of VA facili)es mindfulness medita)on (85%) guided imagery (74%) yoga (73%) acupuncture (60%)
Many Yoga Studies, but not with Vets Can improve func)onal outcomes in pa)ents with non-specific chronic low back pain poten)al benefit in young to mid-life adults with depressive disorders or elevated depressive symptoms, and those with symptoms of anxiety or insomnia
Yoga and Veterans I see old people and they started sort of going into the fetal posi)on as the older they get and I didn t want to see myself walking down the street curled over like a ques)on mark.so I gave [yoga] a shot and I m much more flexible than I ever was. I mean I m reaching things that you know that I never could reach you re not going to believe how good it is, benefit to your body and mind and emo)onally it s just, it really is unbelievable. Bolton et al, Biopsychosocial benefits of movement-based complementary and integra)ve health therapies,. Under review.
A Popula)on Health Approach Needed to understand Veterans outside of individual studies the health outcomes of a group of individuals, including the distribu7on of such outcomes within the group. (Kindig and Stoddart, 2003) includes health outcomes, palerns of health determinants, and policies and interven)ons that link these two hlp://ajph.aphapublica)ons.org/doi/abs/10.2105/ajph. 93.3.380 Prospec)ve, observa)onal, real-world, point of care study
A Learning Healthcare System Data driven approach Engaging with pa)ents to measure outcomes according to their perspec)ves New clinical research paradigm for improving health
PRIMIER Pa)ents Receiving Integra)ve Medicine Interven)ons Effec)veness Registry Bravenet prac)ce-based research network (PBRN) of 20 non-va clinical sites around country VA became engaged in late 2015, star)ng with 3 sites: Washington DC, East Orange NJ, Greater Los Angeles Modify research protocol to fit VA policy
PRIMIER + VA Sites
VA PRIMIER Baseline, 2, 4, 6, 12, 18 months follow up, to track changes over )me Focus on pa)ent reported outcomes PROMIS Perceived Stress Scale (PSS) Measure Yourself Medical Outcome Profile (MYMOP) Integra)ve medicine alendance Diagnosis, procedure codes Costs Research study informed consent, incen)ves
PRIMIER can address.
Recruitment through IM Clinic
Recruitment 9/1/16 Site Baseline 2 mos 4 mos 6 mos 12 mos DC 388 75 50 42 15 LA 77 34 19 9 1 EO 101 52 33 15 0 Total 566 161 102 66 16
60 EO - Services You Received at Your Last Visit (%) 50 40 30 20 10 0
50 EO - For What CONDITION Were You Seeking Treatment (%) 45 40 35 30 25 20 15 10 5 0
Comprehensive Addic)on Recovery Act (CARA) 2016
PROMIS Global Health (EO site) In general, how would you say your quality of life is? 14 5 10 Poor Fair 29 Good Very Good Excellent 42
Perceived Stress Scale How oten did you feel: 1. That you were unable to control the important things in your life? 2. Confident about your ability to handle your personal problems? 3. That things were going your way? 4. Difficul)es were piling up so high that you could not overcome them? Those who par)cipated in yoga at baseline report beler emo)onal health than those who par)cipated in other CIH (10.5 vs. 8.7, t=-2.52, df=95, p<0.01)
Measure Yourself Medical Outcome Profile-2 (MYMOP-2) Aims to measure the outcomes that the pa)ent considers the most important 4 items, on 7 point scale First 2 scales --two symptoms that the pa)ent specifies as important to him or her. 3 rd scale--ac)vity of daily living that is being disrupted or prevented by the illness, which the pa)ent also specifies. 4 th scale--asks the pa)ent to rate their general feeling of well-being All ra)ngs are for the previous week
Yoga for PTSD? (DC) Courtney, Eickhoff, Adams et al, Poster at ICIMH 2016
Courtney, Eickhoff, Adams et al, Poster at ICIMH 2016
CHAR 4 Codes to Capture Workload ACUP BIOF CBHT GIMA MBSR MANT MDTN REIK TAIC HYPN YOGA Acupuncture Biofeedback Cogni)ve behavioral therapy Guided Imagery Mindfulness based stress reduc)on Mantram repe))on Medita)on Reiki Tai Chi Hypnotherapy Yoga
Overall VA Costs for SC Vets (FY16) CHAR 4 Total cost $ Total encounters Total unique parents Avg cost per encounter $ ACUP 3,529,574 11,443 3,842 308.45 MDTN 274,512 1,663 231 165.07 TAIC 180,609 2,240 352 80.63 YOGA 1,107,157 3,292 525 336.32
PRIMIER-Implementa)on
Veterans want yoga, VA is giving it to them, but may access it outside if needed PRIMIER is appropriate method Yoga in VA too expensive right now, may need to partner with community (CARA/My VA)
Thank you to many people! Research Team: Barbara Bokhour, PhD Dorothy Plumb, MA Shibei Zhao, MPH Chris)e Eickhoff Alyssa Adams, PhD Amanda Hull, PhD Stephanie Taylor, PhD Marian Katz, PhD Grace Yen, PhD Wendy Westleigh PRIMIER leadership: Jeff Dusek, PhD Ben Kligler, MD Donald Abrams, MD Rowena Dolor, MD Diane McKee, MD VA Office of PaRent Centered Care: Tracy Gaudet, MD Ben Kligler, MD Laura Krejci, MSW
Ques)ons? Rani.Elwy@va.gov relwy@bu.edu