A Population Health Approach to Examining Yoga’s Impact: The VA PRIMIER Study A. Rani Elwy, PhD

“I know I’m depressed, but I’m not getting 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 meditation. Why won’t the VA give me that?” Based on VA HSR&D IAC 07-087

On October 17, 2015, the front page of the New York Times led with a story of Veterans participating in yoga at a Veterans of Foreign Wars post in Colorado. Tuesday is yoga night; on Wednesday, meditation is offered. Said one Veteran quoted in the article: “We didn’t want a dark dive bar…we wanted a healing place where Veterans could come together and bring our families.”

Started in January 2016

VA Healthcare Analysis & Information Group (HAIG) FY15 Survey CIM was available in 131 (93%) of VA facilities mindfulness meditation (85%) guided imagery (74%) yoga (73%) acupuncture (60%)

Many Yoga Studies, but not with Vets Can improve functional outcomes in patients with non-specific chronic low back pain potential 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 position as the older they get and I didn’t want to see myself walking down the street curled over like a question 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 emotionally it’s just, it really is unbelievable.” Bolton et al, Biopsychosocial benefits of movement-based complementary and integrative health therapies,. Under review.

A Population Health Approach Needed to understand Veterans outside of individual studies “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” (Kindig and Stoddart, 2003) includes health outcomes, patterns of health determinants, and policies and interventions that link these two http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.93.3.380 Prospective, observational, real-world, point of care study

A Learning Healthcare System Data driven approach Engaging with patients to measure outcomes according to their perspectives New clinical research paradigm for improving health

PRIMIER Patients Receiving Integrative Medicine Interventions Effectiveness Registry Bravenet practice-based research network (PBRN) of 20 non-VA clinical sites around country VA became engaged in late 2015, starting 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 time Focus on patient reported outcomes PROMIS Perceived Stress Scale (PSS) Measure Yourself Medical Outcome Profile (MYMOP) Integrative medicine attendance Diagnosis, procedure codes Costs Research study—informed consent, incentives

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 Total 566 161 102 66 16

Comprehensive Addiction Recovery Act (CARA) 2016

PROMIS Global Health (EO site)

Perceived Stress Scale How often did you feel: That you were unable to control the important things in your life? Confident about your ability to handle your personal problems? That things were going your way? Difficulties were piling up so high that you could not overcome them? Those who participated in yoga at baseline report better emotional health than those who participated 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 patient considers the most important 4 items, on 7 point scale First 2 scales --two symptoms that the patient specifies as important to him or her. 3rd scale--activity of daily living that is being disrupted or prevented by the illness, which the patient also specifies. 4th scale--asks the patient to rate their general feeling of well-being All ratings are for the previous week

Courtney, Eickhoff, Adams et al, Poster at ICIMH 2016 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 Cognitive behavioral therapy Guided Imagery Mindfulness based stress reduction Mantram repetition Meditation Reiki Tai Chi Hypnotherapy Yoga

Overall VA Costs for SC Vets (FY16) CHAR 4 Total cost $ Total encounters Total unique patients 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-Implementation

PRIMIER is appropriate method Veterans want yoga, VA is giving it to them, but may access it outside if needed 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 Christie 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 Patient Centered Care: Tracy Gaudet, MD Laura Krejci, MSW

Rani.Elwy@va.gov relwy@bu.edu Questions? Rani.Elwy@va.gov relwy@bu.edu