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

2. “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

4. 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.”

5. Started in January 2016

7. 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%)

8. 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

9. 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.

10. 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
Prospective, observational, real-world, point of care study

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

12. 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

13. PRIMIER + VA Sites

14. 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

15. PRIMIER can address….

17. Recruitment through IM Clinic

18. Recruitment 9/1/16 Site Baseline 2 mos 4 mos 6 mos 12 mos DC 388 75 5042 15 LA 77 34 19 9 1 EO
101 52 33
Total
566
161
102 66 16

21. Comprehensive Addiction Recovery Act (CARA) 2016

22. PROMIS Global Health (EO site)

23. 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)

24. 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

27. Courtney, Eickhoff, Adams et al, Poster at ICIMH 2016
Yoga for PTSD? (DC)
Courtney, Eickhoff, Adams et al, Poster at ICIMH 2016

28. Courtney, Eickhoff, Adams et al, Poster at ICIMH 2016

29. 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

30. 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

31. PRIMIER-Implementation

32. 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)

33. 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

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