Characterizing Therapeutic Pluralism Policies in Latin America: A Qualitative Content Analysis.

Introduction: The 1978 Alma Ata Declaration initiated international recognition of non-biomedical healing systems and their relevance for primary health. World Health Assembly (WHA) resolutions have called for the study and inclusion of traditional and complementary medicine (T&CM) into national health systems through policy development. The increased public, political, and scholarly attention given to T&CM has focused on clinical efficacy, cost-effectiveness, mechanisms of action, consumer demand, and supply-side regulation. Although >50% of WHO member states have T&CM policies, scant research has focused on these policies and their public health implications. This paper defines a novel term "therapeutic pluralism," and it aims at characterizing related policies in Latin America. Methods: A qualitative content analysis of Latin American therapeutic pluralism policies was performed. Policies' characteristics and the reported social, political, and economic forces that have made possible their development were assessed. Pre-defined policy features were categorized on an MS-Excel; in-depth text analyses were conducted in NVivo. Analyses followed the steps described by Bengtsson: decontextualization, recontextualization, categorization, and compilation. Results: Seventy-four (74) policy documents from 16 of the 20 sovereign Latin American countries were included. Mechanisms for policy enactment included: Constitution, National Law, National Policy, National Healthcare Model, National Program Guideline, Specific Regulatory Norms, and Supporting Legislation, Policies, and Norms. We propose a four-category typology of policy approaches in Latin America: Health Services-centered, Model of Care-based, Participatory, and Indigenous People-focused. Common themes countries used when justifying developing these policies included: benefits to the health system, legal and political mandates, supply and demand, and culture and identity. Social forces these policies referenced as influencing their development included: pluralism, self-determination and autonomy, anticapitalism and decolonization, safeguarding cultural identity, bridging cultural barriers, and sustainability. Conclusion: Policy approaches to therapeutic pluralism in Latin America go beyond integrating non-biomedical interventions into health services; they offer perspectives for transforming health systems. Characterizing these approaches has implications for policy development, implementation, evaluation, international collaboration, the development of technical cooperation tools and frameworks, and research.

Racial and Ethnic Disparities in the Incidence of High-Impact Chronic Pain Among Primary Care Patients with Acute Low Back Pain: A Cohort Study.

OBJECTIVE: We assessed whether race or ethnicity was associated with the incidence of high-impact chronic low back pain (cLBP) among adults consulting a primary care provider for acute low back pain (aLBP). METHODS: In this secondary analysis of a prospective cohort study, patients with aLBP were identified through screening at seventy-seven primary care practices from four geographic regions. Incidence of high-impact cLBP was defined as the subset of patients with cLBP and at least moderate disability on Oswestry Disability Index [ODI >30]) at 6 months. General linear mixed models provided adjusted estimates of association between race/ethnicity and high-impact cLBP. RESULTS: We identified 9,088 patients with aLBP (81.3% White; 14.3% Black; 4.4% Hispanic). Black/Hispanic patients compared to White patients, were younger and more likely to be female, obese, have Medicaid insurance, worse disability on ODI, and were at higher risk of persistent disability on STarT Back Tool (all P < .0001). At 6 months, more Black and Hispanic patients reported high-impact cLBP (30% and 25%, respectively) compared to White patients (15%, P < .0001, n = 5,035). After adjusting for measured differences in socioeconomic and back-related risk factors, compared to White patients, the increased odds of high-impact cLBP remained statistically significant for Black but not Hispanic patients (adjusted odds ration [aOR] = 1.40, 95% confidence interval [CI]: 1.05-1.87 and aOR = 1.25, 95%CI: 0.83-1.90, respectively). CONCLUSIONS: We observed an increased incidence of high-impact cLBP among Black and Hispanic patients compared to White patients. This disparity was partly explained by racial/ethnic differences in socioeconomic and back-related risk factors. Interventions that target these factors to reduce pain-related disparities should be evaluated. CLINICALTRIALS.GOV IDENTIFIER: NCT02647658.

Resident Outcomes and Perspectives Over 2 Years of a New Scholarship Curriculum.

BACKGROUND AND OBJECTIVES: Scholarship is recognized as a challenge in many family medicine residency programs. Among evaluations of scholarship curricula, few describe resident experiences of such interventions. To bridge this gap in knowledge, we measured resident confidence, satisfaction, and participation before and after implementing a new scholarship curriculum. METHODS: The redesigned curriculum included a structured project timeline, resident research in progress meetings, faculty mentorship, scholarly skills workshops, and mentored journal clubs. We conducted a curriculum evaluation via surveys of residents prior to implementation and after years 1 and 2, measuring satisfaction with the scholarly environment and opportunities, and confidence and participation in specific scholarly activities using Likert scales from 1 (least confidence) to 5. RESULTS: Compared to baseline (n=28), after 2 years (n=27) of the curriculum, residents reported increased mean confidence in critical appraisal of scientific articles (2.6±1.1 to 3.3±0.7, P=.007), carrying out a scholarly project (2.5±0.8 to 3.4±1.0, P=.005), and writing an abstract (3.0±0.8 to 3.8±0.7, P=.002). As compared to the first year, more residents in the second year participated in quality improvement projects (7.1% vs 29.6%, P=.031) and wrote conference abstracts (10.7% vs 37.0%, P=.022). Over the same period, those very satisfied with the scholarly environment increased from 0 (0%) to 8 (29.6%, P=.017). The June 2020 survey identified increased interest in scholarship because of the antiracism movement (51.9%) and COVID-19 pandemic (40.7%). CONCLUSIONS: Implementation of a redesigned scholarship curriculum was associated with increases in family medicine resident scholarship confidence and satisfaction.

Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care.

Importance: Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP. Objective: To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care. Design, Setting, and Participants: This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020. Exposures: SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral). Main Outcomes and Measures: Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records. Results: Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001). Conclusions and Relevance: In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.

Unrestricted Direct Access to Physical Therapist Services Is Associated With Lower Health Care Utilization and Costs in Patients With New-Onset Low Back Pain.

BACKGROUND: Low back pain (LBP) is one of the most prevalent conditions for which patients seek physical therapy in the United States. The American Physical Therapy Association categorizes direct access to physical therapist services into 3 levels: limited, provisional, and unrestricted. OBJECTIVE: The objective of this study was to evaluate the association of level of access to physical therapist services with LBP-related health care utilization and costs. DESIGN: This was a retrospective cohort study of patients with new-onset LBP between 2008 and 2013; data were from OptumLabs Data Warehouse. METHODS: We identified 59,670 individuals who were 18 years old or older, who had new-onset LBP, and who had commercial or Medicare Advantage insurance through a private health plan. We examined 2 samples. The first was health care utilization among individuals who saw a physical therapist first in states with either unrestricted access or provisional access. The second was LBP-related costs among individuals who saw either a physical therapist or a primary care physician first. RESULTS: Individuals who saw a physical therapist first in states with provisional access had significantly higher measures of health care utilization within 30 days, including plain imaging and frequency of physician visits, than individuals who saw a physical therapist first in states with unrestricted access. Compared with individuals who saw a primary care physician first, pooled across provisional-access and unrestricted-access states, those who saw a physical therapist first in provisional-access states had 25% higher relative costs at 30 days and 32% higher relative costs at 90 days, whereas those who saw a physical therapist first in unrestricted-access states had 13% lower costs at 30 days and 32% lower costs at 90 days. LIMITATIONS: This was a claims-based study with limited information on patient characteristics, including severity and duration of pain. CONCLUSIONS: Short-term LBP-related health care utilization and costs were lower for individuals in unrestricted-access states than in provisional-access states.

Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use.

OBJECTIVE: This study examined the association of initial provider treatment with early and long-term opioid use in a national sample of patients with new-onset low back pain (LBP). DESIGN: A retrospective cohort study of patients with new-onset LBP from 2008 to 2013. SETTING: The study evaluated outpatient and inpatient claims from patient visits, pharmacy claims and inpatient and outpatient procedures with initial providers seen for new-onset LBP. PARTICIPANTS: 216 504 individuals aged 18 years or older across the USA who were diagnosed with new-onset LBP and were opioid-naïve were included. Participants had commercial or Medicare Advantage insurance. EXPOSURES: The primary independent variable is type of initial healthcare provider including physicians and conservative therapists (physical therapists, chiropractors, acupuncturists). MAIN OUTCOME MEASURES: Short-term opioid use (within 30 days of the index visit) following new LBP visit and long-term opioid use (starting within 60 days of the index date and either 120 or more days' supply of opioids over 12 months, or 90 days or more supply of opioids and 10 or more opioid prescriptions over 12 months). RESULTS: Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with decreased odds of long-term opioid use in a propensity score matched sample (AOR (95% CI) 0.21 (0.16 to 0.27) and 0.29 (0.12 to 0.69), respectively). CONCLUSIONS: Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.

Health insurance design and conservative therapy for low back pain.

OBJECTIVES: To determine the association of health insurance benefit design features with choice of early conservative therapy for patients with new-onset low back pain (LBP). STUDY DESIGN: Observational study of 117,448 commercially insured adults 18 years or older presenting with an outpatient diagnosis of new-onset LBP between 2008 and 2013 as recorded in the OptumLabs Data Warehouse. METHODS: We identified patients who chose a primary care physician (PCP), physical therapist, or chiropractor as their entry-point provider. The main analyses were logistic regression models that estimated the likelihood of choosing a physical therapist versus a PCP and choosing a chiropractor versus a PCP. Key independent variables were health plan type, co-payment, deductible, and participation in a health reimbursement account (HRA) or health savings account (HSA). Models controlled for patient demographic and clinical characteristics. RESULTS: Selection of entry-point provider was moderately responsive to the incentives that patients faced. Those covered under plan types with greater restrictions on provider choice were less likely to choose conservative therapy compared with those covered under the least restrictive plan type. Results also indicated a general pattern of higher likelihood of treatment with physical therapy at lower levels of patient cost sharing. We did not observe consistent associations between participation in HRAs or HSAs and choice of conservative therapy. CONCLUSIONS: Modification of health insurance benefit designs offers an opportunity for creating greater value in treatment of new-onset LBP by encouraging patients to choose noninvasive conservative management that will result in long-term economic and social benefits.

Matching Our Mission: A Strategic Plan to Create a Diverse Family Medicine Residency.

BACKGROUND AND OBJECTIVES: Increasing the number of underrepresented minority (URM) physicians improves access and quality of care. URMs are more likely to practice primary care and work in underserved communities. The racial and ethnic diversity of family physicians lags behind the general population. To create a more diverse residency, the Boston Medical Center Family Medicine Residency Program (BMCFMRP) developed, implemented, and evaluated a strategic plan for diversity recruitment. METHODS: In academic year (AY) 2014-2015, we set goals to increase the number of URM applicants and the percentage of matched URMs. From 2014-2017, we implemented an intervention focused on: (1) increasing outreach to URM candidates, (2) revising interviews to minimize bias, and (3) analyzing recruitment data. RESULTS: From 2014-2017, the total number of URM applicants increased by 80% (61 to 110). Evaluating recruitment trends from 2010-2017, there was a statistically significant increase (P<0.001) in the percentage of URM applicants from 13.3% (29 of 218 total applicants) to 19.9% (110 of 402). There was also a significant increase (P=0.029) in the percentage of matched URMs. Before the intervention, the percentage ranged from 0% to 20% (2011: 0% [n=0/6], 2014: 0% [n=0/10], 2013: 20% [n=2/10]). During the intervention, the percentage ranged from 25% to 50% (2017: 25% [n=3/12], 2016: 50% [n=6/12]). CONCLUSIONS: The implementation of a strategic plan for diversity recruitment increased the number of URM applicants and the percentage of URMs matching into the BMCFMRP. Additional research is needed to determine if these strategies produce similar results in residency programs at other institutions and in other medical specialties.

Enhancing yoga participation: A qualitative investigation of barriers and facilitators to yoga among predominantly racial/ethnic minority, low-income adults.

Yoga is underutilized among racial/ethnic minorities and low-income populations. To enhance participation among these demographic groups and to inform a future clinical trial, we conducted a qualitative formative investigation, informed by the Social Contextual Model of health behavior change, to identify barriers and facilitators to yoga that could impact study participation. We recruited twenty-four racially/ethnically diverse adults, with and without prior yoga experience, from a low-income, urban housing community to participate in either an individual interview or focus group. A thematic data analysis approach was employed. Barriers to yoga engagement included the perception that yoga lacks physicality and weight loss benefits, fear of injury, lack of ability/self-efficacy to perform the practices, preference for other physical activities, and scheduling difficulties. Facilitators of yoga engagement included a quality yoga instructor who provides individualized instruction, beginner level classes, and promotional messaging that highlights the potential benefits of yoga, such as stress reduction.

Blood Lead Levels and Potential Risk Factors for Lead Exposures Among South Asians in New York City.

New York City's South Asian children and pregnant women have a disproportionate burden of elevated blood lead levels. This study is the first to investigate blood lead levels and risk factors for lead exposures among South Asian New Yorkers. A survey and a finger-stick blood lead test using a portable analyzer were administered to 230 South Asian adults and children. Blood lead levels of 5 µg/dL or higher were found in 20 % of the adults and 15 % of the children, as compared to 5 % of adults and 2.5 % of children citywide. Factors associated with elevated blood lead levels were recent repair work at home, not speaking English, Bangladeshi or Indian ethnicity, and occupational risk factors. Public health professional should be aware that South Asians may be at an increased risk for elevated blood lead levels.

Yoga versus education for Veterans with chronic low back pain: study protocol for a randomized controlled trial.

BACKGROUND: Chronic low back pain is the most frequent pain condition in Veterans and causes substantial suffering, decreased functional capacity, and lower quality of life. Symptoms of post-traumatic stress, depression, and mild traumatic brain injury are highly prevalent in Veterans with back pain. Yoga for low back pain has been demonstrated to be effective for civilians in randomized controlled trials. However, it is unknown if results from previously published trials generalize to military populations. METHODS/DESIGN: This study is a parallel randomized controlled trial comparing yoga to education for 120 Veterans with chronic low back pain. Participants are Veterans ≥18 years old with low back pain present on at least half the days in the past six months and a self-reported average pain intensity in the previous week of ≥4 on a 0-10 scale. The 24-week study has an initial 12-week intervention period, where participants are randomized equally into (1) a standardized weekly group yoga class with home practice or (2) education delivered with a self-care book. Primary outcome measures are change at 12 weeks in low back pain intensity measured by the Defense and Veterans Pain Rating Scale (0-10) and back-related function using the 23-point Roland Morris Disability Questionnaire. In the subsequent 12-week follow-up period, yoga participants are encouraged to continue home yoga practice and education participants continue following recommendations from the book. Qualitative interviews with Veterans in the yoga group and their partners explore the impact of chronic low back pain and yoga on family relationships. We also assess cost-effectiveness from three perspectives: the Veteran, the Veterans Health Administration, and society using electronic medical records, self-reported cost data, and study records. DISCUSSION: This study will help determine if yoga can become an effective treatment for Veterans with chronic low back pain and psychological comorbidities. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02224183.

Integrative Medicine in a Preventive Medicine Residency: A Program for the Urban Underserved.

The Preventive Medicine Residency Program collaborated with the Department of Family Medicine's Program for Integrative Medicine and Health Disparities at Boston Medical Center to create a new rotation for preventive medicine residents starting in autumn 2012. Residents participated in integrative medicine group visits and consults, completed an online curriculum in dietary supplements, and participated in seminars all in the context of an urban safety net hospital. This collaboration was made possible by a federal Health Resources and Services Administration grant for integrative medicine in preventive medicine residencies and helped meet a need of the program to increase residents' exposure to clinical preventive medicine and integrative health clinical skills and principles. The collaboration has resulted in a required rotation for all residents that continues after the grant period and has fostered additional collaborations related to integrative medicine across the programs.

Yoga vs. physical therapy vs. education for chronic low back pain in predominantly minority populations: study protocol for a randomized controlled trial.

BACKGROUND: Chronic low back pain causes substantial morbidity and cost to society while disproportionately impacting low-income and minority adults. Several randomized controlled trials show yoga is an effective treatment. However, the comparative effectiveness of yoga and physical therapy, a common mainstream treatment for chronic low back pain, is unknown. METHODS/DESIGN: This is a randomized controlled trial for 320 predominantly low-income minority adults with chronic low back pain, comparing yoga, physical therapy, and education. Inclusion criteria are adults 18-64 years old with non-specific low back pain lasting ≥ 12 weeks and a self-reported average pain intensity of ≥ 4 on a 0-10 scale. Recruitment takes place at Boston Medical Center, an urban academic safety-net hospital and seven federally qualified community health centers located in diverse neighborhoods. The 52-week study has an initial 12-week Treatment Phase where participants are randomized in a 2:2:1 ratio into i) a standardized weekly hatha yoga class supplemented by home practice; ii) a standardized evidence-based exercise therapy protocol adapted from the Treatment Based Classification method, individually delivered by a physical therapist and supplemented by home practice; and iii) education delivered through a self-care book. Co-primary outcome measures are 12-week pain intensity measured on an 11-point numerical rating scale and back-specific function measured using the modified Roland Morris Disability Questionnaire. In the subsequent 40-week Maintenance Phase, yoga participants are re-randomized in a 1:1 ratio to either structured maintenance yoga classes or home practice only. Physical therapy participants are similarly re-randomized to either five booster sessions or home practice only. Education participants continue to follow recommendations of educational materials. We will also assess cost effectiveness from the perspectives of the individual, insurers, and society using claims databases, electronic medical records, self-report cost data, and study records. Qualitative data from interviews will add subjective detail to complement quantitative data. TRIAL REGISTRATION: This trial is registered in ClinicalTrials.gov, with the ID number: NCT01343927.

Developing and implementing core competencies for integrative medicine fellowships.

The Consortium of Academic Health Centers for Integrative Medicine defines integrative medicine as "the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, health care professionals, and disciplines to achieve optimal health and healing." Over the past three decades, the U.S. public increasingly has sought integrative medicine approaches. In an effort to train medical professionals to adequately counsel patients on the safe and appropriate use of these approaches, medical schools and residencies have developed curricula on integrative medicine for their trainees. In addition, integrative medicine clinical fellowships for postresidency physicians have emerged to provide training for practitioners interested in gaining greater expertise in this emerging field. Currently, 13 clinical fellowships in integrative medicine exist in the United States, and they are predominantly connected to academic medical centers or teaching affiliate hospitals. In 2010, the Consortium of Academic Health Centers for Integrative Medicine, represented by 56 member academic health care institutions with a shared commitment to advance the principles and practices of integrative medicine, convened a two-year task force to draft integrative medicine fellowship core competencies. These competencies would guide fellowship curriculum development and ensure that graduates possessed a common body of knowledge, skills, and attitudes. In this article, the authors discuss the competencies and the task force's process to develop them, as well as associated teaching and assessment methods, faculty development, potential barriers, and future directions.

Prevalence and patterns of adult yoga use in the United States: results of a national survey.

BACKGROUND: Although yoga appears to be popular in the United States, there are no published studies on yoga's prevalence or patterns of use. METHODS: In 1998 we surveyed by telephone a nationally representative sample of 2055 English-speaking U.S. adults (60% weighted response rate) regarding yoga use. RESULTS: Of the respondents, 7.5% used yoga at least once in their lifetime and 3.8% used yoga in the previous 12 months. Respondents who used yoga at least once were more likely than non-users to be female (68% vs. 51%), college educated (68% vs. 45%), and urban dwellers (93% vs. 74%). Factors independently associated with yoga use at least once included female gender (OR 2.5 [95% CI 1.7-3.8]), baby boomer age group (ages 34-53) compared to pre-baby boomers (> or = 54 (2.3 [1.4-4.0]), education beyond high school (2.2 [1.4-3.5]), residing in large and small metropolitan areas compared to non-metropolitan areas (3.8 [1.8-7.8] and 2.7 [1.3-5.8], respectively), and use of other CAM therapies (5.3 [2.7-10.5]). Of respondents using yoga in the previous 12 months, 64% reported using yoga for wellness, 48% for health conditions, and 21% specifically for back or neck pain. Ninety percent felt yoga was very or somewhat helpful and 76% did not report spending money related to their yoga. CONCLUSIONS: In 1998 an estimated 15.0 million American adults had used yoga at least once in their lifetime and 7.4 million during the previous year. Yoga was used for both wellness and specific health conditions often with perceived helpfulness and without expenditure.