Evaluation of complementary and integrative health approaches among US veterans with musculoskeletal pain using propensity score methods

Abstract

Objectives. To examine the treatment effectiveness of complementary and integrative health approaches (CIH) on chronic pain using Propensity Score (PS) methods. Design, Settings, and Participants. A retrospective cohort of 309,277 veterans with chronic musculoskeletal pain assessed over three years after initial diagnosis. Methods. CIH exposure was defined as one or more clinical visits for massage, acupuncture, or chiropractic care. The treatment effect of CIH on self-rated pain intensity was examined using a longitudinal model. PS-matching and inverse probability of treatment weighting (IPTW) were used to account for potential selection and confounding biases. Results. At baseline, veterans with (7,621) and without (301,656) CIH exposure differed significantly in 21 out of 35 covariates. During the follow-up period, on average CIH recipients had 0.83 (95% confidence interval [CI] 5 0.77 to 0.89) points higher pain intensity ratings (range 5 0-10) than nonrecipients. This apparent unfavorable effect size was reduced to 0.37 (95% CI 5 0.28 to 0.45) after PS matching, 0.36 (95% CI 5 0.29 to 0.44) with IPTW on the treated (IPTW-T) weighting, and diminished to null when integrating IPTW-T with PS matching (0.004, 95% CI 5 -0.09 to 0.10). An alternative IPTW model and conventional covariate adjustment appeared least powerful in terms of potential bias reduction. Sensitivity analyses restricting the follow-up period to one year after CIH initiation derived consistent results. Conclusions. PS-based causal methods successfully eliminated baseline difference between exposure groups in all measured covariates, yet they did not detect a significant difference in the self-rated pain intensity outcome between veterans who received CIHs and those who did not during the follow-up period.