Provider Identified Access Barriers to Delivering Acupuncture to Persons with Traumatic Brain Injury and Chronic Pain: A Cross-Sectional Self-Report Survey

Abstract

Objective:

Traumatic brain injury (TBI) clinical practice guidelines for pain management and rehabilitation support the use of nonpharmacologic complementary and integrative health (CIH) modalities, such as acupuncture for remediating pain. Barriers to delivering CIH modalities, such as acupuncture warrant examination. The objective of this study is to explore provider perspectives on challenges to accessing acupuncture treatment for chronic pain in persons with TBI and describe differences across health care settings.

Setting:

Civilian, Veterans Affairs (VA), and Department of Defense health care systems.

Participants:

Health care providers (n = 145) were recruited from November 2022 to March 2023 via email through professional organizations and health care systems.

Design:

Descriptive cross-sectional self-report online survey.

Main Measures:

A survey assessed barriers using a 5-point Likert scale (always a barrier to never a barrier) using the Levesque Access to Care framework.

Results:

Of the 137 participants who provided information on setting, 86 (63%) worked in civilian health care; 47 (34%) worked in the Department of VA; and 4 (2.6%) in the Department of Defense (8 were missing data). Overall, providers endorsed all ten items as being barriers to accessing acupuncture treatment. However, these barriers were more statistically more frequently reported for civilian providers compared with VA providers for six of the 10 items, including lack of caregiver support (p < 0.0001); own knowledge and understanding of the treatment (p = 0.0025); health care setting culture discourages the treatment (p = 0.0181); lack of qualified providers (p = 0.0467); insurance does not cover (p < 0.0001), and patient cannot afford (p < 0.0001). VA provider respondents were more likely to answer all six items, as “Rarely/Never a Barrier,” while providers in a civilian setting were more likely to respond “Always/Frequently” or “Sometimes” a barrier.

Conclusion:

Results reflect the cultural, organizational, and structural differences that make acupuncture more accessible within the VA. understanding barriers to delivering care is critical to inform implementation strategy mapping efforts, to tailor strategies that are aimed to increase access and engagement with acupuncture treatment in civilian health care settings.

Background

Traumatic brain injury (TBI) affects millions of individuals worldwide every year,¹ often with persistent and significant clinical sequelae.² In the United States alone, approximately three million individuals hospitalized with a TBI developed a long-term disability.³ Both cognitive and physical symptoms can affect an individual after an injury, which can persist for months and even years.² Chronic pain is a common complaint of comorbidity experienced after an injury,^4

–8 and for many individuals, pain affects and is affected by other common complaints of comorbidities after an injury such as depression, anxiety, post-traumatic stress disorder (PTSD), and difficulties with verbal word generation during neuropsychological testing.^9,10

Approaches to pain management are multi-faceted to address the many clinical outcomes that interact with pain.^8,11,12 TBI rehabilitation also approaches the management of the clinical sequelae after injury through a multi-disciplinary and individualized treatment plan.^2,13 Given the concerns of opioid use and for improving treatment approaches in TBI, it is important to highlight that clinical practice guidelines for pain management and recommendations for TBI rehabilitation support the use of nonpharmacologic therapies.^2,11,13

Acupuncture is a nonpharmacologic therapy used to treat a variety of different conditions. It is a technique from a traditional Chinese medicine practice to stimulate specific points on the body, that are chosen based on the condition of focus, by inserting thin needles through the skin.¹⁴ Acupuncture is typically grouped with other modalities collectively named complementary and integrative health (CIH).¹⁵ Research has proposed many neurobiological mechanisms to account for the effect of acupuncture for pain,^16

–19 and a growing body of evidence supports the use of acupuncture for many pain conditions.²⁰ Moreover, clinical practice guidelines recommend its use as a nonpharmacologic option.¹¹ However, there is a lack of research about chronic pain and acupuncture in the setting of TBI.²¹

Acupuncture utilization is growing consistently in the United States.^22
–24 Health care consumers seek acupuncture treatment as an adjunct to other pain treatments, which can also result from unsatisfactory results from conventional medicine.^25
–27 In the United States, some physicians provide acupuncture under their scope of license after receiving acupuncture training.²⁸ However, acupuncture is commonly provided by individuals who received specific acupuncture training, independent of other medical specialty training,²⁹ and the practice is regulated at the state level.³⁰ Individuals seek acupuncture for pain management after TBI,³¹ and health care providers report generally good acceptance or interest for acupuncture and other CIH modalities for their patients for specific clinical conditions.^32

–36

However, determinants for seeking and accessing acupuncture remain unclear, since acupuncture is a self-referral and provider-referral CIH modality. Studies examining predictors for referral to acupuncture and CIH modalities indicate that physicians identifying as female are more likely than male physicians to refer to acupuncture and that family medicine practitioners refer at a higher proportion than other medical specialties.³⁷ Among physicians in the Veterans Health Administration (VHA), increased referral for acupuncture is not associated with patient use of acupuncture, but rather with the belief that acupuncture could increase the patient’s satisfaction.³⁸ Despite the generally favorable attitudes towards acupuncture specifically, this acceptance does not necessarily translate into acupuncture being integrated into care.³⁶

Further exploration is needed to identify potential barriers to receipt of acupuncture, such as insufficient access or recommendation decisions from health care providers. Currently, there is a gap in knowledge of which providers refer for acupuncture and when these referrals occur. However, individuals with TBI do seek acupuncture for pain management and it is important to identify and support the use of nonpharmacologic options for treatment of pain after TBI. The aims of this study are to explore provider perspectives on determinants of individuals with TBI and chronic pain accessing referrals for acupuncture for chronic pain treatment and to explore whether there are differences across health care settings.

Methods

Study design

This project was completed using a descriptive cross-sectional self-report online survey.

Participants

This study was approved by the institutional review board at Craig Hospital. Inclusion criteria targeted U.S.-based providers (1) had two or more years’ experience treating persons with TBI, (2) who were treating persons with TBI and/or chronic pain, and (3) had a minimum of 10 persons with TBI in their clinical practice per year.

Setting

Recruitment was conducted within the TBI Model Systems 21-center network of coordinated inpatient rehabilitation following TBI, distributed across the United States to ensure a broad sampling of different types of representative providers and health care settings.

Procedure

This study was part of a multi-center National Institute on Disability, Independent Living, and Rehabilitation (NIDILRR)-funded TBI model systems collaborative study of chronic pain following TBI. To recruit, we used purposeful representative snowball sampling. Providers were recruited via email and professional listservs from professional organizations (e.g., American Congress of Rehabilitation Medicine), health care systems, and TBI model systems networks. Recruitment emails included an active link to take respondents to the survey for anonymous completion.

Measure

Access to care survey

Consistent with previous work, items measuring barriers to health care access were iteratively developed using the Levesque access to care conceptual framework.^39,40 In this framework, the ability to access care is conceptualized as an interface between the existing health care infrastructure and the populations it serves. The framework highlights dimensions from the supply side (health care environment) and demand side (communities that it supports) of health care that interact to influence health care access. Collectively, the framework provides a mechanistic understanding of facilitators and barriers that can impact health care access and ideal health outcomes that can inform future interventions. Items were focused on health care access constructs and intended to be useable across any type of health care need and subsequent intervention. Items were iteratively reviewed and refined with an advisory board including clinicians, administrators, and persons with TBI lived experience input. Scaling of items was finalized with the study advisory board to represent meaningful ratings. After 21 iterations, the final survey included 10 items rated on a five-point Likert scale—⁴¹Always a Barrier to Never a Barrier (see Supplementary Data S1). Participants were asked to rate the frequency of barriers occurring for acupuncture based on their professional experience.

Analysis

All statistical analyses were performed using SAS v9.4 assuming a significance level of 0.05. The total sample of participants was described based on treatment setting using frequency counts and percentages. The survey responses for each item were described in the same way for the total sample and by civilian and VA health care settings. Significant differences in survey responses between Civilian and VA health care settings were determined using chi-square tests. Those who responded Military health care settings or had missing data were not included in these analyses. For analytic purposes, the survey responses for each item were collapsed into three groups. “Always a Barrier” and “Frequently a Barrier” were collapsed into one group and “Rarely a Barrier” and “Never a Barrier” into another.

Results

Study sample

Characteristics of the respondents (n = 145 health care providers who completed the survey) are summarized in Table 1. Of the 145 participants, 86 (63%) worked in a civilian health care setting, 47 (34%) in a VA setting, 4 (3%) in a military setting, and 8 had missing data for this item. Twenty-six (19%) participants worked in a setting that focused on chronic pain treatment and 120 (86%) worked in a TBI treatment setting. Notably, participants could select all work settings as applicable.

Table 1.

Sample Demographics

	n	%
Health care setting
Civilian	86	62.8%
Veteran	47	34.3%
Military	4	2.9%
(Missing)	8
Chronic pain treatment setting
Yes	26	18.6%
No	114	81.4%
(Missing)	5
TBI treatment setting
Yes	120	85.7%
No	20	14.3%
(Missing)	5

TBI: Traumatic Brain Injury.

Overall challenges with delivering acupuncture to TBI

Across the overall sample of providers, all items were endorsed as being a barrier to delivering acupuncture to persons with TBI with >60% indicating items were always or frequently a barrier (see Table 2). Relatively speaking, the top identified challenge to delivering acupuncture for persons with TBI was the distance to treatment (88.5% endorsed as always or frequently a barrier). Similarly, patient trust and understanding of the benefits of acupuncture was the second most endorsed barrier to care (87% endorsed always or frequently a barrier). Lastly, 81% endorsed a lack of trained providers as frequently or always a barrier. These top barriers highlight the need for greater workforce availability for TBI populations but also the need to intervene with patient and family education about the value of acupuncture care for the treatment of chronic pain.

Table 2.

Survey Differences Between Health Care Settings for Acupuncture Therapies

	Total sample (n = 145) N (%)	Health care setting
	Total sample (n = 145) N (%)	Civilian (n = 86) N (%)	Veteran (n = 47) N (%)	p-Value
	Patient lack of understanding, trust, or beliefs about the efficacy of intervention				0.3583
Always/Frequently a barrier	51 (39.2%)	33 (44.6%)	15 (32.6%)
Sometimes a barrier	62 (47.7%)	34 (46.0%)	24 (52.2%)
Rarely/Never a barrier	17 (13.1%)	7 (9.5%)	7 (15.2%)
TBI Morbidity (cognition, physical limitations) impacting engagement or participation				0.6086
Always/Frequently a barrier	28 (21.5%)	18 (24.3%)	8 (17.4%)
Sometimes a barrier	57 (43.9%)	32 (43.2%)	20 (43.5%)
Rarely/Never a barrier	45 (34.6%)	24 (32.4%)	18 (39.1%)
Patient cultural norms do not support choice of treatment				0.0537
Always/Frequently a barrier	29 (22.3%)	20 (27.0%)	6 (13.0%)
Sometimes a barrier	61 (46.9%)	37 (50.0%)	21 (45.7%)
Rarely/Never a barrier	40 (30.8%)	17 (23.0%)	19 (41.3%)
Lack of caregiver support for the intervention^a				<0.0001
Always/Frequently a barrier^b	23 (17.7%)	16 (21.6%)	3 (6.5%)
Sometimes a barrier^b	61 (46.9%)	45 (60.8%)	16 (34.8%)
Rarely/Never a barrier^b	46 (35.4%)	13 (17.6%)	27 (58.7%)
Distance to treatment setting or lack of transportation				0.1494
Always/Frequently a barrier	50 (38.5%)	32 (43.2%)	15 (32.6%)
Sometimes a barrier	65 (50.0%)	38 (51.4%)	24 (52.2%)
Rarely/Never a barrier	15 (11.5%)	4 (5.4%)	7 (15.2%)
My own knowledge and understanding of the treatment ^a				0.0025
Always/Frequently a barrier	23 (17.8%)	17 (23.3%)	5 (10.9%)
Sometimes a barrier^b	30 (23.3%)	24 (32.9%)	6 (13.0%)
Rarely/Never a barrier^b	76 (58.9%)	32 (43.8%)	35 (76.1%)
My health care setting culture discourages the treatment ^a				0.0181
Always/Frequently a barrier	21 (16.2%)	15 (20.3%)	5 (10.9%)
Sometimes a barrier^b	26 (20.0%)	20 (27.0%)	5 (10.9%)
Rarely/Never a barrier^b	83 (63.9%)	39 (52.7%)	36 (78.3%)
Lack of qualified providers who can deliver the intervention ^a				0.0467
Always/Frequently a barrier	67 (51.9%)	43 (58.9%)	20 (43.5%)
Sometimes a barrier	37 (28.7%)	21 (28.8%)	12 (26.1%)
Rarely/Never a barrier^b	25 (19.4%)	9 (12.3%)	14 (30.4%)
Insurance does not cover the treatment ^a				<0.0001
Always/Frequently a barrier^b	60 (46.2%)	51 (68.9%)	6 (13.0%)
Sometimes a barrier	32 (24.6%)	21 (28.4%)	10 (21.7%)
Rarely/Never a barrier^b	38 (29.2%)	2 (2.7%)	30 (65.2%)
Patient cannot afford the treatment ^a				<0.0001
Always/Frequently a barrier^b	61 (47.3%)	53 (71.6%)	6 (13.3%)
Sometimes a barrier	27 (20.9%)	18 (24.3%)	7 (15.6%)
Rarely/Never a barrier^b	41 (31.8%)	3 (4.1%)	32 (71.1%)

Significant difference between health care settings (α = 0.05).

Significant pairwise comparison.

TBI, traumatic brain injury.

Health care system differences in delivering acupuncture to TBI

Statistically significant differences were found between the health care setting for six of the 10 items which include “Lack of caregiver support for the intervention” (p < 0.0001), “My own knowledge and understanding of the treatment” (p = 0.0025), “My health care setting culture discourages the treatment” (p = 0.0181), “Lack of qualified providers who can deliver the intervention” (p = 0.0467), “Insurance does not cover the treatment” (p < 0.0001), and “Patient cannot afford the treatment” (p < 0.0001). Providers working in a VA setting were more likely to answer all six of these items “Rarely/Never a Barrier” when compared with the civilian providers. Providers in a civilian setting were more likely to respond “Always/Frequently a Barrier” for the “Lack of caregiver support for the intervention”, “Insurance does not cover the treatment”, and “Patient cannot afford the treatment” items and be more likely to respond “Sometimes a Barrier” in the “Lack of caregiver support for the intervention”, “My own knowledge and understanding of the treatment”, and “My health care setting culture discourages the treatment” items as compared with VA providers. The test results for all survey items are described in Table 2.

Discussion

TBI affects millions of individuals every year, many with persistent and significant clinical sequelae; often including persistent chronic pain. TBI clinical practice guidelines for pain management and rehabilitation support the use of nonpharmacologic CIH modalities. Acupuncture is a nonpharmacologic CIH therapy used for the treatment of pain. This study explored provider perspectives on challenges to delivering acupuncture treatment for chronic pain to persons with TBI across civilian and VA health care settings.

Results reflect the cultural, organizational, and structural differences that make acupuncture more accessible within the VA. Understanding barriers to access to care is critical to inform implementation strategy mapping efforts, to tailor strategies that are aimed to increase access and engagement with acupuncture treatment in civilian health care settings. Education and training strategies are needed to increase patient and caregiver knowledge of acupuncture as a valuable pain management modality. However, broader structural, policy and fiscal strategies are needed to address system level barriers, including cultural, workforce, insurance, and cost, to increase access to acupuncture for civilians with TBI-related pain management needs.

The higher prevalence of barriers to acupuncture use observed in civilian providers is most likely attributed to the presence of acupuncture coverage within the VHA.⁴² Outside of the VHA, insurance coverage varies, if it is even offered at all.⁴³ Our results indicate that a majority (over two-thirds) of civilian providers cited both a lack of insurance coverage and a lack of financial resources for the patient as significant barriers. These findings are congruent with a recent study examining trends in insurance coverage in the United States by Candon and colleagues that found that approximately half of acupuncture users do not have insurance coverage.⁴⁴ This lack of coverage presents a potential financial burden for access, and this burden can be prohibitive to receiving an optimal treatment course.⁴⁵

Most providers indicated that a lack of qualified individuals to provide acupuncture was a barrier and that the health care culture discouraged the treatment. Within the VHA’s whole health program, licensed acupuncturists are permitted to provide treatments.⁴² In addition, almost all states in the United States have acupuncture practice acts,⁴⁶ and allow physicians to practice acupuncture as part of their scope of license with little or no additional training.²⁸ A possible reason for this finding may stem from significant time limitations to the patient visit that prohibit acupuncture,^47

–50 thereby creating a need to refer out to another qualified provider who does not have these constraints. While the results of the present study do not identify specific reasons for the lack of qualified acupuncture providers or why there is institution-level discouragement of acupuncture, it is also possible that these findings are intertwined. Even with increasing recommendations for acupuncture in clinical practice guidelines,⁵¹ more practical obstacles require addressing such as the time considerations mentioned, patient costs, and provider uncertainty as to whether or not the treatment will work or is appropriate for a specific patient.^36,52 Moreover, consistent with the present study’s findings, research also notes that a lack of support from leadership contributes to implementation difficulties.³⁶ Future studies should focus on identifying factors associated with the lack of qualified acupuncture providers and the lack of support from the health care organization.

The results of this survey noted that civilian providers reported additional barriers stemming from a knowledge and understanding of the treatment and that there was a lack of caregiver support for acupuncture. These findings align with the current evidence for factors affecting acupuncture recommendations and use. Prior research highlights the importance that health care providers, friends, and family have for the increased utilization of acupuncture.^25,38 The lack of caregiver support partially stems from a lack of familiarity with acupuncture services available.⁵³ In addition, low knowledge by providers about the evidence base for acupuncture including a general lack of public education about acupuncture, can negatively affect acupuncture utilization.^36,53 The results of the present study highlight the continued need for ongoing education efforts for health care providers and consumers about expectations and the current evidence base for acupuncture.

Potential limitations of the present survey findings should be considered when interpreting results. Though recruitment relied on purposeful representative snowball sampling, sampling, and response bias are common challenges in surveying health care providers. For example, providers who are particularly well-versed in brain injury and/or pain management or employed in an academic setting may have been more inclined to complete the survey distributed through the society and research networks. Response bias may also occur if health care providers are inclined to provide socially desirable responses, such as a provider overstating adherence to clinical guidelines or downplaying personal challenges. Self-report surveys are also subject to both intentional and unintentional misrepresentation of one’s experiences and may also be subject to inaccuracies in recall of their experiences (recall bias). For these reasons, the generalizability of results may be limited. Future efforts to evaluate comparisons between civilian, VA, and military settings, using larger datasets will increase the knowledge base from which we can fully understand determinants to access across diverse health care systems. It is also important to note that these barriers are from the perspective of health care providers only and do not include patient perspectives on access to or use of acupuncture for the treatment of pain.

The results of our study indicate future research should focus on identifying implementation strategies to increase access to acupuncture care at cultural, organizational, and structural levels for persons with TBI and chronic pain. Specifically, research is needed to identify specific obstacles to reimbursement for acupuncture services across health care settings. Efforts to overcome other barriers to access to acupuncture in civilian care settings are specifically warranted. Strategies focusing on support structures, provider/leadership knowledge, and acceptance of the modality, as well as financial barriers are needed based on survey data findings.

Conclusions

Interpretation of survey findings indicates that, cultural, organizational, and structural differences within the VA as compared with civilian health care settings, impact access to acupuncture for persons with TBI and chronic pain. Providers in the civilian setting report more barriers to delivering acupuncture care than their VA counterparts. Understanding barriers to acupuncture care is critical to inform implementation efforts; and tailor strategies that are aimed to increase access and engagement with acupuncture treatment in civilian health care settings. Efforts are warranted to reduce barriers to acupuncture care, and to support persons with TBI, who are managing chronic pain.

Footnotes

Authors’ Contributions

J.N.H.: conceptualization, writing—original draft, writing—review and editing, methodology, investigation, and supervision. R.N.R.: funding acquisition, conceptualization, writing—original draft, writing—review and editing, methodology, project administration, investigation, and supervision. J.H.: funding acquisition, conceptualization, writing—original draft, writing—review and editing, methodology, investigation, and supervision. M.S.: data curation, formal analysis, writing—review, and editing. M.D.S.: writing—original draft, writing—review, and editing. F.M.H.: writing—original draft, writing—review, and editing. B.A.C.: writing—review and editing. A.T.: project administration, writing—review and editing. R.H.: writing—original draft, writing—review, and editing. A.M.M.: writing—original draft, writing—review and editing.

Author Disclosure Statement

The authors have no conflicts of interest.

Disclaimer

The views expressed in this article are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. This work was prepared under Contract HT0014-22-C-0016 with DHA Contracting Office (CO-NCR) HT0014 and, therefore, is defined as U.S. Government work under Title 17 U.S.C.§101. Per Title 17 U.S.C.§105, copyright protection is not available for any work of the U.S. Government. For more information, please contact dha.TBICOEinfo@health.mil. UNCLASSIFIED

Funding Information

Research reported in this article was funded and supported through a National Institute on Disability, Independent Living, and Rehabilitation (NIDILRR), a center within the Administration for Community Living (ACL), Department of Health and Human Services Collaborative Grant Award (90DPTB0017) which leveraged the infrastructure of the NIDILRR and the Department of Veterans Affairs (VA) Traumatic brain injury (TBI) Model Systems programs of research James A. Haley Veterans Hospital TBI Model Systems, IRB PR00000094; see additional acknowledgment, characterization and treatment of chronic pain after moderate to severe TBI, 90DPTB0017, IRB PR00039496; Craig Hospital, Rocky Mountain Regional TBI Model System, 90DPTB007 (2017–2022) and 90DPTB0020 (2022–2027), IRB 231579, characterization and treatment of chronic pain after moderate to severe TBI, 90DPTB0017, IRB 1335849; Craig Hospital TBI Model Systems National Data and Statistical Center, 90DP0084 (2016–2021) and 90DPTB0018 (2021–2026), IRB 231626; University of Washington School of Medicine, University of Washington TBI Model System, 90DPTB0008 (2017–2022) and 90DPTB0024 (2022–2027), IRB STUDY00001788; Indiana University School of Medicine, IN TBI Model System, 90DPTB0002 (2017–2022) and 90DPTB0022 (2022–2027), Spaulding Rehabilitation Hospital, Harvard Medical School, Spaulding-Harvard TBI Model System, 90DPTB0011 (2017–2022) and 90DPTB0027-01-00 (2022–2027), IRB 2012P002476; Wayne State University School of Medicine, Southeastern Michigan TBI System, 90DPTB006 (2017–2022) and 90DPTB0030 (2022–2027), IRB 102908B3E; Mayo clinic TBI Model System, 90DPTB0017 90DPTB006 (2017–2022) and 90DPTB0031 (2022–2027), IRB 69-03). This work was also supported by the Department of Defense (DOD) CDMRP Award Number HT9425-23-1-0621. The views expressed in this article are those of the authors and do not necessarily represent the official policy or position of NIDILRR, ACL, HHS; Defense Health Agency, Department of Army/Navy/Air Force, DOD; Veterans Health Administration, or any other U.S. government agency. No official endorsement should be inferred.

Supplementary Material

Supplementary Data S1

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