The Intersection of Dissemination Research and Acupuncture: Applications for Chronic Low Back Pain.

Dissemination research is the study of distributing information and intervention materials to a specific clinical practice or public health audience. Acupuncture, a healthcare practice involving the stimulation of certain body points, often with thin needles, is considered an evidence-based treatment for low back pain (LBP), but is underutilized in the United States. Body: We will use the example of acupuncture for LBP to identify opportunities to leverage dissemination research to increase utilization of acupuncture. Deficits in the awareness or knowledge of acupuncture may limit its adoption by patients and other stakeholders. Thus, we summarize methods to gather data on stakeholder awareness and knowledge of acupuncture for LBP, i.e., audience research. Engaging multiple stakeholder audiences (e.g., health system leaders, primary care providers, patients), is needed to generate knowledge on promising dissemination strategies for each audience. Audience segmentation is important for identifying population subgroups for whom adoption of acupuncture may require a more intensive or tailored dissemination strategy. To illustrate potential audience 'segments', our research discussion focused on developing dissemination strategies by age (i.e., older adults - those age 65 years or older, and younger adults - those under age 65 ). This decision was prompted by Medicare's recent policy covering acupuncture for chronic LBP. We leverage current knowledge of barriers and facilitators of acupuncture use to discuss how further tailoring of dissemination strategies might optimize adoption of acupuncture in both groups of adults. Experimental study designs could then be used to compare the effectiveness of such strategies to increase awareness, knowledge, or adoption of acupuncture. Conclusions: Conducting dissemination research may improve awareness and knowledge of acupuncture, and ultimately the adoption of acupuncture in biomedical settings. We anticipate that the concepts highlighted in this manuscript will also be helpful for those disseminating information about other complementary and integrative health approaches.

Background

Acupuncture, despite being effective for chronic musculoskeletal pain,[1-5] is used by fewer than 2% of Americans each year.[6] There are many factors that influence the adoption of even a proven therapy in health care systems. It is often cited that after a new intervention is developed, studied, and judged to be ‘evidence-based’ it takes an average of 17 years for that intervention to be widely implemented into usual care settings.[7] The field of dissemination and implementation (D&I) research has developed to decrease this research-to-practice gap phenomenon. Dissemination research “is the scientific study of the targeted distribution of information and intervention materials specific to clinical practice or public health audiences.”[8] It is designed to identify the most effective ways to communicate and circulate knowledge. Dissemination research is distinct from implementation research, which involves using strategies to integrate evidence-based interventions within specific settings.[8,9] Little research has focused on the intersection of dissemination research and acupuncture. Identifying how to best communicate information on acupuncture, through dissemination research, will bolster efforts to integrate acupuncture in usual care settings.

We will use the example of acupuncture for low back pain (LBP) to identify opportunities to leverage dissemination research to increase utilization of acupuncture. LBP is a major source of disability and healthcare spending.[10,11] The American College of Physicians recommends nonpharmacologic treatments, including acupuncture, as first-line therapy for acute and chronic LBP as of their 2017 clinical practice guideline.[3] Yet, American adults with LBP are only slightly more likely to report receiving acupuncture in the previous year compared to the general population (3% vs. 2%).[6,12] Acupuncture is rarely covered by insurance, limiting its use for LBP.[13] A lack of knowledge of, or unfavorable attitudes toward, acupuncture can also impede patient[14-19] and provider[20-22] adoption of acupuncture. Less is known about the role of health system leaders, who may facilitate access to acupuncture via decisions made at the organizational level. On January 18, 2020, the Center for Medicare and Medicaid Services (CMS) announced its decision to cover acupuncture for chronic LBP in their Medicare population, removing a major barrier to acupuncture access among older adults. This policy has the potential to increase use of acupuncture for chronic LBP by Americans. However, the impact of this policy may hinge on whether information about acupuncture for LBP, and acupuncture reimbursement policy, reaches health system leaders, clinicians, and the patients who are most likely to benefit. The best way to spread this information to these stakeholders is unknown.

In this commentary, we orient readers to important concepts in dissemination practice and research.[23-25] We apply the concepts of audience research, audience segmentation, and dissemination effectiveness research.[9] We organize potential messages for health system leaders, primary care providers (PCPs), and patients with LBP to demonstrate how dissemination strategies,[26] or discrete actions taken to increase the adoption of acupuncture for LBP, can be tailored to specific stakeholder audiences. We illustrate audience ‘segments’ by considering how these messages may be further tailored for adults above the age of 65 who now have insurance coverage for acupuncture through Medicare’s new policy and younger adults who will still typically pay out of pocket for acupuncture.

Acupuncture

Acupuncture involves the stimulation of certain body points, often with thin needles, for a therapeutic effect. In the United States there are approximately 37,000 Licensed Acupuncturists.[27] Research on acupuncture has increased significantly over the past 20 years[28] and acupuncture is considered an evidence-based practice for managing some conditions.[4] For example, acupuncture is considered a first-line therapy for acute and chronic LBP.[3]

Low Back Pain

LBP is a major public health problem that can develop early in life and recur or persist across the life course.[29,30] About four in five Americans will experience LBP at least once, resulting in more ‘years lived with disability’ than any other health condition.[10] LBP is also among the most costly conditions in the United States, as a result of numerous outpatient visits, advanced imaging, and procedures.[11] Roughly a third of older adults report LBP[31] and the implications of chronic LBP in older adults are more severe. Among older adults chronic LBP is associated with functional decline, falls, and increased mortality.[32-34] Older adults are particularly vulnerable to adverse effects from pharmacological treatments for chronic LBP, such as renal dysfunction, hypertension, or bleeding due to NSAIDs or mental status changes and constipation due to opioids.[35]

Dissemination Research

The spread of information on evidence-based practices often occurs through “push” and “pull” strategies.[36] Initially, scientists promote their work through “push” strategies (e.g., publishing in peer-reviewed journals, press releases from their institution or the journal, or social media). Engaging stakeholders throughout the conduct of clinical research can allow for formal or informal opportunities to characterize key perspectives or audiences that can help shape or target messages for dissemination. Understanding patient demand, and how information about evidence-based practices is sought out, is also important. This is helpful for augmenting how information on acupuncture might be “pulled” into the community (e.g., by patients with LBP) through social networks, word of mouth, and other distribution channels.[37] Similarly, it is also useful to know where PCPs and healthcare leaders typically find information about acupuncture.

Dissemination strategies are used for spreading information about an evidence-based practice to improve awareness, attitudes, knowledge, and intention to adopt a specific evidence based practice.[25] Such strategies applied to acupuncture for LBP need to consider patients, those who might refer to acupuncturists (e.g., PCPs), and others who may be able to remove obstacles to care (e.g., health system leaders). While general strategies are important in spreading information regarding acupuncture broadly, unique barriers may exist for each stakeholder audience. More tailored approaches have advantages over selecting dissemination strategies that are intuitive or have been historically used.[38,39] A systematic, stepped approach has been proposed to inform the development of credible, data-driven dissemination strategies: 1) formative audience research; 2) audience segmentation research; and 3) dissemination effectiveness research.[9] Such an approach is commonly used in marketing and health communication fields, and is being adapted for use within the field of implementation science.[23,24]

Formative Audience Research

Formative audience research seeks to generate data to provide an empirical foundation for the design and distribution of dissemination materials.[40,41] This research can be used to describe the awareness, knowledge or behaviors related to acupuncture among different stakeholder audiences (e.g., health system leaders, PCPs, and patients with LBP). A range of D&I frameworks and models are available to help identify and prioritize relevant stakeholders.[42] As an example, the Exploration, Preparation, Implementation Sustainment (EPIS) framework prompts attention to legislation, funding, policies, advocacy groups, organizational and practitioner networks, professional organizations, and technical assistance support systems.[43] Each stakeholder audience can influence decisions to adopt an evidence-based practice.[43] Relevant questions pertinent to formative audience research about acupuncture for LBP may include: To what extent are health system leaders aware that acupuncture can be helpful for LBP? What factors make a PCP want to refer patients with LBP to acupuncture? To what extent do patients with LBP independently seek acupuncture?

Audience Segmentation Research

Once formative audience research has described a population of interest, audience segmentation can be used to identify subgroups with different propensities to be aware of or adopt acupuncture.[40] Among adults with LBP, the National Health Interview Survey has found Asian Americans, women, those with higher incomes, a college education, and those living on the West coast were more likely to use acupuncture.[12] Similarly, female physicians and those living on the West coast or Northeast are among the most likely to recommend acupuncture to patients with LBP.[44] Patients or physicians with these characteristics may need little additional information via dissemination strategies. It may be more important to further characterize populations less likely to adopt acupuncture for LBP. These may be more likely to benefit from more intensive dissemination strategies tailored to their unique attributes. Given that the list of individual predictors of acupuncture use is potentially long, identifying the most parsimonious cluster of modifiable characteristics may be particularly useful in identifying these subgroups. Latent class analysis is one quantitative approach for identifying distinct groups which are subsequently labeled by researchers based on combinations of important characteristics.[23]

Dissemination Effectiveness Research

Once potential dissemination strategies have been identified, they should be evaluated for effectiveness. The strongest evidence will come from prospective studies that randomize stakeholders to receive different dissemination strategies where outcomes include increased awareness or knowledge of acupuncture, favorable attitudes toward acupuncture, and intention to adopt or actual adoption of acupuncture for LBP (e.g., proportion of patients with LBP who receive acupuncture). One such study compared a website with an ‘optimized design’ informed by four psychological theories and previous formative research to a standard website for patients with LBP.[45] They found that knowledge about acupuncture increased in participants in the optimized group, but an increase in knowledge did not translate to an increased willingness to try acupuncture for LBP.[46] Knowledge of acupuncture alone may not change behavior. Additional dissemination strategies that involve multiple stakeholders (patients, PCPs, and health system leaders) may be more effective.[47,48] This research could also compare a general set of strategies to a more tailored approach for specific audience segments (e.g., older and younger adults).

Tailoring Dissemination Strategies for Younger and Older Adults

In Table 1 we describe sources that stakeholders likely use, key dissemination messages, and potential dissemination research questions. While not an exhaustive list, these examples illustrate potential dissemination strategies that can be used in practice or tested through dissemination research.

Table 1.

A Description of Stakeholder Perspectives for the Use of Acupuncture for Low Back Pain (LBP) in Younger and Older Adults Including the Sources They Turn to for Information, Key Dissemination Messages, and Potential Dissemination Research Questions.

	Adults with LBP
	Age <65	Age ≥65
Patients with LBP
Sources they turn to	Advocacy groups (American Pain Society)	Trade associations (AARP, Health in Aging Foundation, NIA)
Key messages	Acupuncture is safe and effective for LBP[1,2]	Medicare covers acupuncture for chronic LBP
Exemplar research  questions	Determine which language is more effective : ‘evidence-based treatment for LBP’ or ‘complementary’ or ‘integrative’ treatment	Audience research needed in this understudied population and describe their knowledge about and attitudes toward acupuncture for LBP
Primary care providers
Sources they turn to	General medicine journals (JAMA, Ann Intern Med, Ann Fam Med)Professional associations (Society of General Internal Medicine, American College of Physicians)	Geriatrics journals (J Am Geriatr Soc) Professional associations (American Geriatrics Society, Gerontological Society of America)
Key messages	Acupuncture is effective for LBP[1,2]CPGs recommend acupuncture for LBP[3]Acupuncture mechanisms[63–69]	Recommendations for persistent pain management[35,73]Available data suggest acupuncture is effective for LBP[74–76]Ongoing large pragmatic trial (1UG3AT010739)
Exemplar research  questions	Determine which messages are more effective: essages that provide information on the effectiveness of acupuncture versus usual medical care; or messages that also incorporate information on plausible mechanisms of acupuncture	Audience research is needed in this understudied population to describe their knowledge about and attitudes toward acupuncture for LBP
Health system leaders
Sources they turn to	Accrediting organizations (Joint Commission) Government agencies (US Department of Health and Human Services)	Payers (Centers for Medicare & Medicaid Services) Professional Associations (American Geriatrics Society, IHI/AFHS)
Key messages	Emphasize information that aligns with the priorities of health system leaders, such as treatment effectiveness, cost-effectiveness, patient demand	Organize information on acupuncture for LBP to align with the “4Ms”model of the AFHS initiative,[71] i.e., Mentation, Mobility, Medication (reduce polypharmacy), and what Matters most”
Exemplar research  questions	Strategies tailored to health system mission statement versus a general strategy	Messaging aligned with “4Ms” versus a general strategy

CPGs: Clinical Practice Guidelines; AARP: American Association of Retired Persons; NIH: National Institute on Aging; AFHS; Aging Friendly Health System.

To demonstrate potential audience ‘segments’ our discussion focuses on developing dissemination strategies by age (i.e., older adults – those who are age 65 years or older, and younger adults – those under age 65). This decision was prompted by Medicare’s recent decision to cover acupuncture for chronic LBP. While this attenuates financial barriers to acupuncture among older adults, a lack of insurance coverage among most younger Americans continues to be a substantial barrier to care.[49,50] Well-designed dissemination strategies targeted at younger adults who cannot afford acupuncture may ultimately be ineffective because of the lack of coverage. Additionally, dissemination can increase disparities in care if such strategies are effective only in higher income patients who can afford to pay out of pocket.[51] The current opioid crisis has put pressure on policy makers to manage pain with effective non-opioid treatments, and examples of acupuncture reimbursement for lower-income, younger adults by Medicaid are emerging.[52,53] Some younger adults with private insurance already have an acupuncture benefit, e.g., Kaiser Permanente Washington covers acupuncture.[20] Once payment policies are in place in a wider range of plans, evidence-based dissemination strategies can inform health system leaders, PCPs, and patients about acupuncture’s appropriateness for LBP.

Acupuncture for LBP in Younger Adults

Health System Leaders as a Dissemination Audience

Dissemination research could identify what information health system leaders need to know about acupuncture. Health care leadership includes both non-clinician leaders, such as health care executives, focused more on the business aspect of care, to various levels of medical leadership. Non-clinician leadership may be most interested in health services that are at least cost-neutral and hopefully cost-saving or revenue generating as well as being popular enough with patients that their brand stands out. Clinician leadership will focus more on evidence-based treatments that are incentivized by national policy, acceptable to their clinical staff and helpful for their clinical population. For clinicians especially, sharing a relevant clinical practice guideline or policy may be important (e.g., American College of Physicians LBP clinical practice guidelines, VA guidelines for pain management, HHS task force on pain management best practice recommendations).[3,54,55] Communicating studies that suggest acupuncture is cost-effective compared to usual care is important,[56-58] although health systems operating primarily via fee-for-service reimbursement may be more interested in the ability to generate revenue with an acupuncture service. Aligning dissemination strategies with data on patient demand or a health system’s mission statement may also be important to some leaders.[59] Developing dissemination materials for both clinician and non-clinician leaders should identify and prioritize key information that will lead to the adoption of acupuncture in their health system.

Primary Care Providers as a Dissemination Audience

Communicating information on acupuncture to PCPs and their professional societies may enhance adoption of acupuncture. While the mention of ‘acupuncture’ can connote ‘complementary’ or ‘alternative’ medicine to some PCPs, others may already view acupuncture as part of usual care for LBP.[21] PCPs who have used acupuncture themselves are more likely to recommend acupuncture to their patients,[22] so it may be more important to disseminate information to those who have no personal experience with acupuncture. It is unclear whether communicating acupuncture as an “alternative” is detrimental to the adoption of acupuncture by PCPs and other stakeholders, but could be tested. For example: “What is the effectiveness of messages that present acupuncture as a ‘first-line therapy’ for LBP versus acupuncture as a ‘complementary’ or ‘alternative’ approach on acceptability, appropriateness, and PCP referrals to acupuncture for LBP?”

As research on acupuncture is disseminated through push strategies by researchers, the specific information channels issued for dissemination may be important. PCPs often turn to peer-reviewed, general medicine journals (e.g., Annals of Internal Medicine, JAMA, Journal of General Internal Medicine, Annals of Family Medicine). The American College of Physicians guidelines for managing LBP, which recommend acupuncture, were published in the Annals of Internal Medicine,[3] and a large individual-patient data meta-analysis of acupuncture for pain was originally published in the Archives of Internal Medicine (now JAMA Internal Medicine).[1] This meta-analysis included over 20,000 patients from 39 clinical trials of acupuncture for chronic pain, mostly back and neck pain, and found acupuncture clinically superior to usual care for pain relief.[1,2] Highlighting literature published in trusted, general medicine journals is likely more effective than presenting research from acupuncture or other specialty journals.[60]

Additional questions remain around what type of information is most compelling to PCPs. The meta-analyses described above[2] also found the effect sizes comparing acupuncture to “sham acupuncture” were much smaller than those comparing it to usual care. Some PCPs believe acupuncture is a placebo.[61] It remains controversial in biomedical literature.[62] Yet, mechanisms undergirding acupuncture’s effectiveness have been observed. These include local effects related to needle placement, such as remodeling of underlying connective tissue,[63,64] changes in local vasculature,[65] modulating muscle tone,[66] and an increase in extracellular adenosine, a neuromodulator with anti-nociceptive properties.[67] Acupuncture has been linked to the opioid receptor system[68] and acupuncture’s effects on pain can be blocked by Naloxone.[69] Disseminating these multiple mechanisms, and thus communicating the biologic plausibility of acupuncture for LBP, may be important to some PCPs. However, it remains unclear whether disseminating information on specific mechanisms, versus presenting the pragmatic effectiveness of acupuncture over usual care, would result in more referrals to acupuncture by PCPs for patients with LBP.

Adults Aged <65 With LBP as a Dissemination Audience

Dissemination strategies presenting information to patients with LBP may want to rely less on peer-reviewed literature. While acupuncture has widespread name recognition, it has relatively low use among Americans.[6,12] This suggests that awareness of acupuncture in general is high, although individuals may not know acupuncture is helpful for LBP[15] or potentially covered by their health insurance.[17] Additionally, a fear of needles, or pain from needles, may explain the low use of acupuncture.[16,18] Using patient narratives to highlight the benefits of acupuncture for LBP may be more compelling than peer-reviewed literature. Patients who receive acupuncture appreciate the individualized approach to care,[70] and messages could leverage this patient centered aspect of acupuncture. In some settings (rural, low-income) it can be difficult to find an acupuncturist, so disseminating lists of local providers may be helpful. It is less clear how, or if, information should be tailored to patients who are not currently interested in acupuncture, i.e., patients afraid of needles, or who have a strong preference for another treatment (e.g., opioid medication). These may be important segments of the population where tailored messages could be effective. For example, information on the safety of acupuncture and/or the very thin diameter of acupuncture needles may be as important as general information about acupuncture or its effectiveness for LBP. It may also be important to evaluate what type of dissemination strategies are important for populations who are the least likely to use acupuncture (male, non-Hispanic black, and low-income Americans, and those living in the south).[12]

Acupuncture for LBP in Older Adults

Aligning dissemination strategies with existing frameworks used by health system leaders may augment the effectiveness of information about acupuncture for LBP. To meet the need of a growing population of older adults, greater numbers of health system leaders use the “4Ms” model of the Age-Friendly Health System Initiative,[71] which captures key clinical concepts including “mentation”, “mobility”, “medication”, and “what matters most” to older adults.[71] Understanding patients’ goals, priorities, and preferences can set the agenda for adopting the best treatments for managing musculoskeletal pain, maximizing mood and mobility, and minimizing additional medications. Acupuncture for LBP can help optimize the “4Ms” for older adults. Effective management of LBP can result in improved mobility and lower pain,[35] and reduce the need for pain medications, attenuating concerns of polypharmacy.[72] Being able to select a particular treatment (e.g., acupuncture) or avoid additional medications may be what “matters most” to some older adults with LBP, thus meeting their goals and priorities. Dissemination strategies that reframe information on acupuncture for LBP around the ‘4Ms’, compared to information not tailored in this way, may be more effective for increasing awareness of acupuncture for LBP among health system leaders, particularly among those who already endorse this paradigm.

Geriatricians and other PCPs who serve older adults may turn to different sources for information on acupuncture, including age-specific academic journals, e.g., Journal of the American Geriatrics Society (JAGS). Guidelines for managing persistent pain among older adults have encouraged the use of acupuncture as an adjunctive therapy.[35,73] However, few studies on acupuncture have been published in JAGS, and none on acupuncture for LBP. Communicating data on acupuncture from studies that recruited only younger adults may be an ineffective dissemination strategy. We are aware of three small trials of acupuncture for LBP in older adults; all claimed positive results.[74-76] This may be insufficient information for many PCPs who serve older adults. An ongoing, large, pragmatic clinical trial (n = 789) is underway to evaluate the effects of acupuncture for LBP in older adults (1UG3AT010739). This four-healthcare system trial will feature relatively few exclusion criteria so results are maximally applicable to the older Medicare population. Dissemination of these findings to PCPs who care for older adults will be important.

Older Patients With LBP as a Dissemination Audience

Little information is available on the knowledge of or attitudes towards acupuncture among older adults. Audience research is needed. The recent decision by CMS to cover acupuncture for LBP has attenuated known financial barriers.[13] However, details regarding Medicare copays for acupuncture are unavailable at this time, and higher copays have been linked with lower utilization in systems that already reimburse acupuncture for LBP. Direct to consumer messaging on Medicare coverage of acupuncture, potentially augmented by partnering with trusted information sources to which older adults turn (e.g., AARP, Health in Aging Foundation, National Institute on Aging) may increase awareness and adoption of acupuncture for LBP.

Discussion

Effective dissemination of information about an evidence-based practice is often a pre-requisite for its successful implementation within usual care settings.[25,43] Acupuncture researchers should be aware of the various strategies by which they can “push” their findings to key stakeholders. Acupuncture researchers can also engage in dissemination research to help identify the most effective approaches to package and spread this information. A data-driven approach to developing dissemination strategies may be more effective than those based on anecdotes or intuition.[9] We discussed a stepped approach that begins with identifying awareness, attitudes and knowledge of stakeholders (audience research), then identifying subpopulations with diverging dissemination needs (audience segmentation), and finally performing randomized trials that compare the effectiveness of competing dissemination strategies.[9] While not an exhaustive discussion we believe this paper provides important guidance on how to identify, tailor, and evaluate dissemination strategies.

We focused on health system leaders, PCPs, and patients with chronic LBP. However, a wider range of stakeholders are interested in the implementation of acupuncture: caregivers and/or families of patients, biomedical specialists and educators, and their professional associations, acupuncture clinicians or educators and their professional associations, academic researchers, and insurers.[77] Dissemination research on spreading information about acupuncture for LBP to non-Medicare insurers is particularly needed. While interventions that target multiple stakeholders (i.e., multi-level strategies) are likely more effective than approaches that target a single stakeholder, it is rarely feasible to reach all potential stakeholders.[47,48] Strategies that use multiple components, i.e., multi-faceted strategies, also are more effective than those that use a single-component.[47,48] We described segmentation of audience data, which can elucidate subgroups of stakeholders for which strategies can be individualized, i.e., tailored strategies. It is easy to identify challenges in developing and testing multi-level, multi-faceted, and/or tailored strategies. The use of a D&I theory, model, or framework can help guide this complex task.[78]

Dissemination of information on acupuncture for other health conditions may also be appropriate. In an evidence map of acupuncture clinical research, the Veterans Health Administration highlighted a number of areas where acupuncture may be helpful (e.g., cancer symptoms, osteoarthritis, dysmenorrhea, chronic neck pain, headache).[4] The American Society of Clinical Oncology endorsed guidelines from the Society for Integrative Oncology including acupuncture for chemotherapy-induced nausea.[79] Use of acupuncture in the acute care setting can alleviate symptoms, reducing reliance on opioids and other pain medications.[80,81] Yet, it is unknown whether general dissemination strategies are effective for increasing awareness of acupuncture in different settings (acute care, outpatient care) and conditions (LBP, cancer). Formative audience research and audience segmentation research would help identify how acupuncture is perceived in each of these settings, and to generate or adapt dissemination strategies. This approach could also be applied to the broader field of complementary and integrative health (CIH) research. Tracking how dissemination strategies have been applied to various approaches (e.g., chiropractic care, massage therapy, yoga) may help identify strategies that are generally effective and whether unique dissemination strategies exist for particular treatments.

Conclusion

Given known barriers related to attitudes and beliefs of patients and providers around the effectiveness and cost of acupuncture, effective dissemination strategies are needed to enhance uptake of acupuncture for LBP. We have discussed the importance of communicating key information to various stakeholders and outline potential acupuncture-specific dissemination strategies that can be evaluated prospectively in dissemination effectiveness research. Such strategies may result in more rapid expansion in the use of acupuncture for LBP. Lessons learned about disseminating acupuncture can guide dissemination of other safe and effective CIH approaches for LBP and other health conditions.