Rand Center of Excellence for the Study of Appropriateness of Care in CAM

Coulter, Ian

Abstract

In this Center we will adapt a method developed by the RAND Corporation for studying the prevalence of inappropriate health care and which has been previously applied by RAND to chiropractic manipulation and mobilization (M/M) for low back pain. In this Center the method will be applied to study the use of M/M in chiropractic practices for chronic cervical pain (CCP). Until now, however, the RAND method has not included patient outcomes, patient preferences or cost effectiveness in determining appropriateness but only clinical judgment from health professionals. These are serious absences. In the Center, we propose to advance appropriateness methods by adding three additional dimensions to the RAND appropriateness methods: patient outcomes, patient preferences and cost. Although the focus will be on chiropractic M/M for chronic neck pain the objective is to develop an appropriateness methodology that can be used for the study of Complementary and Alternative Medicine in real practices. An extensive review of the literature will be done and a systematic review written. From this review a set of indications based on the literature for performing M/M for CCP will be developed. Once the indications have been created a multidisciplinary panel of nine clinical experts will review the literature synthesis and the set of indications individually and based on the literature and their own clinical experience where applicable, will be asked to rate the appropriateness of M/M for chronic cervical pain. A random selection of practitioners will be selected from four national sites geographically distributed across the US and a random selection of their files is chosen. From these data are abstracted about the treatment given for CCP and the number of times M/M is done for CCP is obtained. We will also interview a sample of patients attending the clinics and do a follow study for their outcomes.

Public Health Relevance

It is increasingly urgent to evaluate the appropriateness of therapies provided to Americans. The point has been reached where such evaluations must also include considerations of cost-effectiveness. The choice of cervical problems is driven by the fact that this area is a significant health problem. Neck pain is second only to low back pain in its frequency in the general population and in musculoskeletal practice.