Clinician Based Appropriateness/Ian Coulter

Coulter, Ian

Abstract

This project 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 Project the method will be applied to study the use of M/M in chiropractic practices for chronic cervical pain (CCP). An extensive review of the literature will be done and a systematic review written (a meta-analysis if this is possible but a synthesis if it is not) with the support of the Systematic Review Core (SRC). From this review a set of indications based on the literature for performing M/M for CCP will be developed. These indications will categorize patients in terms of their symptoms, past medical history, and the results of previous diagnostic tests. The review will also look at the evidence for patient preferred outcomes (from Project 2: Outcomes- Based Appropriateness), patient preferences (from Project 3: Patient Preferences Appropriateness) and costs (from Project 4: Economic-Based Appropriateness). Once the indications have been created (and reviewed by experts in the field) the process to be used is a modified Delphi. A multidisciplinary panel of nine clinical experts will initially receive 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. The panel will then be brought together in a face-to-face meeting and the results of these ratings are then circulated to the panel members. Following group discussions, and revising of the indications, the panels re-rate the indications. In further round of ratings the panel will be given data on patient preferences preferences (from Project 3: Patient Preferences Appropriateness), outcomes (from Project 2: Outcomes-Based Appropriateness), and costs (from Project 4: Economic-Based Appropriateness. Once the work of the expert panel is completed, RAND will generate a set of indications for doing M/M for CCP based on the evidence and clinical experience of the panelists which can then be used to compare actual practice.

Public Health Relevance

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 (see the Data Collection and Management Core for details). From these data are abstracted about the treatment given for CCP and the number of times M/M is done for CCP is obtained. In this way and with the support of the Data Collection and Management Core (DCMC).