To ensure patients receive appropriate care is an overarching goal of all medical research. The most well-known method used to determine appropriateness is based on clinical acumen and evidence as to whether the treatment is safe, efficacious and effective. This Project (Project 4) examines the impact of expanding this method through the inclusion of economic considerations. The addition of economics to the definition of appropriate care brings important information to both the determination of whether the choice of a particular treatment is appropriate, and whether the course of treatment, once chosen, is appropriate. This expansion is not only important for Complementary and Alternative Medicine (CAM) where patient self-referral and out-of pocket payment is common, but also for healthcare in general where ethical strategies for reducing costs are needed. For the appropriate choice of treatment, economics adds the consideration of cost-effectiveness to safety and effectiveness. We will provide information on the cost-effectiveness of manipulation and mobilization (M/M) by chiropractors for chronic neck pain to the Appropriateness Panel (Project 1) to see if this information changes their ratings of M/M appropriateness for the various clinical indications considered. The information on the cost effectiveness of M/M will be generated by a decision analytic model built upon all available relevant evidence? evidence gathered by the Systematic Review Core. From these new cost-inclusive appropriateness ratings we will estimate how the prevalence of appropriate and inappropriate care (estimated by Project 1) change. As a side benefit, the decision analytic model will also be used to calculate the value of knowing more about (i.e., reducing the uncertainty through further research around) each of the model parameters. For the appropriate course of treatment, economics provides information for the definition of length- or end-of treatment rules. Many therapies continue to provide incremental, although diminishing, benefits overtime. Therefore, if only clinical effectiveness is considered, these therapies would be continued indefinitely. However, as long as the health benefit (in this Project measured as reductions in pain and disability) per additional treatment goes down, the cost per additional unit of benefit will go up. At some point, and likely well before the treatment benefits end, the cost to obtain these last benefits can become untenable. Therefore, costs are a key determinant (in addition to safety and continued effectiveness) of the appropriate course of care. We will utilize the data collected by the Data Collection and Management Core, and with the support of the Research Methods Assessment and Management Core will perform a series of analyses to develop preliminary end- or length of treatment algorithms to help guide an appropriate course of M/M for chronic neck pain. The determination of a cost-appropriate course of treatment is especially important for CAM providers for several reasons: many patients pay for care out of pocket;the patient-practitioner relationship can confound the source of treatment effects;the prevalence of chronic conditions seen can require long courses of care and may also require maintenance care;the focus on moving patients toward self-care;and the treatment challenges involved with patients who arrive at CAM only after exhausting all other sources. Note that the length- or end-of-treatment rules developed may result in more or fewer treatments than the usual number allowed by various health plans. Finally, the total cost of inappropriate care will be estimated to help determine the magnitude of the problem and need for further research. Although the focus of these Projects and the Center will be chiropractic manipulation/mobilization (M/M) of chronic cervical pain, the objective is to develop these methods for all CAM (and non-CAM) practices.

National Institute of Health (NIH)
National Center for Complementary & Alternative Medicine (NCCAM)
Research Program--Cooperative Agreements (U19)
Project #
Application #
Study Section
Special Emphasis Panel (ZAT1)
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Rand Corporation
Santa Monica
United States
Zip Code
Herman, Patricia M; Kommareddi, Mallika; Sorbero, Melony E et al. (2018) Characteristics of Chiropractic Patients Being Treated for Chronic Low Back and Neck Pain. J Manipulative Physiol Ther 41:445-455
Hays, Ron D; Spritzer, Karen L; Sherbourne, Cathy D et al. (2018) Group and Individual-level Change on Health-related Quality of Life in Chiropractic Patients with Chronic Low Back or Neck Pain. Spine (Phila Pa 1976) :
Coulter, Ian D; Crawford, Cindy; Hurwitz, Eric L et al. (2018) Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine J 18:866-879