RAND Center of Excellence for the Study of Appropriateness of Care in CAM
| Status: | Recruiting |
|---|---|
| Conditions: | Back Pain, Back Pain, Chronic Pain, Pain |
| Therapuetic Areas: | Musculoskeletal |
| Healthy: | No |
| Age Range: | 21 - Any |
| Updated: | 9/30/2017 |
| Start Date: | September 30, 2011 |
| End Date: | August 31, 2018 |
| Contact: | Ian D Coulter, PhD |
| Email: | coulter@rand.org |
| Phone: | 310-393-0411 |
The RAND approach to appropriateness makes it feasible to take the best of what is known from
research and apply it—using the expertise of experienced clinicians—over the wide range of
patients and presentations seen in real-world clinical practice. The major limitation of the
RAND approach, however, is that it still utilizes a limited definition of appropriateness;
one that relies heavily on safety, efficacy and effectiveness. Until now the RAND method has
not included patient preferences or resource utilization effectiveness. These are both
serious absences. In the past decade we have seen an evolution in outcome measures from
clinician based objective measures to patient-centered and subjective measures. The
development of Patient Based Outcome Assessments (PBOA); Patient Reported Outcomes
Measurement Information System (PROMIS) and the recent establishment of Patient-Centered
Outcomes Research Institute (PCORI) all contest to the growing importance of the patient's
perspective in determining outcomes and therefore also appropriateness. 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
research and apply it—using the expertise of experienced clinicians—over the wide range of
patients and presentations seen in real-world clinical practice. The major limitation of the
RAND approach, however, is that it still utilizes a limited definition of appropriateness;
one that relies heavily on safety, efficacy and effectiveness. Until now the RAND method has
not included patient preferences or resource utilization effectiveness. These are both
serious absences. In the past decade we have seen an evolution in outcome measures from
clinician based objective measures to patient-centered and subjective measures. The
development of Patient Based Outcome Assessments (PBOA); Patient Reported Outcomes
Measurement Information System (PROMIS) and the recent establishment of Patient-Centered
Outcomes Research Institute (PCORI) all contest to the growing importance of the patient's
perspective in determining outcomes and therefore also appropriateness. 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
The primary objective of this Center of Excellence is:
Develop and refine methods for the study of the appropriateness of care in CAM.
This Center of Excellence will have four Projects.
- Project 1: Clinician Based Appropriateness
- Project 2: Outcomes Based Appropriateness
- Project 3: Patient Preferences Appropriateness
- Project 4 : Resource Utilization Based Appropriateness
Because much of CAM faces the challenge of limited evidence], and because these methods are
well-established, we will have as our core project
Project 1: Clinician-Based Appropriateness the application of the RAND approach to the
determination of appropriate care for Manipulation/Mobilization (M/M) for chronic .low back
pain (CLBP) and chronic cervical pain (CCP). This approach uses a mixed (CAM and non-CAM)
panel of expert clinicians to interpret syntheses of all available data on safety, efficacy
and effectiveness and clinical experience to apply these data to the question of care
appropriateness for low back and cervical M/M. This approach has been applied successfully to
M/M for low back pain and a literature review and expert panel was previously done for M/M
for cervical manipulation.
The main objectives of the core project (Project 1) are to develop a set of ratings of the
appropriateness of M/M for chronic low back and chronic neck pain across various patient
presentations, to be used in the determination of the prevalence of appropriate and
inappropriate care in a national sample of these patients, and to provide feedback to the
research community regarding the patient presentations where substantial uncertainty remains
as to the appropriateness of M/M. We will also, however, in the Resource Utilization project
examine M/M in relationship to other forms of a non-invasive therapy for cervical pain to get
comparative ratings of appropriateness.
Objectives of the Other Center Projects. The other projects in the Center each add to the
RAND-based method in different ways by exploring the broader dimensions of appropriateness
which may be applicable for CAM as well as health care in general. Project 2 (Outcomes Based
Appropriateness) will examine the patient-assessed outcomes which, in part, contribute to the
determination of appropriateness made by patients. Its objectives include developing
CAM-sensitive PROMIS measures for patients using manipulation/mobilization for CLBP and CCP
and to analyze data collected from a national study of chiropractic patients with CLBP and
that can be used to evaluate appropriateness of their care from the patient's perspective.
Given the prevalence of patient self-referral in CAM and the health system-wide focus on
patient-centered care, Project 3 (Patient Preference Appropriateness) will examine how
patient preferences affect what is considered to be appropriate care. Objectives here include
understanding how CLBP and CCP patients decide to use M/M and determining what they believe
is appropriate care. Finally, given the high proportion of out-of-pocket costs in CAM and the
dramatic rise of healthcare costs in general, Project 4 (Resource Utilization Based
Appropriateness) will examine how cost affects both which care is most appropriate and the
appropriate course of care once implemented. Objectives here include providing data on the
relative cost-effectiveness of care options for CLBP and CCP to the Appropriateness Panel
(Project 1) to see if cost data changes their ratings, and analyzing data from our national
sample to begin to understand the characteristics of an appropriate course of care once M/M
is chosen.
Develop and refine methods for the study of the appropriateness of care in CAM.
This Center of Excellence will have four Projects.
- Project 1: Clinician Based Appropriateness
- Project 2: Outcomes Based Appropriateness
- Project 3: Patient Preferences Appropriateness
- Project 4 : Resource Utilization Based Appropriateness
Because much of CAM faces the challenge of limited evidence], and because these methods are
well-established, we will have as our core project
Project 1: Clinician-Based Appropriateness the application of the RAND approach to the
determination of appropriate care for Manipulation/Mobilization (M/M) for chronic .low back
pain (CLBP) and chronic cervical pain (CCP). This approach uses a mixed (CAM and non-CAM)
panel of expert clinicians to interpret syntheses of all available data on safety, efficacy
and effectiveness and clinical experience to apply these data to the question of care
appropriateness for low back and cervical M/M. This approach has been applied successfully to
M/M for low back pain and a literature review and expert panel was previously done for M/M
for cervical manipulation.
The main objectives of the core project (Project 1) are to develop a set of ratings of the
appropriateness of M/M for chronic low back and chronic neck pain across various patient
presentations, to be used in the determination of the prevalence of appropriate and
inappropriate care in a national sample of these patients, and to provide feedback to the
research community regarding the patient presentations where substantial uncertainty remains
as to the appropriateness of M/M. We will also, however, in the Resource Utilization project
examine M/M in relationship to other forms of a non-invasive therapy for cervical pain to get
comparative ratings of appropriateness.
Objectives of the Other Center Projects. The other projects in the Center each add to the
RAND-based method in different ways by exploring the broader dimensions of appropriateness
which may be applicable for CAM as well as health care in general. Project 2 (Outcomes Based
Appropriateness) will examine the patient-assessed outcomes which, in part, contribute to the
determination of appropriateness made by patients. Its objectives include developing
CAM-sensitive PROMIS measures for patients using manipulation/mobilization for CLBP and CCP
and to analyze data collected from a national study of chiropractic patients with CLBP and
that can be used to evaluate appropriateness of their care from the patient's perspective.
Given the prevalence of patient self-referral in CAM and the health system-wide focus on
patient-centered care, Project 3 (Patient Preference Appropriateness) will examine how
patient preferences affect what is considered to be appropriate care. Objectives here include
understanding how CLBP and CCP patients decide to use M/M and determining what they believe
is appropriate care. Finally, given the high proportion of out-of-pocket costs in CAM and the
dramatic rise of healthcare costs in general, Project 4 (Resource Utilization Based
Appropriateness) will examine how cost affects both which care is most appropriate and the
appropriate course of care once implemented. Objectives here include providing data on the
relative cost-effectiveness of care options for CLBP and CCP to the Appropriateness Panel
(Project 1) to see if cost data changes their ratings, and analyzing data from our national
sample to begin to understand the characteristics of an appropriate course of care once M/M
is chosen.
Inclusion Criteria:
- Current chiropractic patient over 21 years with chronic low back pain and chronic
cervical pain.
- They must have had the pain for 3 months.
Exclusion Criteria:
- Under 21, non-specific chronic low back pain or cervical pain, personal injury case
able to access the project on line.
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