Woman receiving facial massage

RAND Center of Excellence for the Study of Appropriateness of Care in Complementary and Alternative Medicine

In 2013, RAND was funded through a cooperative agreement by the National Center for Complementary and Integrative Health (NCCIH) to establish the RAND Center of Excellence for the Study of Appropriateness of Care in Complementary and Alternative Medicine (CAM). CAM is now called Complementary and Integrative Health or CIH, and this Center of Excellence for Research in CIH (CERC) was established to advance the methodology of researching appropriateness in CIH care.

With rising health care costs, it is increasingly urgent to evaluate the appropriateness of available therapies. Traditionally, the appropriateness of a therapy was determined solely by effectiveness and safety—i.e., clinical appropriateness. Although investigating the clinical appropriateness of CIH therapies is important, given the amount of self-referral and self-pay for these therapies, the point has been reached where the determination of appropriateness should also consider patient preferences and cost-effectiveness so that the overall value of these treatments, to patients, providers, and society, can be determined.

CERC was intended to develop appropriateness methods further and make these types of studies possible in a broader selection of CIH for a variety of conditions. In addition, CERC examined whether the Patient-Reported Outcomes Measurement and Information System (PROMIS) health-related quality of life measure(s) are adequately sensitive in CIH populations, adapted Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures to chiropractic, and tested crowdsourcing using MTurk as a data collection system.

The CERC was a collaboration among RAND, UCLA, and the Samueli Institute but was located and administered at RAND. Sixteen research staff were employed on this project, and the total budget for the project was over $8 million. The NCMIC Foundation provided additional support for analyses of the data gathered by CERC.

Lessons Learned

  1. The rate of inappropriate care was low (0% to 3%) across a large random sample of chiropractic patients’ charts.
  2. Clinical scenarios where manipulation and mobilization were rated as inappropriate were best predicted by major neurologic findings for chronic low back pain, and by the presence of red flags for chronic neck pain.
  3. Members of the appropriateness panels indicated that information on cost and patient preferences is important to the appropriateness of care. However, manipulation and mobilization are relatively inexpensive making their ratings insensitive to cost, and it is the preferences of individual patients that are most important.
  4. Patients with chronic low back pain and chronic neck pain who use chiropractic care tend to be highly-educated, in pain for an average of 14 years, using chiropractic care for an average of 11 years, and highly satisfied with this care.
  5. These chiropractic patients gave a slightly lower global rating to their provider than did patients in a general medical survey but gave their provider higher ratings in getting answers to questions the same day and being seen within 15 minutes of their appointment time.
  6. Most (70%) of these patients have a goal for their treatment of pain management rather than cure.
  7. These patients’ stated willing to pay for pain reduction indicate that they are “buying” reductions from what they believe their pain would have been if they didn’t see their chiropractor—i.e., they value maintenance of their current mild pain levels.
  8. These patients saw their chiropractor an average of 2.3 times per month. Those with insurance coverage and chronic low back pain, with worse function, just starting care, and being treated by a chiropractor who saw more patients per day had more visits per month. Those about to end care or whose treating chiropractor had 20-30 years’ experience had fewer visits per month.
  9. On average patients’ saw slight but significant improvement in pain, function and five of the six domain scores of the PROMIS-29 over the 3-month study period. For those with chronic low back pain only visit frequency greater than weekly increased their rate of improvement.
  10. Nonpharmacologic therapies for chronic low back pain are generally effective and cost-effective from the societal and payer perspectives, and many are also cost saving, especially from the societal perspective.