Spinal Manipulative Therapy vs. Prescription Drug Therapy for Care of Aged Medicare Beneficiaries with Neck Pain

据估计，390万美国老年人患有颈部疼痛（NP），这是第四大残疾原因 国际吧然而，人们对目前NP治疗方法的比较价值知之甚少。的 在美国，脊柱疼痛的管理是低效的、昂贵的，并且有时是危险的。因此， 迫切需要评估非药物治疗替代方案，并确定安全、高价值的 管理战略。对于患有NP的老年人来说，这一需求至关重要，他们往往患有共病，易受 不良事件，并倾向于使用高成本的干预措施。处方药治疗（PDT）和 脊柱推拿疗法（SMT）是NP广泛使用的治疗策略，但其对NP的比较价值 NP不确定。由于NP通常是持续性的，许多患者感到被迫寻求持续的护理，但 长期使用PDT（主要是阿片类药物和NSAID）治疗NP引起了安全性问题，特别是对于老年人。 SMT的使用-在系统评价中显示出与其他干预措施相似的有效性-通常 由于长期治疗的价值也是不确定的，因此受到保险公司的限制。因此，有一个紧迫的 需要比较这两种方法（SMT和PDT）在NP管理中的长期价值， 医疗保险受益人本项目的总体目标是评估 SMT与PDT相比，用于老年医疗保险受益人的NP管理。积极参与， 学生，这个项目也是为了加强在南加州大学的研究环境 健康科学。中心假设是，SMT用于NP提供了上级价值， 到PDT。中心假设将通过追求三个相关但独立的具体 目的：（1）比较SMT与PDT的短期和长期安全性，以不良反应的可能性为衡量标准。 结果，（2）比较SMT与PDT的短期和长期效率，以升级率衡量 护理NP，（3）比较SMT与PDT的短期和长期成本，由支付者衡量 费用和病人分担。旨在降低偏倚和混淆风险的严格方法将 包括加权倾向评分法和工具变量法。这项研究的方法是 创新，因为对非药物治疗方法的价值知之甚少， 老年人中的NP。该项目承诺通过评估一个非- 高风险处方药的替代药物。SMT治疗NP的上级价值的证据 将促进从慢性镇痛药使用的危害向非 药物干预。该项目还包括一项实际计划， 服务研究-与学生参与-两个教育机构，培训互补和 综合医疗保健临床医生。研究贡献预计将是重大的，因为证据 支持SMT有望提高老年NP患者护理的安全性、效率和价值。

An estimated 3.9 million older US adults suffer from Neck Pain (NP), the fourth leading cause of disability worldwide. However, little is known about the comparative value of current treatment approaches to NP. The management of spine pain in the United States is inefficient, costly, and sometimes hazardous. Thus, there is an acute need to evaluate non-pharmaceutical treatment alternatives and identify safe, high-value management strategies. The need is critical for older adults with NP, who tend to be comorbid, vulnerable to adverse events, and prone to the utilization of high-cost interventions. Prescription drug therapy (PDT) and spinal manipulative therapy (SMT) are widely used treatment strategies for NP, but their comparative value for NP is uncertain. Because NP is often persistent, many patients feel compelled to seek ongoing care, but the chronic use of PDT (primarily opioids and NSAIDs) for NP raises safety concerns, particularly for the elderly. The utilization of SMT - which shows similar effectiveness to other interventions in systematic reviews - is often limited by insurers because the value of prolonged treatment is also uncertain. There is, therefore, a pressing need to compare the long-term value of these two approaches (SMT and PDT) for management of NP in Medicare beneficiaries. The overall objective of this project is to assess both short- and long-term value of SMT as compared to PDT for management of NP in older Medicare beneficiaries. With active engagement of students, this project is also intended to strengthen the research environment at Southern California University of Health Sciences. The central hypothesis is that utilization of SMT for NP offers superior value as compared to PDT. The central hypothesis will be tested objectively by pursuing three related but independent specific aims: (1) compare the short- and long-term safety of SMT vs. PDT as measured by the likelihood of adverse outcomes, (2) compare the short- and long-term efficiency of SMT vs. PDT as measured by rates of escalation of care for NP, and (3) compare the short- and long-term costs of SMT vs. PDT as measured by payer expenditures and patient cost sharing. Rigorous methods intended to reduce risk of bias and confounding will include weighted propensity scoring and instrumental variable methodology. The approach to this research is innovative because relatively little is known about the value of non-pharmacological treatment approaches for NP among older adults. This project promises to challenge the status quo by assessing the value of a non- pharmacologic alternative to high-risk prescription drugs. Evidence of the superior value of SMT for care of NP will facilitate an innovative shift away from the hazards of chronic analgesic use and toward non- pharmacological interventions. The project also includes a practical plan for introducing large-scale health services research – with student participation - to two educational institutions that train complementary and integrative healthcare clinicians. The research contribution is expected to be significant because evidence favoring SMT promises to improve the safety, efficiency, and value of care for older adults with NP.