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

据估计，美国有390万老年人患有颈部疼痛(NP)，这是导致残疾的第四大原因 全世界。然而，目前对NP的治疗方法的比较价值知之甚少。这个 在美国，脊柱疼痛的管理效率低、成本高，有时甚至是危险的。因此，有 迫切需要评估非药物治疗替代方案并确定安全、高价值的 管理策略。对于患有NP的老年人来说，这种需求至关重要，他们往往会合并疾病，容易患上 不良事件，并容易利用高成本的干预措施。处方药疗法(PDT)和 脊柱手法治疗(SMT)是治疗NP的广泛应用的治疗策略，但它们对 NP是不确定的。由于NP通常是顽固的，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非类固醇抗炎药)治疗NP会引起安全问题，特别是对老年人。 SMT的利用--在系统评价中显示出与其他干预措施类似的有效性--通常是 由于长期治疗的价值也不确定，因此受到保险公司的限制。因此，有一个紧迫的问题 需要比较这两种方法(SMT和PDT)在非手术治疗中的长期价值 医疗保险受益人。该项目的总体目标是评估以下项目的短期和长期价值 SMT与PDT在老年医疗保险受益人的NP管理方面的比较。通过积极参与 学生们，这个项目也是为了加强南加州大学的研究环境 健康科学学院。中心假设是利用SMT治疗NP相比具有更高的价值 致PDT。中心假设将通过追求三个相关但独立的具体假设来进行客观检验 目的：(1)比较SMT和PDT的短期和长期安全性，通过不良反应的可能性来衡量 结果，(2)比较SMT和PDT的短期和长期效率，通过升级速度来衡量 对NP的护理，以及(3)比较SMT和PDT的短期和长期成本，由支付者衡量 支出和患者费用分担。旨在减少偏见和混淆意愿的风险的严格方法 包括加权倾向评分和工具变量方法。这项研究的方法是 创新是因为人们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非政府组织的价值挑战现状 高风险处方药的药理替代品。SMT在治疗NP方面的优越价值的证据 将促进创新的转变，从长期使用止痛药的危害转向非 药物干预。该项目还包括一项实际计划，以引入大规模健康 服务研究--有学生参与--提供给两个教育机构，这两个机构培训互补的 综合性医疗保健临床医生。这项研究的贡献预计将是巨大的，因为有证据表明 支持SMT有望提高老年NP患者的安全性、效率和护理价值。

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.