Clinician Based Appropriateness/Ian Coulter

该项目将采用兰德公司开发的一种方法，用于研究不适当的医疗保健的流行情况，该方法以前曾被兰德公司应用于治疗腰痛的脊椎推拿和活动（M/M）。在这个项目中，该方法将被应用于研究M/M在慢性颈椎疼痛（CCP）的脊椎治疗实践中的使用。 在系统性综述核心（SRC）的支持下，将对文献进行广泛综述，并撰写系统性综述（如果可能，则为荟萃分析，如果不可能，则为综合）。根据这篇综述，将根据文献制定一组用于CCP的M/M适应症。这些适应症将根据患者的症状、既往病史和既往诊断测试的结果对患者进行分类。该综述还将研究患者偏好结局（来自项目2：基于结局的适当性）、患者偏好（来自项目3：患者偏好适当性）和成本（来自项目4：基于经济的适当性）的证据。一旦创建了适应症（并由本领域专家审查），将使用的过程是修改后的德尔菲。由9名临床专家组成的多学科小组将首先单独接收文献综述和适应症集，并根据文献和他们自己的临床经验（如适用），要求他们对M/M治疗慢性颈椎疼痛的适当性进行评级。然后，小组将举行一次面对面的会议，然后将这些评级结果分发给小组成员。在小组讨论和适应症修订后，专家组对适应症进行了重新评级。在下一轮评级中，小组将获得患者偏好（来自项目3：患者偏好适当性）、结果（来自项目2：基于结果的适当性）和成本（来自项目4：基于经济的适当性）的数据。一旦专家小组的工作完成，兰德公司将根据小组成员的证据和临床经验，为CCP制定一套M/M的适应症，然后将其用于比较实际做法

This project will adapt a method developed by the RAND Corporation for studying the prevalence of inappropriate health care and which has been previously applied by RAND to chiropractic manipulation and mobilization (M/M) for low back pain. In this Project the method will be applied to study the use of M/M in chiropractic practices for chronic cervical pain (CCP). An extensive review of the literature will be done and a systematic review written (a meta-analysis if this is possible but a synthesis if it is not) with the support of the Systematic Review Core (SRC). From this review a set of indications based on the literature for performing M/M for CCP will be developed. These indications will categorize patients in terms of their symptoms, past medical history, and the results of previous diagnostic tests. The review will also look at the evidence for patient preferred outcomes (from Project 2: Outcomes- Based Appropriateness), patient preferences (from Project 3: Patient Preferences Appropriateness) and costs (from Project 4: Economic-Based Appropriateness). Once the indications have been created (and reviewed by experts in the field) the process to be used is a modified Delphi. A multidisciplinary panel of nine clinical experts will initially receive the literature synthesis and the set of indications individually and based on the literature and their own clinical experience where applicable, will be asked to rate the appropriateness of M/M for chronic cervical pain. The panel will then be brought together in a face-to-face meeting and the results of these ratings are then circulated to the panel members. Following group discussions, and revising of the indications, the panels re-rate the indications. In further round of ratings the panel will be given data on patient preferences preferences (from Project 3: Patient Preferences Appropriateness), outcomes (from Project 2: Outcomes-Based Appropriateness), and costs (from Project 4: Economic-Based Appropriateness. Once the work of the expert panel is completed, RAND will generate a set of indications for doing M/M for CCP based on the evidence and clinical experience of the panelists which can then be used to compare actual practice