Economic Based Appropriateness/Patricia Marie Herman

项目说明 确保患者得到适当的护理是所有医学研究的首要目标。最广为人知的用于确定是否合适的方法是基于临床敏锐度和证据，以确定治疗是否安全、有效和有效。本项目(项目4)通过纳入经济考虑因素，审查了推广这一方法的影响。在适当护理的定义中加入经济学，对于确定选择某一特定治疗是否适当，以及一旦选定治疗疗程是否适当，都带来了重要的信息。这种扩展不仅对患者自我转介和自付费用很常见的补充和替代医学(CAM)很重要，而且对需要降低成本的道德战略的一般医疗保健也很重要。 对于适当的治疗选择，经济学在安全性和有效性的基础上增加了成本效益的考虑。我们会向适当性小组(计划1)提供脊医治疗慢性颈痛的成本效益资料，看看这些资料会否改变他们对所考虑的各种临床适应症的手法与动员(M/M)的适合性评级。关于M/M成本效益的信息将由决策分析模型生成，该模型建立在系统审查核心收集的所有现有相关证据的基础上。根据这些新的包含成本的适当性评级，我们将估计适当和不适当护理的流行率(由项目1估计)如何变化。作为一个附带好处，决策分析模型还将用于计算对每个模型参数有更多了解(即通过进一步研究来减少不确定性)的价值。 对于适当的疗程，经济学为定义治疗长度或结束治疗规则提供了信息。许多疗法继续提供递增的好处，尽管加班的好处正在减少。因此，如果只考虑临床疗效，这些治疗将无限期地继续下去。然而，只要每个额外治疗的健康福利(在本项目中衡量的是疼痛和残疾的减少)下降，每增加一个福利单位的成本就会上升。在某种程度上，很可能在治疗福利结束之前，获得这些最后福利的成本可能会变得难以为继。因此，费用是适当护理过程的一个关键决定因素(除了安全性和持续有效性之外)。我们将利用数据收集和管理核心收集的数据，并在研究方法评估和管理核心的支持下进行一系列分析，以开发初步的结束或治疗长度算法，以帮助指导慢性颈部疼痛的适当M/M疗程。 确定成本合理的疗程对于CAM提供者来说尤其重要，原因有几个：许多患者自掏腰包支付护理费用；患者与从业者的关系可能会混淆治疗效果的来源；慢性病的流行可能需要长时间的护理，也可能需要维持护理；重点是将患者转移到自我护理；以及只有在用尽所有其他来源后才到达CAM的患者所面临的治疗挑战。注意，制定的治疗时长或结束规则可能会导致比各种健康计划所允许的通常数量多或少的治疗。 最后，将估计不适当护理的总成本，以帮助确定问题的严重性和进一步研究的必要性。虽然这些项目和中心的重点将是慢性颈痛的脊椎手法/活动(M/M)，但目标是为所有CAM(和非CAM)实践开发这些方法。

Project Description To ensure patients receive appropriate care is an overarching goal of all medical research. The most well-known method used to determine appropriateness is based on clinical acumen and evidence as to whether the treatment is safe, efficacious and effective. This Project (Project 4) examines the impact of expanding this method through the inclusion of economic considerations. The addition of economics to the definition of appropriate care brings important information to both the determination of whether the choice of a particular treatment is appropriate, and whether the course of treatment, once chosen, is appropriate. This expansion is not only important for Complementary and Alternative Medicine (CAM) where patient self-referral and out-of pocket payment is common, but also for healthcare in general where ethical strategies for reducing costs are needed. For the appropriate choice of treatment, economics adds the consideration of cost-effectiveness to safety and effectiveness. We will provide information on the cost-effectiveness of manipulation and mobilization (M/M) by chiropractors for chronic neck pain to the Appropriateness Panel (Project 1) to see if this information changes their ratings of M/M appropriateness for the various clinical indications considered. The information on the cost effectiveness of M/M will be generated by a decision analytic model built upon all available relevant evidence¿ evidence gathered by the Systematic Review Core. From these new cost-inclusive appropriateness ratings we will estimate how the prevalence of appropriate and inappropriate care (estimated by Project 1) change. As a side benefit, the decision analytic model will also be used to calculate the value of knowing more about (i.e., reducing the uncertainty through further research around) each of the model parameters. For the appropriate course of treatment, economics provides information for the definition of length- or end-of treatment rules. Many therapies continue to provide incremental, although diminishing, benefits overtime. Therefore, if only clinical effectiveness is considered, these therapies would be continued indefinitely. However, as long as the health benefit (in this Project measured as reductions in pain and disability) per additional treatment goes down, the cost per additional unit of benefit will go up. At some point, and likely well before the treatment benefits end, the cost to obtain these last benefits can become untenable. Therefore, costs are a key determinant (in addition to safety and continued effectiveness) of the appropriate course of care. We will utilize the data collected by the Data Collection and Management Core, and with the support of the Research Methods Assessment and Management Core will perform a series of analyses to develop preliminary end- or length of treatment algorithms to help guide an appropriate course of M/M for chronic neck pain. The determination of a cost-appropriate course of treatment is especially important for CAM providers for several reasons: many patients pay for care out of pocket; the patient-practitioner relationship can confound the source of treatment effects; the prevalence of chronic conditions seen can require long courses of care and may also require maintenance care; the focus on moving patients toward self-care; and the treatment challenges involved with patients who arrive at CAM only after exhausting all other sources. Note that the length- or end-of-treatment rules developed may result in more or fewer treatments than the usual number allowed by various health plans. Finally, the total cost of inappropriate care will be estimated to help determine the magnitude of the problem and need for further research. Although the focus of these Projects and the Center will be chiropractic manipulation/mobilization (M/M) of chronic cervical pain, the objective is to develop these methods for all CAM (and non-CAM) practices.