Use of Acupuncture for Chronic Pain within an Integrated Health Plan

最近大量的研究检查了许多类型的补充和替代(CAM)疗法的有效性和生物学基础。然而，CAM在现实世界中的使用在很大程度上被忽视了，尽管有人呼吁以实践的方式研究CAM疗法，并敦促高度优先考虑包括临床结果、成本效益以及患者和提供者的决策过程在内的研究。因此，对丰富认识的需求越来越大，特别是考虑到S越来越受欢迎，幸运的是，它为研究提供了大量新的数据。最近的研究表明，美国人寻求CAM治疗慢性肌肉骨骼疼痛(CMP)的频率远远高于其他任何疾病。在治疗中医的CAM疗法中，针灸和脊椎按摩(A/C)护理是被医生团体接受程度最高的疗法之一，也是支持其使用的最佳证据之一。此外，最近用于慢性疼痛的阿片类药物治疗和手术干预的提供数量惊人地增加[尽管其费用高、潜在的不良反应和不大的疗效]表明，有必要评估与有希望的非药物/非手术CAM治疗的结果相关的结果，这些治疗往往被患者很好地接受，并在社区中越来越多地使用。此应用程序响应NCCAM计划公告PAR-08-045，结果、成本效益和使用CAM的决策过程。这项多阶段、混合方法研究将：(1)使用来自大型HMO的电子病历(EMR)的信息进行回溯性研究，以识别可能与不同的A/C利用倾向和/或与此类护理相关的不同结果相关的独特的CMP患者群(例如，具有不同的人口统计学特征、疼痛病史、使用对抗疗法和CAM健康服务的患者和/或与此类护理相关的不同结果；(2)使用定性访谈来探索对抗疗法提供者对空调和患者寻求和保留CAM护理的决定的建议；以及(3)与接受传统中医服务的仔细匹配的对照参与者相比，前瞻性地评估与接受空调相关的医疗服务/成本以及更广泛的临床和功能结果。敏感性分析将比较单纯依赖电子病历数据的方法与用常规收集的患者和临床医生数据补充电子病历数据的分析。成功完成这些总体目标将评估与实际使用空调服务有关的成果。这三项回顾、定性和前瞻性研究还将使我们更清楚地了解使用空调治疗CMP背后的决策过程，以及一种可应用于其他卫生保健环境、CAM治疗和临床人群的可移植方法。

Substantial recent research examines the efficacy and biological basis of many types of complementary and alternative (CAM) therapies. However, ¿real-world¿ use of CAM has been largely overlooked, despite calls for CAM therapies to be studied in the manner in which they are practiced and urging high prioritization for research that includes clinical outcomes, cost-effectiveness, and the decision-making process for patients and providers. There is, therefore, heightened need for enriched understanding¿particularly given CAM¿s growing popularity, which fortunately offers stores of new data for research. Recent studies suggest that Americans seek CAM treatments far more often for chronic musculoskeletal pain (CMP) than for any other condition. Among CAM treatments for CMP, acupuncture and chiropractic (A/C) care are among those with the highest acceptance by physician groups and the best evidence to support their use. Further, recent alarming increases in delivery of opioid treatment and surgical interventions for chronic pain¿despite their high costs, potential adverse effects, and modest efficacy¿ suggests the need to evaluate the outcomes associated with promising non-pharmacological/non-surgical CAM treatments for CMP, which are often well accepted by patients and increasingly used in the community. This application responds to the NCCAM program announcement PAR-08-045, ¿Outcomes, Cost-Effectiveness and the Decision Making Process to Use CAM.¿ This multi-phase, mixed methods study will: (1) conduct an retrospective study using information from electronic medical records (EMRs) of a large HMO to identify unique clusters of patients with CMP (e.g., those with differing demographics, histories of pain condition, use of allopathic and CAM health services, and comorbidity profiles) that may be associated with different propensities for A/C utilization and/or differential outcomes associated with such care; (2) use qualitative interviews to explore allopathic providers¿ recommendations for A/C and patients¿ decisions to pursue and retain CAM care; and (3) prospectively evaluate health services/costs and broader clinical and functional outcomes associated with the receipt of A/C relative to carefully matched comparison participants receiving traditional CMP services. Sensitivity analyses will compare methods relying solely on EMR-derived data versus analyses supplementing EMR data with conventionally collected patient and clinician data. Successful completion of these aggregate aims will provide an evaluation of outcomes associated with the real-world use of A/C services. The trio of retrospective, qualitative, and prospective study will also provide a clearer understanding of the decision-making processes behind the use of A/C for CMP and a transportable methodology that can be applied to other health care settings, CAM treatments, and clinical populations.