Use of Acupuncture for Chronic Pain within an Integrated Health Plan

最近的大量研究检查了许多类型的补充和替代（CAM）疗法的疗效和生物学基础。然而，现实世界CAM的使用在很大程度上被忽视了，尽管呼吁CAM疗法以其实践的方式进行研究，并敦促高度优先考虑研究，包括临床结果，成本效益以及患者和提供者的决策过程。因此，特别是鉴于CAM越来越受欢迎，这就更加需要丰富的理解，幸运的是，CAM为研究提供了新的数据存储。最近的研究表明，美国人寻求CAM治疗更经常慢性肌肉骨骼疼痛（CMP）比任何其他条件。在CMP的CAM治疗中，针灸和脊椎按摩（A/C）护理是医生群体接受度最高的治疗方法，也是支持其使用的最佳证据。此外，最近阿片类药物治疗和手术干预治疗慢性疼痛的数量惊人地增加，尽管其成本高，潜在的不良反应和适度的疗效，这表明需要评估与CMP有前途的非药物/非手术CAM治疗相关的结果，这些治疗通常被患者接受，并越来越多地在社区中使用。此应用程序响应NCCAM程序公告PAR-08-045，<$结局，成本效益和决策过程中使用CAM。<$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）的信息进行回顾性研究，以识别CMP患者的独特集群（例如，具有不同人口统计学特征、疼痛状况史、对抗疗法和CAM健康服务使用情况以及合并症特征的患者），这些可能与A/C使用的不同倾向和/或与此类护理相关的不同结果相关;（2）使用定性访谈来探索对抗疗法提供者对A/C的建议以及患者寻求和保留CAM护理的决定;和（3）相对于接受传统CMP服务的仔细匹配的比较参与者，前瞻性地评估与接受A/C相关的健康服务/成本以及更广泛的临床和功能结果。敏感性分析将比较仅依赖于EMR衍生数据的方法与使用常规收集的患者和临床医生数据补充EMR数据的分析。成功完成这些总体目标将提供与现实世界使用A/C服务相关的结果评估。回顾性、定性和前瞻性研究三重奏还将更清楚地了解使用A/C进行CMP背后的决策过程，以及可应用于其他医疗保健环境、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.