Abstract ID: 3333

Primary Topic: Patient-Centered Outcomes Research
Secondary Topic: Research Methodology

Results from RAND/NCCIH Center of Excellence for Research on CAM: Patient-Centered Methods for Determining the Appropriateness of Manipulation and Mobilization for Chronic Neck and Low Back Pain
Ian D Coulter, PhD, RAND Corporation, Santa Monica, CA, United States; Ron D. Hays, PhD, UCLA, Los Angeles, CA, United States; Gery Ryan, PhD; Patricia M. Herman, ND, PhD; Lara G. Hilton, MPH, RAND Corporation, Santa Monica, CA, United States

Late Breaker: No


This symposium provides the results of the 4-year RAND/NCCIH Center of Excellence for Research on CAM (1U19AT007912-01). The Center includes four projects and an ancillary R21 study examining the appropriateness of one form of complementary and integrative health (CIH) care. The studies focus on chiropractic manipulation/mobilization for chronic low back and cervical pain, but the methods are applicable to other therapies and conditions. We used the traditional method of determining treatment appropriateness with the RAND/UCLA expert panel process using evidence and clinical experience of effectiveness and safety, but extended it by incorporating patient preferences, resource utilization, and patient-reported outcomes into the determination of the appropriateness with data collected from 2024 patients sampled from 125 chiropractic clinics from throughout the U.S. The panels were asked to rerate appropriateness after considering these new data inputs to determine whether their appropriateness ratings changed. The definition of appropriateness was expanded to match the needs of CIH where patient preferences are expressed in self-referral and out-of-pocket payments are common, and, thus, patient preferences and costs can also be important in the determination of appropriate care. An ancillary study examined whether crowdsourced data could be used as an efficient and effective patient data collection method in future studies.  

This symposium will provide a brief overview of the organization of the Center, followed by results from each of the projects and culminating in the key findings from the expert panels after they had been asked to consider patient-reported preferences and costs in their new appropriateness ratings. Project-specific results include national data on outcomes including patient experiences with care, health-related quality of life, and patient preferences, and economic simulation models of the relative cost-effectiveness of nonsurgical interventions for chronic low back and neck pain.


The appropriateness methodology provides what is known from research to experienced clinicians who translate the evidence into practice considering the range of patient presentations in real-world clinical practice. Understanding the appropriateness of care is essential to improve clinical outcomes, determine the need for guidelines and inform policy. If most of the care provided is judged to be appropriate, then no changes to clinical guidelines are needed. If a substantial amount of care is judged to be inappropriate or indeterminate, then policies to improve practice or more research are needed, respectively. The addition of patient preferences, resource utilization, and patient-centered outcomes to the traditional appropriateness methods is essential for complementary and integrative health policy and health care in general.


  • Articulate the traditional procedure for assessing the appropriateness of care and the use of these ratings in health policy.
  • Report on the appropriateness of manipulation and mobilization in a large representative sample of U.S. chronic low back and neck pain patients when only effectiveness and safety are considered.
  • Identify elements of patient preferences, outcomes, and resource utilization that should be included, along with effectiveness and safety, in the determination of care appropriateness.
  • Report on the appropriateness of manipulation and mobilization in our sample when patient preferences, resource utilization and patient-reported outcomes are considered.

Methods/Session Format

The proposed symposium will consist of a total of 90 minutes of presentations and discussion:

Person, Topic


Ian D. Coulter, PhD-Center background and overview of initial appropriateness panel results


Ron D. Hays, PhD- PROMIS and CAHPS results and relationship to appropriateness


Gery Ryan, PhD-Patient preferences regarding their chronic pain care


Patricia M. Herman, ND, PhD-How resource utilization may affect appropriate choice and duration of treatment


Lara G. Hilton, MPH-Results of associated R21 on feasibility of crowdsourcing pain data


Ian D. Coulter, PhD-Impact of patient-centered outcomes on expert panel ratings of appropriateness


Ian D. Coulter, PhD – Leads discussion and Q&A


 Total symposium time



  • Overview of the center, introduction to appropriateness method and findings from the appropriateness panels when only effectiveness and safety are considered (Ian D. Coulter, PhD)
  • Results of psychometric testing of PROMIS and CAHPS on this population and the relationship of these outcomes to the appropriateness of care (Ron Hays, PhD)
  • Findings from surveys on patient preferences, satisfaction, expectations, coping behaviors, and pain profiles which may affect the ratings of appropriateness (Gery Ryan, PhD)
  • Results of the economic simulation models on the relative cost-effectiveness of alternative interventions which may affect the ratings of appropriateness (Patricia Herman, ND, PhD).
  • Results from using crowdsourcing as an alternative data collection method for clinical research (Lara Hilton, MPH)
  • Changes seen in the ratings of the appropriateness of manipulation and mobilization after patient-centered data are introduced (Ian D. Coulter, PhD)
  • Discussion (Lead by Ian Coulter)