A Model of Integrative Care for Low-Back Pain
David M. Eisenberg, MD,1,2Julie E. Buring, ScD,3Andrea L. Hrbek,3Roger B. Davis, ScD,1
Maureen T. Connelly, MD,4Daniel C. Cherkin, PhD,5Donald B. Levy, MD,3,6
Mark Cunningham,6Bonnie O’Connor, PhD,7and Diana E. Post, MD3
Objectives: While previous studies focused on the effectiveness of individual complementary and alternative
medical (CAM) therapies, the value of providing patients access to an integrated program involving multiple
CAM and conventional therapies remains unknown. The objective of this study is to explore the feasibility and
effects of a model of multidisciplinary integrative care for subacute low-back pain (LBP) in an academic teaching
Design: This was a pilot randomized trial comparing an individualized program of integrative care (IC) plus
usual care to usual care (UC) alone for adults with LBP.
Subjects: Twenty (20) individuals with LPB of 3–12 weeks’ duration were recruited from an occupational health
clinic and community health center.
Interventions: Participants were randomized to 12 weeks of individualized IC plus usual care versus UC alone.
IC was provided by a trained multidisciplinary team offering CAM therapies and conventional medical care.
Outcome measures: The outcome measures were symptoms (pain, bothersomeness), functional status (Roland-
Morris score), SF-12, worry, and difficulty performing three self-selected activities.
Results: Over 12 weeks, participants in the IC group had a median of 12.0 visits (range 5–25). IC participants
experienced significantly greater improvements at 12 weeks than those receiving UC alone in symptom both-
ersomeness (p=0.02) and pain (p=0.005), and showed greater improvement in functional status (p=0.08). Rates
of improvement were greater for patients in IC than UC in functional status (p=0.02), bothersomeness
(p=0.002), and pain scores (p=0.001). Secondary outcomes of self-selected most challenging activity, worry, and
the SF-12 also showed improvement in the IC group at 12 weeks. These differences persisted at 26 weeks, but
were no longer statistically significant.
Conclusions: It was feasible for a multidisciplinary, outpatient IC team to deliver coordinated, individualized
intervention to patients with subacute LBP. Results showed a promising trend for benefit of treating patients
with persistent LBP with this IC model, and warrant evaluation in a full-scale study.
of U.S. adults routinely use complementary and alternative
medical (CAM) therapies to treat their principal medical
conditions.1,2,3,4Total visits to CAM practitioners exceeded
300 million annually.1,2,4Total expenditures for CAM thera-
our nationally representative surveys conducted
between 1990 and 2007 demonstrated that a third or more
and $34 billion in 2007.4Out-of-pocket expenditures for CAM
care expenditures.4Despite the popularity of and substantial
expenditures on CAM therapies, their effect on clinical out-
comes and health care costs remains controversial.5,6,7,8
Low-back pain (LBP) is the most common medical con-
dition for which adults use CAM therapies.1,2LBP is com-
mon, costly, and clinically challenging. An estimated 50% of
adults experience significant LBP annually, and 70%—80% of
1Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
2Samueli Institute, Alexandria, VA.
3Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.
4Department of Population Medicine, Harvard Medical School, Boston, MA.
5Group Health Research Institute, Seattle, WA.
6The Osher Center for Integrative Medicine, Brigham and Women’s Hospital, Boston, MA.
7Alpert Medical School, Brown University, Providence, RI.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 18, Number 4, 2012, pp. 354–362
ª Mary Ann Liebert, Inc.
adults are afflicted by LBP at some time in their lives.9,10,11In
1998, total health care expenditures incurred by individuals
with LBP were estimated at $91 billion (1% of gross domestic
product) with incremental expenditures attributable to back
pain estimated at $26 billion.12These estimates excluded
short- and long-term disability costs. Additional worker
productivity losses due to pain-related conditions (with LBP
as one of the three most costly) have been estimated at $61
billion per year.13In addition, wide variation in the medical
and surgical management of LBP reflects widespread pro-
fessional uncertainty about optimal care for this common
Among adults with LBP surveyed in 1997–1998, 59% saw
both a medical doctor and used one or more CAM modali-
ties.2In addition, nearly one third of all visits to CAM pro-
viders in 1997–1998 were made for the treatment of back or
neck pain.2,16,17The evidence-based Clinical Guidelines
jointly published by the American College of Physicians and
the American Pain Society identified eight treatments for
chronic LBP with ‘‘moderate’’ evidence of effectiveness (none
had strong evidence), including four CAM therapies: acu-
puncture, massage, spinal manipulation, and yoga.18How-
ever, these studies evaluated individual CAM modalities as
opposed to multiple CAM (and conventional) modalities, as
is commonplace in real-life settings.19Moreover, while other
investigators have studied the effectiveness of various mul-
tidisciplinary approaches to the treatment of LBP, these have
emphasized conventional medical and psychologic treat-
ments with little or no use of CAM therapies as key com-
ponents of their ‘‘integrative care teams.’’20,21,22,23,24
To address this gap in knowledge, a pilot randomized trial
was designed to explore the effectiveness of an individual-
ized program of multidisciplinary, integrative care—which
included CAM practitioners—plus usual care compared to
usual care alone for adults with LBP. It is hypothesized that
coordinated access to both conventional and CAM practices
delivered by a team trained to provide individualized,
multidisciplinary care will provide superior outcomes for
patients with subacute LBP.
Materials and Methods
Recruitment occurred between July 2004 and October 2005
at Harvard Vanguard Medical Associates, a large multi-
specialty group practice in Boston, and at the Occupational
Health Department of Brigham and Women’s Hospital
(BWH). Study procedures were approved by the human
subjects committees of Harvard Vanguard Medical Associ-
ates, Partners Healthcare, and Harvard Medical School.
Patients 18–70 years old, presenting to these sites for an
evaluation of work-related or non-work-related LBP, were
screened for eligibility by a clinician. Exclusions included
LBP for less than 21 or more than 84 days; pain above the
lower back; LBP too mild (<3 when asked: ‘‘During the past
week, on a scale of 0–10 where 0=no pain and 10=worst
pain ever, how bad is your back pain?’’); history of back
surgery in the last 3 years; history of vertebral fracture or
dislocation; progressive or severe neurological symptoms;
known spondylolisthesis, scoliosis, or ankylosing spondyli-
tis; pacemaker or implanted defibrillator; underlying sys-
temic or visceral disease causing back pain; known
osteoporosis; taking systemic corticosteroids; pregnancy
(suspected or known); history of cancer (other than non-
melanoma skin cancer) within past 5 years; unexplained
weight loss or recent unexplained fever; bleeding disorder
or taking anticoagulant medication; severe or disabling co-
existing problem; major organ transplantation; immuno-
suppressive medication; intravenous drug use; unable to
speak or understand English; or unavailable for appoint-
ments within study guidelines.
Follow-up interviews were conducted by telephone at 2, 5,
12, and 26 weeks. Interviewers were not blinded, but per-
formed all interviews according to a predetermined script.
Primary outcomes were defined as changes from baseline to
12 weeks in functional status, symptom relief, and pain.
Functional status was measured using the modified Roland-
Morris Disability Questionnaire,25,26which includes 23 yes–
no questions about daily activities such as difficulty getting
dressed and climbing stairs (23=maximal dysfunction).
Symptom relief was measured as bothersomeness of the
worst symptom (LBP, sciatica, or numbness) over the past 24
hours on a 0–10 scale (0=not bothersome, 10=extremely
bothersome).27,28LBP was measured by asking subjects
about their worst pain over the prior 24 hours using a 0–10
scale, with 0=no pain and 10=worst pain ever.
Secondary outcomes included worry about one’s back
problem and overall mental and physical health. Worry was
measured using a scale from 0 (no worry) to 10 (extremely
worried). The Medical Outcomes Study Short-Form (SF-12,
acute version) was used to measure overall mental and
physical health, on subscales ranging from 0 (worst) to 100
(best).29,30In addition, participants were asked at baseline to
identify three important activities in their daily life that LBP
or sciatica had made difficult, and to rate the difficulty of
each on a 0–10 scale.
Eligible patients with subacute LBP were randomized in a
2:1 ratio to integrative care plus usual care (IC refers to this
adjunctive intervention group throughout the article) versus
usual care (UC) alone. Participants randomized to UC con-
tinued to receive treatment at their primary care facilities,
typically including nonsteroidal anti-inflammatory drugs,
muscle relaxants, as-needed referrals to physical therapy,
limited bed rest, education, and activity alterations. IC was
provided by a trained multidisciplinary team with licensed
practitioners who could provide the following services if
needed: acupuncture, chiropractic, internal medicine consul-
tation and referral as appropriate, massage therapy, occupa-
tional therapy, physical therapy, mind–body techniques,
neurology consultation, nutritional counseling, orthopedics
consultation, and psychiatry and rheumatology consultation
and referrals as appropriate. See Figure 1 for overview of the
The team was trained one full day per week for 14 con-
secutive weeks to refer nonhierarchically to fellow team
members to maximally enhance a patient’s functionality with
the fewest encounters. Training was co-led by a professional
facilitator, a medical anthropologist and the team’s medical
INTEGRATIVE CARE FOR LOW-BACK PAIN 355
presentations by each member; (2) experiential education in-
cluding hands on diagnosis and treatment by each member
on other team members; (3) the diagnosis and treatment of
volunteer subjects with chronic LBP, referred by team mem-
ber physicians, in full view of all team members; and (4) the
development of a shared treatment protocol for implementa-
tion of the pilot randomized controlled trial.
Participants were evaluated at the initial visit by a medical
doctor and CAM clinician (Fig. 2). The two evaluators then
met to develop an individualized treatment plan. Treatments
were provided up to 2 times per week (with up to 2 treat-
ment modalities per session) for up to 12 weeks as needed.
Cases were discussed at weekly team meetings. Team
members were encouraged to refer across disciplines (listed
in Fig. 1) to maximally reduce symptoms and enhance pa-
tient function (i.e., capacity to perform routine tasks), and to
prospectively engage each patient in participatory therapies
to the extent accepted by each patient. The shared goal was
to help each patient achieve maximal improvement with a
minimum number of visits over a 12-week period. Type and
frequency of treatments provided were recorded. Scope-of-
practice guidelines were established for staff chiropractors,
acupuncturists, and massage therapists, consistent with their
professional scope of practice in Massachusetts. However,
the integrative care team did not prescribe herbs, vitamins,
or supplements as part of the study, nor did they perform
cervical manipulation, consistent with hospital guidelines at
the time the study was implemented.
For each outcome, the IC versus UC groups were compared
using Wilcoxon rank-sum tests evaluating the change in score
from baseline. To examine the rate of improvement over the
12-week treatment period, linear regression models were
created. These included the baseline value of the outcome,
a treatment-group indicator, study week, and a treatment-
group–study-week interaction term as covariates. Generalized
estimating equations with an autoregressive correlation
structure were used to account for within-participant corre-
lation. Likelihood ratio tests were employed to evaluate
whether the rates of improvement were different between
treatment groups. All analyses were performed on an inten-
tion-to-treat basis. Planned analyses were conducted using
last value carried forward to replace missing data. To ensure
that results were not artifacts of this approach, all analyses
were repeated using only observed data. None of the results
was substantively changed. Data reported here are based on
the planned, intention-to-treat analyses. In this pilot study, no
adjustments were made for multiple tests.
Ninety-eight (98) patients were screened for the study (Fig.
3). Of these, 8 were eligible but declined to participate, and 70
were ineligible, primarily due to chronicity of pain (n=30),
pain too mild (6), age not in range (5), not an employee or
member of the health plan participating (6), or for a history of
one of several additional exclusionary conditions (23), in-
cluding osteoporosis (4); scoliosis, spondyolisthesis, or anky-
losing spondylitis (3); not able to be enrolled in time window
(3); not LBP (2); infrequent pain (2); prior spine surgery (2);
spinal fracture (1); fibromyalgia (1); skin cancer (1); pacemaker
(1); steroid use (1); intravenous drug use (1); and pregnancy
(1). The 20 participants who remained eligible and willing
were randomized in a 2:1 ratio, 14 to IC and 6 to UC.
All baseline measures were obtained prior to randomiza-
tion (Table 1). The two groups were well balanced at baseline
except for the following: (1) percentage involved with
Worker’s Compensation claim (higher number in IC group);
(2) number of days spent in bed (higher in UC group); and (3)
satisfaction with baseline ‘‘usual care’’ (higher in UC group).
Over 12 weeks, participants in the IC group had a median
of 12.0 visits (range of 5–25). One minor adverse event was
reported (pain at an acupuncture site) out of over 170 CAM
treatments provided to the IC group. As shown in Table 2
and Figure 4, at 12 weeks, there were statistically significant
benefits in the IC group compared to UC with regard to
mean pain scores (0.6 versus 5, p=0.005), and bother-
someness (1.4 versus 5.7, p=0.02). Mean functional status
(Roland score) was substantially better in the IC group (3.9
comes Study Short-Form 12.
Overview of study design. SF-12, Medical Out-
controlled trial. CAM, complementary and alternative med-
Integrative care team protocol for pilot randomized
356 EISENBERG ET AL.
versus 11), but did not reach statistical significance (p=0.08).
These differences between groups narrowed slightly at 26
weeks and were no longer statistically significant, except for
pain. The secondary outcomes of self-selected most chal-
lenging activity, worry, and the SF-12 physical scale also
showed benefit in the IC group at 12 weeks.
A secondaryanalysis using longitudinal
showed that IC participants experienced significantly greater
improvement in the three primary outcomes over 12 weeks
(Table 3). Functional status (Roland score) improved by an
average of 0.89 points per week (95% confidence interval:
0.61, 1.17) for IC compared to 0.32 (-0.004, 0.64) for UC
(p=0.02); bothersomeness improved by 0.39 (0.29, 0.48)
points per week for IC compared to 0.05 (-0.08, 0.19) for UC
(p=0.002); and pain scores improved by 0.30 (0.24, 0.37)
points per week for IC compared to 0.04 (-0.10, 0.19) for UC
(p=0.001). The benefits remained but were no longer sta-
tistically significant at 26 weeks.
LBP is a common, costly, and suboptimally managed
condition. It is also a prime candidate for studies that explore
the effectiveness and cost-effectiveness, or lack thereof, of
‘‘integrative care models’’ that combine access to both con-
ventional and complementary care options. The results of
this prospective pilot randomized trial address the hypoth-
esis that coordinated access to a trained multidisciplinary,
outpatient team consisting of medical doctors, allied health
care personnel, and licensed CAM providers may result in
enhanced clinical outcomes for adults with persistent LBP
when compared to usual care alone. The results suggest that
(1) it is feasible to assemble and train a clinical team of
conventional and licensed CAM providers within an aca-
demic teaching hospital; (2) treatments delivered by CAM
professionals within this model as applied to patients with
LBP are safe; and (3) access to an expanded multidisciplinary
(i.e., integrative care) model may benefit patients with per-
sistent LBP. However, confirmation of the findings of this
pilot study in a fully powered trial needs to be established in
order to consider possible implications for clinicians, econ-
omists, and self-insured corporations.
This pilot study has raised a number of issues that would
need to be addressed in a full-scale trial designed to defini-
tively evaluate these questions: (1) sufficient numbers of el-
igible patients with back pain would be required to ensure
the comparability of the baseline characteristics between the
treatment groups, as well as to provide adequate power to
detect clinically meaningful treatment effects; (2) there was a
high loss to follow-up in the UC group, and approaches to
maximize follow-up rates such as offers of financial incen-
tives for completion of all outcome measures, which should
ideally be applied to both UC and IC groups, need to be
considered; (3) blinding on the part of interviewers will be
essential in any subsequent trial; and (4) in this pragmatic
study, there was no a priori algorithm delineating specific
referral patterns. No 2 patients received identical patterns
(i.e., ‘‘fingerprints’’) or ‘‘doses’’ of ‘‘integrative care.’’ Indeed,
this may not be dissimilar from the need for individualized,
nonidentical care for individuals with a variety of complex,
INTEGRATIVE CARE FOR LOW-BACK PAIN357
chronic medical conditions such as cancer, diabetes, or de-
pression. A full-scale trial would need to balance the need for
a reproducible intervention model that does not overly
constrain clinicians caring for LBP patients, and the need to
explore treatment patterns for subgroups of LBP patients to
determine whether optimal treatment algorithms can be
developed and prospectively tested.
A major limitation in this study relates to the likely dif-
ferences between study arms regarding patient contact and
communication with clinical providers. It is possible that the
observed differences between groups were the result of en-
hanced patient contact, interaction, education, and encour-
agement by the several members of the integrative care team
participating in each patient’s treatment, and that this en-
hanced contact, as opposed to increased use of CAM thera-
pies, was the ‘‘active ingredient’’ leading to the observed
differences. Indeed, the results of studies by Karjalainen
et al.20,21clearly indicated that added to usual care, a mini-
intervention by a physician specializing in back pain and a
physiotherapist involving a clinical examination, informa-
tion, support, and simple advice reduced daily symptoms
and absenteeism, and led to better treatment satisfaction and
adaptation to pain, compared with UC for patients with
Table 1. Baseline Characteristics for All Participants by Intervention Group:
Integrative Care (IC) by Usual Care (UC)
Characteristic IC (n=14)UC (n=6)
Mean age in years (SD)
High School grad
Mean baseline outcome measures (SD)
Expectation of improvement in 12 weeks
for this episode of LBP
(0 [no improvement] to 10 [complete recovery])
Function: Modified Roland Disability Questionnairea
(0–23 scale, 23=worst)
Symptoms: bothersomeness of worst symptomb,c
(LBP, sciatica, numbness)
(0=not bothersome, 10=extremely bothersome)
(0=no pain, 10=severe pain)
Difficulty with the worst of 3 self-reported activitiese
(0=no difficulty, 10=extremely difficult)
Worry or concern about LBPf
(0=no worry, 10=extremely worried)
Physical SF-12 subscale
(0–100 scale: higher score indicates better function)
Mental SF-12 subscale
(0–100 scale: higher score indicates better function)
Days in bed in the last week
Days work/school missed in the last week
Days activities reduced in the last week
Percent rating initial UC care for LBP as ‘‘excellent’’
8.7 (1.6) 8.2 (1.5)
15.7 (5.8) 16.0 (6.7)
6.2 (1.8)7.2 (2.6)
4.8 (1.6)5.7 (3.1)
9.0 (1.1) 8.8 (1.0)
6.3 (1.9)6.7 (2.8)
32.5 (5.7)36.6 (4.8)
48.9 (9.3) 47.0 (14.5)
aAverage Roland scores over 16 indicate moderate to high levels of pain and dysfunction.
bSymptom bothersomeness scores of 8 or higher indicate moderate to high levels of pain and dysfunction.
cUsing a scale from 0 to10, with 0 being not at all bothersome and 10 being extremely bothersome, how bothersome was your low-back pain
and/or sciatica in the past week?
dUsing a scale from 0 to 10, with 0 being no pain and 10 being ‘‘worst pain ever,’’ how bad is your low-back pain and/or sciatica in the past
eAll participants were asked, ‘‘Your (first/second/third) activity was ________. Using a scale from 0 to 10, where 0 is not at all difficult and
10 is extremely difficult, please rate how difficult this activity is to perform.’’
fUsing a scale from 0 to 10, where 0 is ‘‘no worry’’ and 10 is ‘‘extremely worried,’’ how would you rate your worry or concern about your low-
back pain and/or sciatica today?
SD, standard deviation; LBP, low-back pain; SF-12, Medical Outcomes Study Short-Form.
358EISENBERG ET AL.
In another study intended to evaluate ‘‘an integrative care
program’’ to treat subjects with subacute LBP, Lambeek
et al., in studies reported in 2007, 2009, and 201022,23,24
compared subjects (n=40) half of whom were randomized to
receive usual care and half to receive a model of ‘‘integrated
care’’ that combined a ‘‘patient-directed and workplace-
directed’’ intervention provided by a multidisciplinary team,
including an occupational physician. The conclusions of the
Lambeek et al. studies, like those of the Karjalainen et al.
studies, included the observation that subjects treated by a
multidisciplinary team experienced improved clinical out-
comes as compared with ‘‘usual care.’’ Importantly, how-
ever, both the Karjalainen and Lambeek studies excluded
licensed CAM professionals (e.g., chiropractors, massage
Table 2. Mean Outcome Scores for Integrative Care (IC) Versus Usual Care (UC) (Primary Outcomes Bolded)
OutcomeTime Mean (SD) Mean (SD)p-Value*
Days in bed
Days at home
Reduced activity days
Satisfaction with usual careb(% excellent)
Satisfaction with integrated care (% excellent
aMean (standard deviation) for each outcome score.
bFor both study groups: Usual Care, and Integrated Care plus Usual Care.
*p-Value based on change from baseline.
**p-Value statistically significant (p<0.05).
SF-12, Medical Outcomes Study Short-Form.
INTEGRATIVE CARE FOR LOW-BACK PAIN359
therapists, and acupuncturists) from their respective multi-
disciplinary teams. Ultimately, the question of which com-
bination of licensed health care professionals, including both
CAM and conventional providers, should ideally be in-
volved in optimally cost-effective, multidisciplinary ap-
proaches to treat persistent lower back pain will remain
unanswered until a fully powered trial with a comparable
attention control such as integrated conventional care only is
included. Lambeek et al. estimated that a sample of ap-
proximately 150 subjects would be needed for a properly
powered study to address this question.22
Finally, a future trial needs to track not only clinical and
functional outcomes, but also relevant financial outcomes
including costs of patient visits, diagnostic tests, surgical
procedures, medications, absenteeism, work status, worker
productivity, short- and long- term disability payments, and
employee replacement costs.
Evaluating these questions is important for two reasons.
The first relates to the enormous societal costs of LBP and the
need for novel therapeutic strategies to contain or reduce
health care expenditures. Luo et al. reported that on average,
individuals with LBP incur health care expenditures about
60% higher than individuals without LBP, with incremental
expenditures attributable to the management of LBP in the
United States accounting for 2.5% of all health care expen-
ditures in 1998.12In a more recent analysis of the Medical
Expenditure Panel Survey (n=22,258),31investigators re-
ported that total estimated expenditures among respondents
with spine problems increased 65% from 1997 to 2005.
However, age- and sex-adjusted measures of physical func-
tion, work limitations, social limitations, and mental health
among LBP sufferers were all considerably worse in 2005
than in 1997.31Even a modest but statistically and clinically
significant difference in symptoms, functional status, pro-
ductivity, and utilization of services among LBP patients
scores for Pain, Bother-
someness, and Roland (func-
tional status). IC, integrative
care; UC, usual care.
Study results: mean
Table 3. Regression Model Resultsa
Bothersomeness 0.39 (0.29, 0.48)
Days in bed
Days at home
0.89 (0.61, 1.17)0.32 (-0.004, 0.64) 0.02
0.05 (-0.08, 0.19) 0.002
0.04 (-0.10, 0.19) 0.001
0.10 (-0.06, 0.25) 0.01
0.10 (-0.04, 0.25) 0.34
0.38 (-0.10, 0.85) 0.01
0.30 (0.24, 0.37)
0.43 (0.33, 0.54)
0.21 (0.06, 0.36)
1.27 (0.97, 1.58)
0.17 (-0.41, 0.75) 0.23 (-0.09, 0.54) 0.97
0.05 (-0.005, 0.10) 0.04 (-0.04, 0.13) 0.85
0.17 (0.06, 0.29) 0.14 (-0.005, 0.29) 0.68
0.28 (0.16, 0.39)0.19 (0.07, 0.30) 0.41
aDuring the 12-week treatment period, adjusted for baseline level.
bEstimated slope (b) and its 95% confidence interval per change in
outcome per week in each treatment group.
IC, integrative care; UC, usual care; SF-12, Medical Outcomes
360EISENBERG ET AL.
would have a significant impact on overall health care costs
in the United States and could translate into a savings of
billions of dollars annually.
Second, while the popularity of CAM therapies by U.S.
adults is no longer debated, the role of these therapies in
future models of coordinated, evidence-based, preference
driven, fiscally responsible health care remains unclear. The
Institute of Medicine, in its report entitled ‘‘Complementary
and Alternative Medicine in the United States,’’ includes the
following recommendation regarding the need for additional
studies to evaluate ‘‘integrative models’’ of care: ‘‘Studies
show that patients frequently do not limit themselves to a
single modality of care—they do not see complementary and
alternative medicine (CAM) and conventional medicine as
being mutually exclusive— and this pattern will probably
continue and may even expand as evidence of therapies ef-
fectiveness accumulate. Therefore, it is important to under-
stand how CAM and conventional medical treatments (and
providers) interact with each other and to study models of
how the two kinds of treatments can be provided in coor-
dinated ways. In that spirit, there is an urgent need for health
systems research that focuses on identifying the elements of
these integrative medical models, their outcomes and whe-
ther they are cost effective when compared to conventional
Historically, federal agencies including the National In-
stitutes of Health, the Agency for Healthcare Research and
Quality, Centers for Medicare and Medicaid, the Department
of Defense, and the Veterans Administration have not
sponsored research aimed at evaluating the cost effective-
ness—or lack thereof—of emerging models of multidisci-
plinary, ‘‘integrative care’’ in the treatment of common
medical conditions. This study argues that such comparative
effectiveness research in this area is feasible, promising, and
warranted, at least with regard to adults with persistent LBP.
This work was supported in part by grants from the Na-
tional Center for Complementary and Alternative Medicine
(AT00905, AT005065) and the Bernard Osher Foundation.
No competing financial interests exist.
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Address correspondence to:
David M. Eisenberg, MD
Harvard Medical School
180 Longwood Avenue
Boston, MA 02115
362 EISENBERG ET AL.