The often persistent nature of low back pain (LBP) compels many patients to seek long-term ongoing care for pain control and preservation of function. Safety issues and escalating costs tied to current care pathways highlight the need to identify safe, high value strategies for long-term management of chronic LBP. This is particularly the case for elderly Medicare beneficiaries, a population that is comorbid, vulnerable to adverse events and prone to the utilization of high-cost interventions. Prescription drug therapy and spinal manipulation are guideline-concordant treatment strategies for chronic LBP, but their comparative value for long-term care is uncertain, and the long-term utilization of these treatments is controversial. The chronic use of opioids and NSAIDs for LBP raises safety concerns ? particularly for the elderly, but the utilization of spinal manipulation services - which show similar effectiveness to other interventions in systematic reviews - is often limited by insurers because the value of prolonged utilization remains unknown. There is, therefore, a critical need to evaluate non-pharmaceutical alternatives and compare these two approaches (spinal manipulation and prescription drug therapy) for long-term management of chronic LBP in Medicare beneficiaries. The long- term goal is to contribute to the identification of clinically valuable strategies for management of chronic spine pain. The overall objective of the proposed project is to assess the value of spinal manipulation services (SMS) as compared to prescription drug therapy (PDT) for long-term management of chronic LBP. Through active engagement of students, this project is also intended to strengthen the research environment at Southern California University of Health Sciences. The central hypothesis is that among aged Medicare beneficiaries with chronic LBP, utilization of SMS offers superior value (to both patient and payer) for long-term care as compared to PDT. The rationale for the proposed research is that evidence for the value of SMS for long-term care of chronic LBP will identify a safe and viable alternative to long-term PDT. The central hypothesis will be tested objectively by pursuing two related but independent specific aims: (1) Compare SMS and PDT treatment for chronic LBP for their association with objective healthcare outcomes. (2) Compare SMS and PDT treatment for chronic LBP for their association with self-reported quality of life and satisfaction with care. These aims will be accomplished through (1) analysis of nationally representative Medicare claims data, and (2) surveying random samples of the same subject population studied by claims analysis. Rigorous methods intended to reduce risk of selection bias will include weighted propensity scoring informed by the survey results. The project will make use of an innovative approach by deterministically linking claims data to survey data. The research questions are innovative because they promise to challenge the status quo of LBP treatment to shift toward non-pharmacological interventions. The research contribution is expected to be significant because evidence favoring the value of SMS promises to improve the value of care for persistent chronic LBP.