Council on Chiropractic Guidelines and Practice Parameters Best Practice: Common Questions & Answers

Eugene A. Lewis, DC, MPH CCGPP Chairman

The best practice initiative undertaken by the Chiropractic Guidelines and Practice Parameters is progressing at a steady pace, with the Introduction and first completed chapter of the document (lumbar spine disorders) scheduled for release in early 2005. The dedicated volunteers of the Commission who are compiling the literature strive to be as thorough as possible. The sheer volume of research gathered to date is very impressive and will no doubt result in reliable evidence-based treatment options for all types of clinicians who want to serve their patients in an appropriate manner. This initiative focuses on the “process of care” instead of arbitrary treatment recommendations found in ordinary guidelines. This article will attempt to answer the most common questions CCGPP has been receiving concerning the development of the best practice initiative. For further information please visit our website.

Q: How did CCGPP members (aka Council) get chosen?

A: Members were appointed by the respective organizations that founded CCGPP. Those organizations are: American Chiropractic Association; Association of Chiropractic Colleges; Congress of Chiropractic State Associations; Consortium for Chiropractic Research (founding member but not current member); Council on Chiropractic Education (founding member but not current member); Federation of Chiropractic Licensing Boards; Foundation for Chiropractic Education and Research; Foundation for Chiropractic Tenets and Science (founding member but not current member); International Chiropractors Association (founding member but not current member); National Association of Chiropractic Attorneys; and National Institute of Chiropractic Research

Q: How did researchers (aka Commission) get chosen?

A: Chiropractic colleges provided the majority of researchers. CCGPP solicited from all schools; team leaders also selected others according to experience, education and needed skill sets.

Q: Is this “Mercy” all over again?

A: No, CCGPP was appointed to look at all protocols, guidelines, parameters and research related, applicable and useful for the chiropractic profession, including information from outside the US.

Q: How many previous participants from “Mercy” are involved?

A: Eight out of 82 CCGPP council and commission participants were members of the “Mercy Conference” commission. Four others submitted opinions to Mercy but were not part of the commission. It is inevitable that some researchers from one project will overlap into our project as it is a small profession and necessary skill sets to perform all tasks required are in need.

Q: “I disagree with the presence of Dr.

on CCGPP. He/she is too far from my philosophical perspective.”

A: CCGPP has carefully tried to stay away from philosophical conflicts. The Congress of Chiropractic State Associations (COCSA), the organization responsible for commissioning CCGPP, is well-known for its apolitical nature and one-third of our council members derive from this organization. Our job is to build a database of information for chiropractic, and to effectively do that, we need to steer clear of potential political issues. Since our creation, CCGPP research commission chairpersons have come from diverse philosophic environments.

Q: What kind of studies will be considered valid?

A. In order to be considered valid, studies will have to be able to pass scrutiny by those within the chiropractic profession as well as outside the chiropractic profession. This means that standardized, widely adopted international instruments of examination and review of literature will be used, of course, and all studies will have to pass through these filters. An added advantage of this necessary process is that undoubtedly some studies which have been critical of chiropractic care but were constructed using faulty methodology will be identified as such for the first time in a widely distributed publication for many outside the chiropractic profession to contemplate.

Q: Will subluxation be included?

A: Yes, all research material pertaining to subluxation is being examined for publication.

Q: What best practices models are being used?

A: A variety of models, since this is the first time this has been written for the chiropractic profession. David Sackett is the leading international authority on best practices and certainly he has had a major impact on everyone’s consideration of this subject.

Q: Why is the document condition-based?

A: The document is condition-based because CCGPP was formed largely, but not only, to address problems revolving around issues of reimbursement and this industry is currently in a condition-based format.

Q: How will CCGPP address techniques?

A: It will not address technique because of the exceptionally small amount of information available in the literature.

Q: Will the document address chiropractic philosophy?

A: Philosophy, certainly an underpinning of everything that chiropractors do, is not a focus of best practices and would be exceptionally difficult to place in that sort of framework.

Q: “I’d like a certain piece of literature included……”

A: CCGPP always welcomes submissions of pertinent literature from any interested party and our addresses are listed at the conclusion of this article. That being said, we are making a significant effort to be as comprehensive as possible and since our organization is employing both a professional research group as well as our own researchers examining multiple databases, it is likely that we already have the literature in question.

Q: What opportunity will exist for input by stakeholders?

A: Pre-publication comment with advance notice of this published online on our website in chiropractic journals and made known by other methods will solicit input from the chiropractic profession and from others, including patients, students, the insurance industry, governmental agencies and all other stakeholders.

Q: Will COCSA or some other group “sign off” on this?

A: No, COCSA and all of the other organizations to whom CCGPP members report have already appointed the existing representatives to find the resources to write and publish this document.

Q: What’s the cost of the finished product to field doctors?

A: CCGPP is hopeful that it will be able to contract with underwriters to provide a copy or other access to the best practices document for all US practicing chiropractors at no charge. This has not been finalized yet.

Q: What is CCGPP going to do with any profits?

A: Any and all income from royalties from the sale of the best practices document will be placed in a fund used for updating this document.

Q: What if there is a significant body of research that affects this document after publication or other need to alter the document?

A: Thanks to contemporary technology, it will be a relatively simple matter to update this document. Deadlines for updating the entire document have already contractually been set for no longer than every 24 months. This is a living document and it can be modified perpetually. Any unexpected issues can be dealt with and are planned for by the design of this entire process.

Q: What’s the focus of the best practices document?

A: CCGPP is placing a special focus on the process of care, identification of risk factors and case complexity, techniques of response monitoring, with benchmarks for intervening when the response is below average. This focus helps all parties to recognize that there is a broad spectrum of individuals served in chiropractic offices with varied presentations to be addressed.

Q: Best practices give information about the best care for patients but doesn’t address frequency and duration of care. How credible will it be if it doesn’t set limits?

A: First of all, there is virtually no supported literature for frequency or duration of care. Nearly all of this information used is arrived at by consensus or is quite arbitrary. CCGPP is providing a database of information from which chiropractic bodies in individual jurisdictions can arrive at guidelines for frequency and duration of care if needed. The insurance industry understands this issue also and CCGPP is taking care to place this in proper context for them, addressing their concerns as well as concerns within our own profession. We necessarily have to regard the best practices project as a problem-solving exercise for those on all sides in the chiropractic care industry and are charged with producing a document which can withstand scrutiny from all those parties.

Q: What if there isn’t enough evidence on a topic?

A: Consensus will dictate the conclusion.

Q: What if we just waited to see if there is more evidence before publishing?

A. The demand for this document is overdue and waiting longer for any reason has been deemed as unacceptable. Furthermore, although the chiropractic profession is in need of significantly more research funding, there is surprisingly quite a bit of information on many of our focus topics. CCGPP has also applied for a number of grants which we hope can pave the way for much more research in the profession, so we are addressing the issue directly.

Q: What will CCGPP say about wellness care?

A: This is an important area for our profession and will be addressed. Since there is virtually no research in this area, consensus will also be the rule.

Q: What’s the budget for this process?

A: $475,000 for 2004 is the budget, as it takes a considerable amount of funding to produce a quality product.

Q: What’s the timetable for this process?

A: The completed document will be released in mid 2005

Q: What’s the difference between best practices and guidelines?

A: CCGPP operating definition of best practices and process “Best practices” incorporate not only the most current explicit evidence based practices, but allows for filling the holes where the data is conflicting or absent (and those gaps are very large) by adopting formal consensus conclusions, which usually means there are a variety of equally appropriate ways of doing something. Best practices is the most contemporary approach and is employed by other health care professions as well as those in many others non-health areas. “Guidelines” are a more narrow interpretation of existing information, often used to formulate so called “stop-care points,” and are frequently arbitrary, with little available information to support most guidelines or may be subject to variable interpretation, depending on the reviewer. CCGPP is not writing guidelines for practice. CCGPP researches multiple databases and provides information to stakeholders in regard to (1) what evidence exists to support which procedures and (2) what strength this evidence is, recognizing that there may be quite a bit of evidence for some procedures and none for others. All must be documented for credibility, as this publication will be reviewed by many groups and individuals both inside and outside our profession who often if not always use comparable tools in their own professional life.

Q: Why are we doing this?

A: This project is being undertaken because all evidence is not interpreted or used equally and the chiropractic profession has been victim to this misinterpretation repeatedly. It is necessary because it is necessary to develop a common database of evidence available to the profession as a whole. Chiropractic participation in the interpretation of evidence relevant to the profession, reducing arbitrary and capricious interpretation/quoting of the evidence: (e.g. reinterpretation of the AHCPR guides. e.g. statements such as “Manipulation may be used for up to one month in acute back pain,” or e.g. statements such as “There is no evidence for use of spinal manipulation in chronic back pain patients.”). This project is also critical to empower local chiropractic organizations to respond with a common database to challenges from payers and policy makers (e.g. local guidelines development; e.g. local negotiations/rebuttals).

Q: How are you doing this?

A: We are placing the target users (chiropractors) as substantively involved in evaluating the evidence, accounting for clinical realities and patient expectations. Standardized instruments are employed to evaluate and rate the published evidence. Formal consensus process is used to evaluate clinical experience where evidence is lacking. Broad dissemination to all stakeholders is important and will be employed with multiple approaches.

Q: What makes you think the CCGPP product will get into the carriers’ hands any better than all the other previously released documents?

A: This is a primary reason why we’ve specifically contracted with a specialized publisher-distributor with considerable previous experience in this type of market penetration. We will also be using all other avenues, including the insurance relations staff of national organizations. CCGPP is currently traveling to and meeting with insurers to advance this document and help the industry see that they too are a part of the chiropractic profession and that adoption of chiropractic best practices is in their interest.

Q: What is going to prevent the carriers, governmental agencies and others from taking this document out of context?

A: Obviously, the chiropractic profession cannot force anyone to use the best practices document in a certain manner. When receiving payment, chiropractic doctors do need to recognize that these groups are our partners in a sense, whether this fact is liked or not. What CCGPP can do is solicit industry input in advance, give our own critical responses in return and make every effort to build bridges with these groups before, during and after publication as described in the preceding response. Having a “CCGPP Quick Response Team” ready for unexpected problems is one way that we feel might help to meet this challenge quickly and effectively.

Q: Will this document address the chronic management of permanently injured patients, and/or those who have already participated in other forms of management and rehabilitation, surgery, etc., but who still need care?

A: This is a sore point with all of us. We are writing a document, which will place a heavy emphasis on levels of presentation and risk stratification for the variations we see in the office. Obviously, a major task is getting the carriers to implement recognition of this fairly.

Q: Please discuss how members of the committees were chosen, if any conflicts of interest exist, and why it was important to include entities outside the Chiropractic profession in this project.

A: Members of CCGPP are volunteering hundreds of hours in order to complete the best practices project in order to act proactively, better serve our profession, our educators and students, our patients, prospective patients and others. CCGPP serves all stakeholders that we either impact on or who have an impact on our profession. In recruiting those who are on this body, national associations and colleges have appointed or asked many to serve, while others have been asked to be part of this very large and lengthy undertaking because they have required skill sets and or previous experience but also because they may represent a stakeholder view that is necessary to the successful construction and or implementation of this project. This means that, in order to be compliant with internationally recognized instruments for measuring validity such as the well-known AGREE document, CCGPP needs to have participation from many quarters. This is one reason that a review of the now well-known ACOEM guidelines by a CCGPP subgroup last month found that this publication failed to meet internationally accepted criteria: It did not have adequate participation of all stakeholders. Nearly all CCGPP members are in full-time private practice, with a number of others on chiropractic college faculties, as we have solicited for help from all of our colleges. CCGPP members experience the same angst that all of the other front line chiropractic doctors do in terms of reimbursement and other problematic issues. Many, myself included, have been or are currently representing our state and national associations in lobbying for improved chiropractic benefits and we know the battlefield well. Several, including myself, have been or are currently involved in association litigation against payers. CCGPP members sign conflict-of-interest statements. However, as indicated above, CCGPP requires input from many stakeholders, including the payer industry, so we specifically recruited a very small minority of those who work full time or part time for payers and other stakeholders or knew about their involvement in advance but needed the special skill set that they possessed. Not only that, CCGPP plans to continue to solicit opinions from payers, patients, governmental agencies, those in other health care professions, educators and others outside chiropractic. Not only is it required by standardized instruments of document construction, it is only common sense. To omit these varied viewpoints through simple but unfortunate emotional reaction only invites negative reviews of the completed best practices document by all those individuals who routinely use the aforementioned measuring instruments in their everyday activities.

About the Author

Eugene A. Lewis, DC, MPH, is a graduate of Logan College of Chiropractic and has practiced in Greensboro, North Carolina since 1979. He earned his Master of Public Health from the University of North Carolina at Greensboro. Dr. Lewis has served as president of the North Carolina Chiropractic Association, president of the Southeastern Chiropractic Federation and has been a member of the North Carolina State Board of Chiropractic Examiners. He has served as a Commissioner of the North Carolina State Radiation Protection Commission and as a benefits advisor to the North Carolina Health Planning Commission. Dr. Lewis was a member of the Commission for Chiropractic Quality Assurance and Practice Parameters, which published Guidelines for Chiropractic Quality Assurance and Practice Parameters in 1993. He has been a member of the Council on Chiropractic Guidelines and Practice Parameters since 1997 and has been chairman since 2002. Dr. Lewis is a Fellow of the International College of Chiropractors. He can be reached through the CCGPP office at PO Box 2054, Lexington, SC 29071, 803-808-0640, or [email protected].