We appreciate the opportunity to provide your readers with factual information about the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) and our Best Practice document, as well as the chance to correct some of the factual errors and points of misinformation, which have recently been disseminated, including that by Mr. Leonard of the Wisconsin Chiropractic Association. The Congress of Chiropractic State Associations (COCSA) and nearly all of the other recognized chiropractic organizations in the United States created the CCGPP in 1995 to examine evidence to support chiropractors in practice. COCSA created CCGPP, specifically, to respond to a pervasive and crucial problem: disparity and discrimination by third party payors against the chiropractic profession. Real Tools to Fight Back with The real purposes of the CCGPP Best Practices document are the following: l.To give providers, our patients, and other stakeholders a scientifically sound and defensible library of peer reviewed evidence pertaining to chiropractic care, including conditions, diagnosis and treatments commonly used by DCs. . 2. To rank the evidence in a scientific manner to help doctors and patients make informed choices. 3. To develop ways to make this information useable and relevant to the average DC by using multiple platforms for dissemination and implementation of the information, including interactive websites, seminars, online data bases and other approaches. 4. To set up an ongoing process which would grow and develop over time, in- corporating not only new literature evidence, but also consensus evidence. 5. To protect and encourage respect for and use of the clinician's experience and clinical acumen, as well as patient preferences in contrast to a reliance on only scientific literature, particularly for coverage decisions. It's Not 1950 Much has changed in the chiropractic world in the past fifty years, and in the world of health care as well. People who pay the bills for health care, including insurers, employers and, yes, patients, are demanding evidence of treatment effectiveness beyond mere anecdote. The newspapers are full of stories about "proven" treatments that have now been shown to be useless. Provider groups of all types have heard the call, and are using evidence from their own perspectives to increase their market share over competitors who are slower to respond. Certainly, the PT's have made it clear that they expect to dominate manual treatment in the future, and are using scientific literature in addition to politics to further their goals, at our expense. In addition, care purchasers who must make a "pay or don't pay" decision on every claim, are demanding evidence of efficacy. Numerous internal (insurance) carrier guidelines which limit chiropractic care and access are used tens of thousands of times every day to make such coverage decisions, and they were not written with chiropractic input. In addition to providing a library of information for chiropractors, CCGPP was created to provide a more realistic and fair effect on substantiation of care by insurers. CCGPP was structured to provide a comprehensive look at what the scientific literature says, and filter it through a chiropractic perspective. CCGPP also addresses what to do when the scientific literature is lacking, contradictory or equivocal, by employing internationally established protocols to set consensus by chiropractors concerning chiropractic care. Chiropractic Best Practices: Not Fear, Just Facts Continued from previous page It's about the Process If a chiropractic "best practice" document is to have credibility and legitimacy, it must be able not only to withstand scientific scrutiny, but, more importantly, it must follow a very carefully circumscribed process to positively influence decisions by government regulators, legislators, and insurance payors. In the world of health care, the internationally recognized standard of construction and evaluation of documents such as best practices is the AGREE protocol. AGREE sets out how to collect evidence, rate it, and determine what to do at each phase of the project. Fail to follow the AGREE protocol and a document will be considered flawed. Follow it carefully, and legitimacy and credibility will be the likely result. CCGPP has been very careful to follow the process laid out by AGREE, which includes transparency, specific feedback approaches, and editorial independence. The process calls for throwing a wide net to look at all relevant literature, but also specifies what kind of literature we look at to derive conclusions. For example, we do not use case studies, though certainly they have value. This is because case studies do not have the same impact that studies with larger sample sizes do (and arc universally excluded). This has been a source of frustration for some of our critics, but it is necessary to remain true to the established process. Another aspect of the process, with which some critics have problems, is the system used to grade evidence. There are several scales used but, generally, they follow an alphabetical scheme. "A"- level studies have the most evidence, followed by B, C and D. However, a lower grade does not connote worthlessness. It simply means there is less compelling evidence. That can be for a variety of reasons, as we shall see. Modality Services. Many treatment approaches, such as physical therapy modalities, have inconclusive or conflicting research evidence for several reasons. For one thing, specific modalities are not often studied independently, e.g., electrotherapy vs. placebo. It is more likely that electrotherapy or some other modality be used in conjunction with another treatment, which makes it difficult to tell how effective it is by itself. Researchers also have perhaps not asked the right questions, such as when the therapy is to be employed. Is ultrasound just as useful on the twenty-fifth visit as it is on the first? Research design can significantly affect the results. What has been quite clear for many years is that the evidence shows that active treatment is more effective than passive treatment. That reality has been reflected, in part, in insurance payment policies and the reimbursement policies of Medicare and other government agencies for more than a decade. The CCGPP stratification of evidence for modalities is certainly nothing new, despite recent cries that the sky is falling. Some have made dire pronouncements of financial losses looming for DCs who use modalities. We believe such tactics simply play on doctors' fears of anything new, and fail to recognize the facts. First, the market has already corrected for the disparity in evidence for different treatments (it is refened to as the relative value, and is used to calculate fees). Secondly, there are hundreds, if not thousands, of treatments with similar ratings, used by providers of all stripes, which are reimbursed every day. To assume that all treatments with less than a "B" rating are suddenly no longer going to be reimbursed is not logical or realistic. What the lower ratings really mean is that there may be better treatments to consider first (like manipulation/adjustment, exercise and advice), but modalities still have their place, and will still be reimbursed. Again, our rankings are nothing new, and are no secret to the carriers. They arc simply an honest appraisal by a mature profession. What does the low back chapter say? Among other things, it gives "A" ratings to the things most of us do most of the time: manipulation/adjustments, advice to our patients, and instruction in exercise. It helps us decide what tests are most effec- Chiropractic Best Practices: Not Fear, Just Facts Continued from pg. 52 tive and when we should order them, and it reviews the other types of treatments we should consider when treating our patients for certain conditions. Are there going to be areas of controversy? Of course! We're talking about chiropractic here, and much of what we do and are taught we don't all agree on. However, we can use evidence and consensus as a starting point for discussion about how to resolve some of these controversies, which can only benefit our profession and, ultimately, our patients. We also cannot forget that, in this chapter and others to follow, a major reason for the document is to provide current literature to give answers for chiropractors who are wading through the ever-increasing volumes of literature emerging from around the world and who are seeking information on expeditious responses for their patients. This is certainly a major focus of the lower back chapter: making practice easier in this age of information overload by pointing the way to verified answers to the questions of everyday patient contact. The low back chapter and others are aimed at helping the chiropractor. Guidelines vs. Best Practices This profession has a justifiable concern about guidelines, given that guidelines developed by non-DCs have often been used to curb care. Guidelines place an unreasonable emphasis on scientific evidence, particularly randomized controlled trials. As most of us know all too well, those studies often do not reflect real life, and fail to take into account the perspective of the doctor who is actually treating the patient, and the needs and desires of that unique patient. They also frequently do not address the complexities of practice: comorbidities, age, previous history and the many other presentations that make some cases much more difficult to provide care for than others. Best practices in an evidence-based health care context recognizes this inherent defect, and specifically articulates that appropriate care is to be based on a triad which includes the best scientific evidence, coupled with physician experience and perspective, as well as patient preferences. One important factor to recognize is that, with guidelines, the scientific literature trumps all. With best practices, when the literature is equivocal or conflicting, the doctor and patient perspective becomes paramount. The CCGPP best practices document also addresses the aforementioned accompanying factors that influence the process of care, in order to provide a more realistic snapshot of the corresponding actions of the provider. Where from here? The low back chapter is only the first step in a long series of steps. There are other chapters ahead, including neck, upper and lower extremities, soft tissue, pediatrics, wellness and geriatrics, among others. First, we collect and organize the literature, rate the evidence and, where there is little or conflicting evidence, develop a consensus. Then the real work begins, as we develop a process to translate research and consensus into practical information which practicing doctors can use to answer the question, "What is the best care I can give my patient?" What are my options here, and what is the evidence for each, in terms of diagnostic testing and treatment? What works best, and when? We expect to have an interactive website which providers and patients can access to answer their questions, providing greater consistency and predictability of care for our patients. The process is "iterative," meaning, this is the first draft, and we will refine, update and change it every two years as more evidence appears. Lastly, we have a rapid response team dedicated to fighting abusive practices by third party payors who attempt to misinterpret the document. And if we do nothing? Then we continue to be at the mercy of insurance companies, workers compensation carriers, the government, and others with their own agendas that do not include a mainstream chiropractic perspective. It is incredibly naive to believe that no one will notice that we have not tried to substantiate what we do as a profession, or that others outside the profession do not have access to the same information we have. This document is an information base, designed to provide all stakeholders with reliable, verifiable and scientific evidence, describing a chiropractic perspective, from which rational and supportable treatment decisions can be made. Some, have advocated that CCGPP do nothing or use an ad hoc process (e.g., "A few smart doctors should be able to quickly put something together") that would be disregarded as lacking credibility and are trying hard to convince others to parrot these views without even bothering to read the document or investigate the pro- Chiropractic Best Practices: Not Fear, Just Facts Continued from pg. 54 cess that more than 135 people involved in CCGPP have volunteered countless hours toward for the past eleven years. Others, thankfully, recognize that the profession is at a crossroads, and is already overdue in creating our own database, our own defensible and credible description of what chiropractic practice is for the majority of DCs. Some will use vague scare tactics, predictions of dire consequences, or try to muddy the waters by attempting to make this about personalities, philosophy or their own agendas. We believe the majority of DCs will recognize, as we do, that we must have the intellectual and scientific integrity to examine honestly what we do as DCs, and use that information to better serve our reason for existing: our patients and their welfare. Visit CCGPP '.v website at www.cciipp.org to learn more about the CCGPP and the new best practice document and how you can support and donate to this project. A CCGPP representative will gladly travel to your state to present information and answer questions. Dr. Whalen is a 1986 graduate of Palmer College of Chiropractic-West, and has served in numerous volunteer leadership positions over the past twenty years, including a term as President of the California Chiropractic Association. He is Board Certified as a chiropractic neurologist, and has lectured extensively on a variety of topics, including workers' compensation. He currently serves as chair of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP). Dr. Lewis is a graduate of Logan College of Chiropractic and has practiced in North Carolina since 1979. He has been a member of the Council on Chiropractic Guidelines and Practice Parameters since 1997, served as Chairperson from 2002-2005 and is currently Immediate Past Chairperson and liaison to chiropractic educational institutions from CCGPP. Dr. Lewis is a Fellow of the International College of Chiropractors.
