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The Academy of Chiropractic Orthopedists |
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New! Master of Science Degree - 2010 Project NEW! AMA Resolution 814 and Report New! Orthopedic Coalition Definitions Academy Response to CCGPP Best Practices Document Frequently Asked Questions (FAQ) Link Your Website to the Academy Membership Application Form (PDF file) Recredentialing Info and Application Form
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Academy Response to the Low Back See the CCGPP's response to the Academy Letter To: Council on Chiropractic Guidelines and Practice Parameters From: Academy of Chiropractic Orthopedists, Executive Director and Review Committee RE: CCGPP Low Back Best Practices Document
The Academy of Chiropractic Orthopedists is honored to be able to express our opinion regarding the CCGPP Low Back Best Practices Document. As an organization dedicated to the advancement of the chiropractic profession, we fully support the goal of producing practice guidelines and practice parameters that would fairly represent the practice of chiropractic. However, upon reviewing the CCGPP Low Back Best Practices document, we are greatly concerned that the basic procedure methods used to create the document will undermine its intentions and cause significant unintended consequences. We would ask that the CCGPP withdraw the document until these concerns are appropriately addressed. As we understand, the CCGPP chose to use a "best practices" model or "evidence-based medicine" model to construct its document. The "best practice" models have replaced traditional "authority-based" models in the medical community. They are designed to use a variety of research-based information including randomized controlled trials, systematic reviews and met-analysis in order to provide medical doctors with the "best" approach to patient care. However, in applying this approach to a chiropractic realm, one must consider the extreme lack of overall research and clinical trials available for review compared to that of the medical profession. This lack of evidence from which to draw is especially important as the CCGPP has chosen a common grading system to express and define this lack of evidence. Regardless of the disclaimers in place as well as the definitions within the document, by applying the commonplace grading system of "A,B,C,D," the CCGPP has created a document that will produce significant confusion and misinterpretation as well as bias within all consumer groups: chiropractors, patients, medical doctors, and insurance companies. Using the "A,B,C,D" system, procedures including modalities are graded as a "D" because there is not enough research supporting the modality, even though it is still backed by expert opinion. Considering the general lack of research within the profession, we questioned why research alone was used to grade certain procedures. In the medical arena, only 25% (or less depending upon your source) of procedures and modalities have valid research including double blind studies or RCT's – but they do not grade those procedures as "failing." Although the CCGPP within its document has defined the grade of "D" as "supported by expert opinion, and usual and customary clinical practice," the societal bias that accompanies something or someone with a "D" grade is certainly much more recognizable. Regardless of any disclaimers or definitions placed by the CCGPP within the document, the ACO has serious concerns that procedures such as x-rays and modalities, and anything else receiving a grade of "B" or below, will start to be questioned by patients and insurers. To the CCGPP, a "D" may simply mean that there is "not enough research," but to the rest of society, a "D" is a failing grade. Why, as a profession desiring to raise its standards and professionalism, would we approve the use of anything that was perceived as "failing?" Why should we expect patients or insurance companies to reimburse for anything that was perceived as a "D" grade? Are we, as a profession, willing to give up 30-40% of our income for the next 5-10 years until more "research" is available to overturn such a grade simply because this specific grading system was used? Although we applaud the committee's foresight to recognize and design this document as an "ongoing dynamic process and initiative rather than a one-time publication" that would be "consistently updated," we question the effectiveness of these updates. The ability for the CCGPP to disseminate this "updated" information is one concern, but then to assume that consumers (including chiropractors, patients and insurance companies) will promptly apply any new updates is even of greater concern. Once "poor grades" for a procedure are released within a document, it will be years before the "research" is available (assuming someone actually has the funds to produce the valid research that would be necessary to overturn such a grade) and is able to be integrated within the profession and public at large. Furthermore, while those knowledgeable in the field of research may understand the difference between a "best practice" recommendation, a guideline, and a standard of care, there are many in the professional and insurance communities who will be inclined to apply a "best practices" document as a standard of care without accepting deviations. This makes the grading system used within the document by CCGPP even more of a risk to the profession. Once released to the public, the Low Back Best Practices document will likely be considered "Low Back Best Practices Guidelines and Standards of Care." Retracting such a document will be impossible. We have great respect for the people who have dedicated so much time in producing this document. As we all know, chiropractic in general is certainly in need of some guidelines. However, if the CCGPP continues to use the "best practices" model and applies the grading system of "A,B,C,D," regardless of any clinical criticisms, the unintended consequences that will be associated with this document are enormous and disastrous to the profession. The continued use of this socially biased grading system will undermine the entire intent of the CCGPP. We would respectfully request that the CCGPP withdraw this document until it is able to apply a system of grading that will not cause devastating unintended consequences. Sincerely,
J.R. Brandt, DC, FACO
Wendy L.C. Varish, DC, FACO cc: Academy Board Council on Chiropractic Guidelines and Practice Parameters Responds to Academy Letter on Low Back Best Practices Document The Council on Chiropractic Guidelines & Practice Parameters has responded to the Academy Board's concerns on some issues with the process. They contacted the Academy and an informative telephone discussion was held. CCGPP was asked to send a letter with a summary of our conversation. Dr. Whalen has sent the following letter for your review. The Academy will maintain contact with CCGPP and with the process to offer suggestions and recommendations as this work continues. August 15, 2006
James Brandt, D.C., F.A.C.O. Dear Dr. Brandt: Thank you for your recent response to the Council on Chiropractic Guideline's release of our low back draft. We expect vigorous debate, heated discussions and a frank exchange of ideas on a topic as relevant and important as the CCGPP Best Practices document. We expect DC's to differ in their perspectives on this issue, and for some to reject it outright. Involvement of the profession in this debate requires that reviewers can place some reasonable degree of reliability on information which is widely disseminated and which comes under some imprimatur of professional authority. With respect to the distinction between "Guidelines" and "Best Practices," we refer you to the introductory portion of the Low Back chapter, authored by Dr. Triano, in which he elaborates at some length regarding the differences in the terminology. It was and remains our intention to avoid any discussion or conclusions regarding dosage issues or frequency of care, particularly given the dearth of relevant scientific evidence on the topic. Instead, the document focuses on benchmarks of care. The foundational goal of CCGPP was to develop a stratified library of evidence based on the most current nationally and internationally recognized standards. To that end, we have diligently followed those development guidelines, in order to assure validity and credibility of the document. Failure to do so reduces any resulting document's credibility, particularly outside the profession. Part of those standards require that interested stakeholders outside the profession be part of the process. This does not provide them with any degree of undue influence over the conclusions, but does significantly improve our credibility. How often have DC's complained when other guidelines are adopted without any chiropractic input? The process CCGPP is using demonstrates to the rest of the world, including insurers, other professions, government agencies and our patients that we are serious about doing this correctly, and reveals a level of professional maturity. This is not another Mercy. The development of guidelines and best practices documents has evolved considerably in the 14 years since Mercy, and the experience with Mercy is but one other reason we are purposely avoiding any discussion of dosage with the current document. We remain grateful to ACO, and all organizations who had the foresight and generosity to provide funding for this crucial project, sight unseen. We remind all our stakeholders that this is but the first draft of the first chapter of the first iteration of the full document, and there is much work to be done. We expect feedback from the profession and others to affect the ultimate document, and encourage organizations like yours to provide appropriate feedback, but to also continue to financially support the process. We would be pleased to have you link your website to ours, and hope you would contact us to facilitate the linkage. Finally we want as much participation as possible from our stakeholders and would welcome your participation on the CCGPP board. I will see that the issue is placed on the agenda for our upcoming Board meeting in Baltimore. If I or any member of the CCGPP can address your concerns, please feel free to contact us. Sincerely,
Wayne M. Whelan, DC, DACAN |
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