The Mercy Guidelines -- which have already been rejected by nearly every major chiropractic organization in the country -- lost even more credibility recently when they were pulled from the National Guideline Clearinghouse (NGC).

The NGC is a comprehensive database of evidence-based clinical practice guidelines and related documents produced by the Agency for Healthcare Research and Quality (AHRQ), in partnership with the American Medical Association and the American Association of Health Plans.

According to the NGC, the purpose of the database (available online at http://www.ngc.gov) is to provide health care professionals and providers access to objective, detailed information on clinical practice guidelines and to further the dissemination, implementation and use of those guidelines.

Although the Mercy Guidelines document -- formally titled the Guidelines for Chiropractic Quality Assurance and Practice Parameters -- had been listed in the NGC database, its inclusion spurred controversy from chiropractic critics.

At issue were several weaknesses in the methodology used to develop the Mercy guidelines. According to a position paper issued by the World Chiropractic Alliance, flaws in the Mercy document abound.

To be considered valid, guidelines must consider all available scientific evidence, the paper points out. Yet, on this issue, "Mercy badly missed the mark. Selective reviews of literature abound in this document, particularly in areas relating to the vertebral subluxation complex."

The Institute of Medicine of the National Academy of Science also notes that an important aspect of guideline development is an "open forum," during which "...every individual interested in providing oral or written testimony relevant to the guideline is invited to do so."

"This is in sharp contrast to the 'rules' of quasi-secrecy enforced at Mercy," the WCA paper explains. "Committee meetings were closed to observers. Only commissioners, observers, and support staff were permitted to attend plenary sessions, and only commissioners were permitted to speak."

In contrast, the Council on Chiropractic Practice (CCP) held an open forum where any interested person could address the panel and present evidence. The panel also accepted written submissions from individuals who were unable to attend the open forum.

Christopher Kent, D.C., addressed many of these same issues in a letter published in the Nov/Dec 2001 issue of Journal of Manipulative and Physical Therapy (JMPT).

Kent explained the flaws in the Mercy document, while showing how these problems were avoided during the development of the CCP Guidelines (Council on Chiropractic Practice Clinical Practice Guideline No. 1, Vertebral Subluxation in Chiropractic Practice).

"The process followed by CCP to ferret out the best available evidence is in sharp contrast to the biased and incomplete reviews of literature included in the Mercy guidelines," he explained in his letter. "The CCP guideline had the intellectual honesty to include evidence that disagreed with some of the final recommendations. A preponderance of evidence standard was employed when making final recommendations."

Kent also pointed out the extreme lack of support given to Mercy by the profession, despite having been supported and funded by major companies such as NCMIC and OUM, and aggressively "marketed" to D.C.s.

"The rubber meets the road with practitioner acceptance," he stated. "A guideline not accepted by those affected by it has little value." He referred to a survey he conducted of 454 D.C.s, only one percent of whom judged the Mercy document as having a favorable effect on their practice, while 70% said it had an adverse effect.

"We cannot allow ill-conceived and poorly developed documents to distort the true character of chiropractic," Kent recently told The Chiropractic Journal. "The CCP developed an exceptional guideline, which has been accepted by a large portion of the profession."