August 2006

CCGPP: Here we go again!

by Dr. Terry A. Rondberg

When the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was formed in 1995, it promised it would produce a document minus many of the flaws and overt biases present in the widely rejected "Mercy" document.

The CCGPP leaders specifically noted that the document they developed would "appeal to all philosophies and, by the very nature of a best practices document, it should be useful for all types of practitioners." They went on to say: "Our intent is that it will serve as a useful information source for all chiropractors as well as those who interact with the chiropractic profession."

Yet, the organizations with representatives of the CCGPP show no attempt to obtain input from "all philosophies." Here are the groups listed as being involved in the CCGPP:

***  American Chiropractic Association

***  Association of Chiropractic Colleges

***  Congress of Chiropractic State Associations

***  Federation of Chiropractic Licensing Boards

***  Foundation for Chiropractic Education and Research

***  National Association of Chiropractic Attorneys

***  National Institute for Chiropractic Research

Look, also, at three of the individuals who lead the CCGPP:

Chairman, Wayne Whalen, DC, DACAN,  is a Board certified chiropractic neurologist who lectures for the ACA‑aligned California Chiropractic Association as well as the California Society of Industrial Medicine and Surgery. He bills himself as a Workers' Compensation Expert who offers Auto & Personal Injury Care. One of his ads reads: "Helping Your Headaches, Back & Neck Pain Extremity Injuries, TMJ & More."

Vice‑Chair Mark D. Dehen, DC focuses his career on ergonomic consulting and injury prevention for local industries.

Research Commission Chair, John J. Triano, DC, who served on the Mercy Conference steering committee, was named "Researcher of the Year" by the American Chiropractic Association, and is one of Dr. Arlen Fuhr's associates in the National Institute of Chiropractic Research (NICR).

It's no wonder, then, that the first document to be produced by the CCGPP was the "Best Practices Lower Back Draft Document," part of what it calls its Chiropractic Clinical Compass series.

The composition of the CCGPP leadership has already caused at least one state organization to question the ability of the group to come to objective conclusions.

Earlier this year, the Georgia Council of Chiropractic (GCC) passed a resolution stating there is ample evidence that "the Chairman of the Commission of the CCGPP has formally expressed views which are contrary to the beliefs of the majority of practicing chiropractors," and that he "is collaborating with members of the managed care industry in order to promote a chiropractic identity that is in conflict with the majority of practicing chiropractors."

The resolution went on to emphasize that the organization "considers said collaboration with the managed care industry a direct conflict of interest with the duties of the Commission of the CCGPP" and called for his resignation.

Not really evidence‑based

Another major flaw in the document is the way in which the CCGPP selected and used the evidence to support its arbitrary "grading" system. Being evidence‑based is the ideal for all guidelines and best practice documents. This is why the Council on Chiropractic Practice (CCP) used and promoted this method, as opposed to the consensus method used to create the Mercy guidelines. The CCP also wisely chose to provide details on the nature of the evidence, rather than try to grade them. When the "grade" depends on the amount of research published in peer‑reviewed journals, the obvious advantage will go to the medical, mechanistic approach most often studied by medical, and (sadly) chiropractic researchers.

Furthermore, contrary to its claims, the CCGPP is not evidence‑based. Take a look at some of the questions included in the article "Common Questions and Answers Regarding the Best Practice Initiative," by Eugene A. Lewis, DC, who served as a member of the Mercy Guidelines Commission as well as president of the CCGPP.

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 if there isn't enough evidence on a topic?

A: Consensus will dictate the conclusion.

Let me see if I understand the process.

Dr. Triano and a group of "scientists" handpicked by him and his colleagues will scrutinize the literature and apply their own filters to determine which are valid.

They will look at "all research material" about the subluxation and if they don't think it's enough. they'll decide the conclusion by "consensus." How can this be categorized as evidence‑based?

Is there any doubt that the research already conducted on subluxation will be dismissed by Triano, who has stated repeatedly that such evidence is nearly non‑existent?

In one of his quotes, found on the Internet, he stated: "Little scientific information is presently available to resolve the questions of impact on human health that the FSL (Functional Spinal Lesion) may have." (The FSL is, according to the Journal of the American Chiropractic Association, Sept. 2002, Triano's own model of subluxation.)

Triano also stated, in an article for Chiropractic & Osteopathy (2005, 13:9), that: "A number of models are impractical, implausible or even indefensible from a purely scientific point of view (e.g., subluxation‑based healthcare), from a professional practice perspective (e.g., the primary care model), or simply from common sense (e.g. Innate Intelligence as an operational system for influencing health)."

In that same article, he states: "But, until we can demonstrate that we are effective where others are not, the proposition of chiropractic as the 'wellness profession' is not defensible," and "The vast majority of human health problems that require an intervention do not fall within the chiropractic therapeutic spectrum."

This is the individual in charge of the process of reviewing the research for the CCGPP guidelines that could regulate your practice.

Incidentally, in case you think this document will harm only subluxation‑based chiropractors, take a look at the different adjunctive therapies which received very low ratings. Based on the CCGPP  ratings, it's likely that insurance companies will reject many claims for modalities used by non‑subluxation‑based DCs as well. In some ways, it's an equal opportunity sledge hammer!

Take it or leave it

The lack of any input from the profession into the development of the document itself is troubling as well.

According to the CCGPP, this document is the culmination of more than a decade of work by the group, yet it was available for review and comment by the profession for just 60 days, after which, according to the CCGPP, "the lower back team will then examine the results obtained for any potential impact on the chapter, with changes being made as necessary."

It seems unlikely that, after supposedly working for 10 years on this document, any substantive changes would be made in response to comments received during this two‑month window. Interestingly, the CCGPP is also asking from input from the insurance industry. As the CCGPP put is: "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."

A tool for the insurance industry

Further, the CCGPP has openly admitted that the document focused on chiropractic as a treatment for conditions because "the CCGPP was formed largely, but not exclusively, to address problems revolving around issues of reimbursement, and this industry is currently in a condition‑based format."

It has also "specifically chosen a publisher/research organization/distributor for its abilities and history in placing such documents in the hands of payers and policy makers."

I question why chiropractic guidelines developers have put such an effort into addressing the concerns of the insurance industry and making sure they all get a copy. Such a document is supposed to be for the use of chiropractors to ensure the best quality care for their patients, not to give the insurance adjusters justifications to reject chiropractic claims, as was the case with the Mercy Guidelines.

Compare this to the CCP, which throughout its development process held open meetings and solicited comments and input from all doctors including technique developers and researchers. Although it's the only chiropractic guidelines recognized by the National Guideline Clearinghouse (a comprehensive electronic database administered by the Agency for Policy and Health Care Research which allows access to accepted guidelines from various health care disciplines) it was never embraced by the insurance industry since it wasn't designed to be a tool for their use.

I realize that third party payers are, for now at least, tied to the chiropractic profession and they will have an interest in any guidelines developed. My discomfort comes from the CCGPP's repeated references to its efforts to accommodate the needs of the insurance industry. My concern (and I'm sure the CCGPP will either ridicule or dismiss this concern) is that those needs were given equal if not greater weight than the needs of chiropractors and their patients. I, for one, don't see those needs as being identical or even compatible.

A veil of secrecy

As was the case with Mercy, the secrecy surrounding the CCGPP's process is worrisome. In some of its statements, the CCGPP claims to have involved "nearly 100 chiropractic scientists, field practitioners, vendors, and friends." Yet, it also states: "The CCGPP is a steering organization comprised of 20 individuals. 16 are chiropractors with one in education, one in research and 14 in full‑time Private Practice. There is a vendor representative, a representative from the chiropractic colleges and attorneys representing the National Association of Chiropractic Attorneys"

Although it adds that "a research commission with several dozen members reports to and is supervised by CCGPP," I could find no details on who these members are or what organizations or colleges they are affiliated with.

Learning from our mistakes

They say that if we don't learn from history, we're doomed to repeat it. Our history with the Mercy Consensus Conference was disastrous and the resulting document was rejected by nearly every national and state chiropractic organization ‑‑ including the groups that initially supported it! It hurt nearly all DCs financially and was embraced only by the insurance industry and some power‑hungry board members who used it as a bludgeon against subluxation‑based chiropractors.

At this point, we can't stop the CCGPP from completing this document but we can minimize the damage it can do by voicing strong and public objections to its bias and methodology. Every state organization needs to review the draft document and decide if: a) this document fairly and accurately reflects your organization's positions, and b) whether it reached its conclusions in a scientific and unbiased manner. (If you didn't receive a copy of the document from the CCGPP, you can download a copy at www.worldchiropracticalliance.com/ccgpp.

If not, say so. Issue a position paper rejecting the document and demanding that the CCGPP cease its efforts to publish and distribute it.

Send copies of your decisions and official statements to the World Chiropractic Alliance at CCGPP@www.worldchiropracticalliance.org so we can share them with the profession in upcoming issues of The Chiropractic Journal.

This is a shotgun wedding and you need to "speak now or forever hold your peace." If you don't, you'll have to live under the shadow of CCGPP 'til death (or bankruptcy) do you part.