December 2006

CCGPP: Are you listening?

by Dr. Terry Rondberg

Ever since the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) released the draft of its first guidelines ‑‑ which they prefer to call "best practices" documents ‑‑ the roar of dissent from the profession has been deafening. At last count, more than 30 state organizations have rejected the document in addition to the World Chiropractic Alliance, the Council on Chiropractic Practice, the International Chiropractors Association and the Federation of Straight Chiropractors and Organizations.

One of its major cheerleaders, the American Chiropractic Association, was lukewarm in its reception of the draft, stating in its ACAnews that the ACA "advises CCGPP to gain additional feedback from doctors in the field and colleges so as to better reflect the clinical perspective and create more consensus around the project." The article also revealed that the ACA had submitted comments to the CCGPP, which "express(ed) concern that the document will not be received favorably by clinicians and state associations because it has a 'researcher's slant' and contains information that third‑party payers may use to deny claims."

Even the Congress of Chiropractic State Associations (COCSA), which sponsored the effort, wrote to CCGPP Chairman Wayne Whalen, DC, noting "we are concerned that many of our members are responding negatively to the document." The letter, signed by COCSA President, Stephen Simonetti, DC, urged CCGPP to withhold publication of the document until after a meeting between CCGPP and state association leaders on November 11, 2006 in Baltimore.

Personally, I disagree with Dr. Simonetti's contention that "right now, the profession is reacting out of fear of the unknown" and because "the best practices concept and process is so new to the profession that it is a difficult one for them to grasp." I think the majority of our profession is fully capable of reading and analyzing the document and understanding both its content and intent. To shrug off the widespread rejection of the draft merely as an over‑reaction or ignorance of best practice concept does a great disservice to our profession's leaders and state groups.

So far, I haven't seen any response to that letter from the CCGPP, either on the COCSA or CCGPP's website, which are the principal lines of communication the groups have with the profession. In fact, the CCGPP is apparently ignoring all the protests and dissent. Their website contains a section on "concerns" which serves simply to assert how important it is to the profession and some vague explanations of the process for "stakeholders." There's no mention, as far as I can find, of any of the lengthy and negative critiques submitted by dozens of organizations.

The entire tone of the site is one of "business as usual," with announcements that subsequent chapters of the draft will be made available as they are finalized. Clearly, the CCGPP intends to publish the guidelines whether or not the profession approves.

I use the term "guidelines" advisedly. The CCGPP's own name includes the term, and even the Work Loss Data Institute (WLDI), which has partnered with the CCGPP to produce and distribute the documents, refers to them as guidelines. The CCGPP claims these are not guidelines but best practices guides. The difference, they say, is "primarily in the way the recommendations are handled." But let's get real: courts of law, state boards, insurance companies, and other "stakeholders" will not care what they're called. They'll use them to regulate and limit the profession.

There are many things wrong with the CCGPP, and the flaws have been amply cataloged by chiropractic organizations, researchers and individual doctors. Yet, the CCGPP refuses admit and address the problems or even respond to its critics. In its arrogance it continues to ignore the profession, except to exhort doctors to accept it simply because it was developed by the CCGPP.

Here's what one article on CCGPP's website says: "So, how can DC's use the new CCGPP Best Practice document to their advantage? Read it! Understand it! Some of the best minds in our profession toiled tirelessly to provide you with a useful summary of what is most likely to work best for your patients."

Some of the best minds in the profession? That statement alone would generate a year‑long debate, but the idea that the members of the CCGPP, many of whom are not in practice and haven't been for years, are in a position to tell practicing DCs what is most likely to work best for their patients is the epitome of arrogance.

Is CCGPP's Research Commission Chair, John Triano, DC, the best person to tell you what's best for your patients? After all, this is the same person who, in an article for Chiropractic & Osteopathy (2005, 13:9), stated: "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)."

Repeatedly, the CCGPP promised it would be open to input from the profession. They never claimed they would do anything with the input other than "review" it. They are under no obligation to change a single word of their documents no matter how many organizations reject it.

The CCGPP states, in bold, red capital letters, that: "IF COMMENTS ARE WITH RESPECT TO SUBJECT MATTER SUBSTANCE, THEY WILL BE REVIEWED BY THE TEAM. ALL COMMENT TOPICS WILL BE PUBLISHED IN THE FINAL VERSION WITH RESPONSES REFLECTING THE AGREEMENT/DISAGREEMENT AND RATIONALE."

It's interesting that they say only that the "comment topics" will be published in the final version. What about the comments themselves? Will they have the courage to put dissenting opinions in the document? Will they address the problems of substituting personal opinions for evidence, or of the ill‑conceived idea of partnering with the WLDI in the first place? Will the final document have a place for comments from organizations such as the WCA, or state groups like the Wisconsin Chiropractic Association, Maryland Chiropractic Association, New York Chiropractic Council, Georgia Chiropractic Association, Association of New Jersey Chiropractors and dozens of others?

It's doubtful we'll know until the WLDI starts publishing the documents and marketing them to insurance companies. The CCGPP certainly isn't talking.