March 2006

see also: CCP discusses chiropractic problems, solution

CCP President rebuts erroneous Dynamic Chiropractic report

(Note: This letter was written and submitted to Dynamic Chiropractic in order to correct erroneous statements concerning the Council on Chiropractic Practice (CCP), made by Wayne N. Whalen, DC, is his article, “A Moment of Mercy and a Clinical Compass.” [1]  Dynamic Chiropractic   failed to published the letter, which was then submitted to The Chiropractic Journal in order to share this vital information with the profession.)

The Council on Chiropractic Practice (CCP) was established in 1995 as an apolitical, non-profit organization, and is not affiliated with the ACA, ICA, WCA, FSCO, COCSA, FCLB, or any state association.  The process used to develop the CCP guidelines was open to any interested DC.  All DCs were welcome to participate in the peer review process. 

Dr. Whalen’s ad hominem remark characterizing the CCP guidelines as “touted by a small fringe group” is disingenuous. 

According to a 2003 study on "How Chiropractors Think and Practice: The Survey of North American Chiropractors," published by the Institute for Social Research at Ohio Northern University, "For all practical purposes, there is no debate on the vertebral subluxation complex. Nearly 90% want to retain the VSC as a term. Similarly, almost 90% do not want the adjustment limited to musculoskeletal conditions. The profession ‑‑ as a whole ‑‑ presents a united front regarding the subluxation and the adjustment." [2]   90% of the profession can hardly be considered a “small fringe group.”  If there is a fringe group within the profession, it composed of the 10% that renounce the subluxation and wish to limit chiropractic care to persons presenting with musculoskeletal symptoms.

The claim that the National Guidelines Clearinghouse (NGC) is “merely a collection of guidelines less than 5 years old” is deceptively incomplete.  NGC was originally created by the Agency for Healthcare Research and Quality (AHRQ) in partnership with the American Medical Association and the American Association of Health Plans (now America's Health Insurance Plans [AHIP]). All of the criteria below must be met for a clinical practice guideline to be included in NGC.

1. The clinical practice guideline contains systematically developed statements that include recommendations, strategies, or information that assists physicians and/or other health care practitioners and patients make decisions about appropriate health care for specific clinical circumstances.

2. The clinical practice guideline was produced under the auspices of medical specialty associations; relevant professional societies, public or private organizations, government agencies at the Federal, State, or local level; or health care organizations or plans. A clinical practice guideline developed and issued by an individual not officially sponsored or supported by one of the above types of organizations does not meet the inclusion criteria for NGC.

3. Corroborating documentation can be produced and verified that a systematic literature search and review of existing scientific evidence published in peer reviewed journals was performed during the guideline development. A guideline is not excluded from NGC if corroborating documentation can be produced and verified detailing specific gaps in scientific evidence for some of the guideline's recommendations.

4. The full text guideline is available upon request in print or electronic format (for free or for a fee), in the English language. The guideline is current and the most recent version produced. Documented evidence can be produced or verified that the guideline was developed, reviewed, or revised within the last five years. [3]

Guidelines submitted to the NGC are evaluated by ECRI, a collaborating agency of the World Health Organization, before being included in the clearinghouse.

In addition to the NGC, the CCP guidelines are included in "Healthcare Standards: Official Directory," considered to be  “the most respected index of healthcare standards. It is relied upon by clinicians, medical malpractice attorneys, paralegals, medical-legal nurse consultants, risk managers, insurers, health plan administrators, patient safety officers, librarians, and others charged with staying on top of the changing landscape of healthcare standards, clinical guidelines, and U.S. federal and state laws and regulations.”  [4]

The statement by Dr. Whalen that the NGC annotated bibliography “notes that the CCP guidelines are ‘unsuitable for use in clinical practice’” is also misleading.  The paper by Cates et al [5] is but one of several articles included in the annotated bibliography.  This paper merely expresses the opinions of the authors.  It does not represent the position of the NGC.  Persons who follow the link will be lead to my critique [6] of the Cates et al paper, conveniently ignored by Dr. Whalen.  It should be noted that the NGC annotated bibliography also contains an article I co-authored which is critical of the Mercy guidelines [7].  As with the Cates et al paper, it does not represent an evaluation by the NGC, but merely a reference to a relevant publication.

Finally, Dr. Whalen makes the unsubstantiated claim that the CCP guidelines “are used by almost no one in the profession, and are completely ignored by those in authority outside the profession…”  The extent of their utilization will be the object of further research by CCP.  However, we know that the CCP guidelines have been accepted in courts of law, and have been used to successfully defend chiropractors in a variety of settings.

Although Dr. Whalen is entitled to his personal opinions, the factual errors in his article demand correction.

Sincerely,

Christopher Kent, DC

President, Council on Chiropractic Practice

References

1.  Whalen WN: A moment of Mercy and a clinical compass.  Dynamic Chiropractic (December 17, 2005);23(26):1-.

2.  McDonald W, Durkin K, Iseman S, et al: How Chiropractors Think and Practice. Institute for Social Research. Ohio Northern University. Ada, OH. 2003.

3.  http://www.ngc.gov/about/inclusion.aspx

4.  http://www.ecri.org/Products_and_Services/Products/Healthcare_Standards_Directory/Default.aspx

5.  Cates JR,    Young DN,    Guerriero DJ,    Jahn WT,    Armine JP,    Korbett AB    Bowerman DS,    Porter RC,    Sandman TD,    King RA:  Evaluating the quality of clinical practice guidelines.  J Manipulative Physiol Ther (2001 Mar-Apr) 24(3):170-6.   

6.  Kent C: Evaluating the quality of clinical practice guidelines (letter).  J Manipulative Physiol Ther (2001 Nov-Dec) 24(9):612-8.     

7.  Kent C, Rondberg T, Dobson M: A survey response regarding the appropriateness of professional practice guidelines to subluxation-based chiropractic. J Vertebral Subluxat Res ;1(2):13-8.