January 2007

COCSA fails to endorse CCGPP document

Recommends list of changes, demands second review

Delegates to the Congress of Chiropractic State Associations (COCSA) spent more than eight hours during their annual meeting ‑‑ held in Baltimore, Nov. 8‑12, 2006 ‑‑ in what the group characterized as "intense discussion" with leaders of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP).

Although the CCGPP was originally created at the request of all member organizations of COCSA in 1995, the group failed to endorse the draft of the low back pain document released last year by the CCGPP. Instead, COCSA members unanimously approved a list of recommendations to CCGPP, including the suggestion that the document incorporate changes suggested by COCSA member organizations.

The specific recommendations made by COCSA included:

***  Consider the written recommendations received and make the appropriate revisions to the current draft to allow for the concerns, additions and omissions to be considered and follow this procedure for future drafts.

***  Change the name of the document to truly reflect the intent and use of the document.

***  Ensure expanded input allowing the duly elected CCGPP representatives to truly act as liaisons between the member associations and the CCGPP Board.

***  Consider redrafting the document's overview and introduction to make it easier to read and understand, including a shorter more concise narrative, written in non‑academic language with bullet points for better understanding.

***  Keep the process open to allow other organizations, researchers, and concerned stakeholders to be included in it.

***  Consider rewriting the research compilation to make it more user‑friendly to those affected.

***  Ensure that the commentary process will be well advertised in advance so that the stakeholders will be fully engaged.

***  In the absence of higher levels of evidence and research, consider the use of the clinical experience and case studies/course studies.

During the COCSA sessions, CCGPP representatives including Chairman John Triano, DC, made several PowerPoint and video presentations before answering questions from the floor. Several COCSA state delegates quizzed Dr. Triano on various concerns. One delegate, from Wisconsin, asked about "ownership" of the CCGPP document. Since COCSA had initially commissioned the CCGPP, the question concerned whether or not COCSA "owned" the document and could mandate either changes in it or its withdrawal.

Triano restated the CCGPP's position that the CCGPP was completely autonomous and was the sole owner of the document and not obliged to follow the instructions of COCSA or even incorporate changes suggested by the doctors who provided input during the 60‑day review period. The only recourse open to COCSA was to submit written comments and suggestions, he noted.

On several occasions during the session, Triano emphasized that the document would be revised by and at the discretion of the CCGPP and would not be available for a second review by the profession before being published by the Work Loss Data Institute (WLDI), a company that markets guidelines to the insurance industry.

However, after questioning and "intense discussion" it became obvious that many of the delegates disagreed vehemently with the contents of the document, the process used to develop it, and the attitude of the CCGPP.

After being asked one final question just before the CCGPP was scheduled to leave and the assembly was scheduled to vote, Triano suddenly changed course, saying the CCGPP would resubmit the revised version of the low‑back draft to stakeholders for comment on the 'user‑friendly' status, format and for consideration of responses to stakeholder comments.

"The chiropractic profession, as well as all other stakeholders, will receive 45 days notice before release of this new draft and an additional 45 days to respond to the draft when it is released," COCSA announced. "Furthermore, CCGPP agreed to adopt the title 'Chiropractic Clinical Compass' for the CCGPP Best Practice process."

The CCGPP defined the process as "an iterative process (which) shall include but not be limited to the research literature synthesis and stratification, the application of and utilization of this process in practice, and the dissemination, implementation, evaluation, and revision process applied to the various aspects of our profession: to include the experiential, experimental and clinical orientation of practitioners in order to promote Best Practices and improve the quality of patient care within our profession."

While COCSA leaders publicly commended the CCGPP for its efforts, others were less optimistic about the CCGPP's willingness to make substantive changes in its document. In the case of the Mercy guidelines, which were developed by many of the same people involved in CCGPP, the widespread rejection of the document did not deter the Mercy Commission from distributing it to insurance companies who proceeded to use it as a weapon against chiropractors.

So far, more than 30 state, national and international organizations have rejected the CCGPP guidelines and others have refused to endorse them unless drastic changes are made.