October 2007

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CCGPP Ratings
Are case studies 'legitimate' research?
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CCGPP fails to support chiropractic for wellness

Also gives low rating to many types of care for pregnant women or older adults

The draft of the newest chapter of the "Best Practices" document released last month by the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) contains statements and conclusions that could prove devastating to the chiropractic profession.

"In it, the CCGPP gives insurance companies the weapons they need to drastically curtail payments to any DC who uses adjustments or spinal manipulation to address general health issues or provide wellness care. It also gives rogue regulatory boards the weapons they need to go after and sanction subluxation based chiropractors who provide this care."

The chapter, entitled "Chiropractic Management of Prevention and Health Promotion; Nonmusculoskeletal Conditions; And Conditions Of The Elderly, Children And Pregnant Women," makes it clear that, from the data the CCGPP members considered, there is not enough evidence to support the use of chiropractic for patients who are not presenting with specific non‑musculoskeletal health issues.

Also not supported by CCGPP were a number of other services often provided by chiropractors, including prenatal care and spinal adjustments or manipulation to address low back pain in pregnant women. Not a single one of the "A" rated services is considered primarily a chiropractic function (see  summary of ratings).

To arrive at these dubious conclusions, the CCGPP members did a literature search using the terms "chiropractic" AND "visceral" OR "nonmusculoskeletal" OR "nonmusculoskeletal;" "manipulation" AND "visceral" OR "nonmusculoskeletal" OR "nonmusculoskeletal." Additional searches were done by specific condition names for any conditions for which randomized trials were identified.

A total of 276 relevant articles were found. However, 148 of them were summarily dismissed from consideration because they didn't meet the "overall guidelines for the CCGPP evaluation process." Among these were 21 commentaries or expert opinion articles, 34 descriptive surveys and 93 case study reports of 1‑2 cases.

Shockingly, the CCGPP also ignored all case studies, regardless of how many patients were involved. It explained its decision only with the statement that "even though there are a large number of patients described in case reports, these reports can only provide evidence that patients with the conditions described have sought care from chiropractors; case reports cannot provide convincing evidence to support best practices."

In the end, the only research to hold any sway with the CCGPP were the relatively rare Randomized Controlled Trials (RCTs), which centered primarily on a handful of specific disease conditions. This is contrary to the trend in medical research, which places value on formal case studies and expert opinions. In many heath situations, it is difficult if not impossible to conduct an adequate number of RCTs and the medical community often turns instead to case studies to acquire an understanding of various medical interventions.

The failure to consider anything but RCTs is one reason so many chiropractic services received low ratings, which could adversely affect the ability of DCs to receive payments for those services.

Experience has proven that, particularly when it comes to chiropractic, insurance companies seek justifications for denying claims. It is also well established that "private health plans and government health insurance programs in the United States base their coverage decisions on evidence criteria," according to Alan M. Garber, staff physician, Veterans Affairs Palo Alto Health Care System and director of the Center for Health Policy at Stanford University. ("Cost‑Effectiveness and Evidence Evaluation as Criteria for Coverage Policy," Health Affairs, May 2004.)

Or, as Arlen Furh, DC, noted in a Dynamic Chiropractic article in 2003, "Insurance companies and other third‑party payers (TPPs) relish the denial of claims for services rendered on the grounds that a particular procedure is 'experimental'."

Although the word "experimental" was not used in the CCGPP document, the lack of sufficient evidence to support care could easily be used in the same way by private and government health care plans.

"This document invalidates just about any kind of chiropractic care for non‑musculoskeletal conditions, as well as any care for pregnant women or older patients," stated Terry A. Rondberg, DC, president of the World Chiropractic Alliance. "What chiropractors are left with is counseling patients on giving up cigarettes, exercising more, and breastfeeding. There is nothing here that supports chiropractic care, despite a wealth of strong evidence proving its effectiveness."

Renowned chiropractic researcher, Christopher Kent, DC, JD, concurs. Dr. Kent, who received the Researcher of the Year award from both the World Chiropractic Alliance and International Chiropractors Association, pointed out another potential danger of the CCGPP conclusion.

"It takes little imagination to see what state boards and other regulators will do with this," he warned. "In today's politically charged atmosphere, a board could easily target a particular class of doctors and charge them with endangering patients by providing care unsupported by research and disavowed by the CCGPP guidelines. It has happened in the past and it will happen with even more frequency once this document is published."

Despite the CCGPP's call for input from the profession, few people see any chance of influencing the document.

The first chapter generated widespread disapproval, with many organizations, including the World Chiropractic Alliance, International Chiropractors Association and Federation of Straight Chiropractors and Organizations rejecting the CCGPP conclusions as well as the process used to develop them. Organizations from more than 30 states have called for the withdrawal of the low‑back document and even the Congress of Chiropractic State Associations, which initially sponsored and formed CCGPP, refused to endorse the document without significant changes.

According to a CCGPP announcement this summer, the CCGPP was making minor editing on the first chapter to "improve its clarity and readability," but will not be "amending the existing research or conclusions."