September 2007

CCGPP releases next chapter

DCs have 60 days to submit comments

In mid‑August, the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) released the next chapter of its "Best Practices" document, as well as a revised Introduction and is giving the profession 60 days to review and comment on the new sections, which are available at www.ccgpp.org. The new chapter focuses on Methodology.

This release will be followed, on Sept. 1, by the section on Wellness, Non‑musculoskeletal and Special Populations. With one additional draft scheduled for release approximately every 30 days beginning with Upper Extremity Conditions on October 1 followed by Low Back Part A, Cervical Spine, Soft Tissue, Thoracic Spine, and Lower Extremities.

The first chapter was released more than a year ago and created widespread dissension in the profession. Numerous chiropractic organizations, including the World Chiropractic Alliance, the International Chiropractors Association, the Federation of Straight Chiropractors and Organizations and even the Congress of Chiropractic State Associations (COCSA), which created the CCGPP and initiated the process, either refused to endorse the draft of the first chapter or rejected it and the entire CCGPP project.

The CCGPP claims that, because of the negative feedback it received at that time, it has "elected to perform a more comprehensive review of the literature pertaining to diagnostic issues, which will further delay re‑release of portions of the low back chapter."

In a press release issued on Aug. 10, the CCGPP noted that it received more than 600 comments including "a large number of urgent requests ... for high quality evidence of efficacy to support care, particularly in addressing third party payor denials and to assist with regulatory hearings."

However, the statement argued that the literature review the CCGPP has already completed "demonstrates excellent quality of literature support for the primary chiropractic treatment approaches to low back pain, which are unlikely to be changed by review of additional literature at this time."

Also in response to the professional outcry, the CCGPP commissioned a chapter on the vertebral subluxation, a topic that had not been included in its plans prior to the release of the first chapter. The committee is headed by Drs. Carl Cleveland III and Meridel Gatterman.

In keeping with the agreements reached with COCSA members in Baltimore last year, the recommendations of constituents have been revisited and addressed. Among other suggestions was the need to improve formatting, and to that end professional assistance has been retained to make the document more readable and user friendly. The Council is quick to point out, however, that editing is for the purpose of clarity and readability and no changes are to be made in content or conclusions.

The Council also announced the appointment of Cheryl Hawk, DC, PhD, of Cleveland Chiropractic College, as new Chair of the CCGPP Research Commission. Dr. Hawk is currently Vice President of Research and Scholarship at Cleveland Chiropractic College. She is a 1976 graduate of National College of Chiropractic and practiced full‑time for 12 years. In 1991, she earned a PhD in Preventive Medicine from the University of Iowa and also became a Certified Health Education Specialist (CHES).

She has been the primary writer of successful grant and contract proposals totaling over $5 million. She is also an author on over 60 peer‑reviewed articles and book chapters. Currently Dr. Hawk serves on the ACA Wellness Campaign Committee and as the CCGPP Team Leader for "Wellness, Non‑musculoskeletal Conditions and Special Populations."

From 2003‑2006, she served as the appointed chiropractic representative on the National Advisory Committee for Interdisciplinary, Community‑Based Linkages of the US Health Resources and Services Administration Bureau of Health Professions. In 2005, she was named "Researcher of the Year" by the Foundation for Chiropractic Education and Research.

"We are very fortunate to have someone of Dr Hawk's caliber take over the reins. Dr Hawk brings a fresh perspective, as well as years of clinical experience and research expertise. We're very excited to have her on board," noted CCGPP Chairman Wayne M. Whalen, DC.

Dr Hawk replaces outgoing Chair Jay Triano, DC, PhD, who stepped down after being appointed as professor and Interim Dean of Graduate Education and Research for the Canadian Memorial Chiropractic College.

Dr. Triano's work with the CCGPP had also come under fire last year, particularly in regards to his involvement with Work Loss Data Institute (WLDI) which was contracted to publish and distribute the final document. It was revealed that Triano was a member of the WLDI Advisory Panel, at least since 2003, according to information on the WLDI website. Many doctors were troubled by Triano's relationship with WLDI because the WLDI's previous guidelines ‑‑ marketed to the insurance industry ‑‑ generally limited chiropractic to six visits in two weeks for low back pain.

Among the major points of contention about the CCGPP process was the fact that, in contrast to the Mercy guidelines, the CCGPP document was touted as being evidence based rather than the result of a consensus of personal opinions. Yet, CCGPP members were given the power to rely on consensus rather than evidence if they deemed the evidence insufficient. Asked what would happen if "there isn't enough evidence on a topic?" Eugene A. Lewis, DC, then‑CCGPP chairman, stated, "Consensus will dictate the conclusion."

Even when ample scientific evidence was available, however, personal opinion and consensus often took precedence. Thomas Sidoti, DC, chairman of the Association of New Jersey Chiropractors (ANJC) Literature Search Committee, pointed out several specific instances where personal opinion appeared to trump existing evidence.

In a letter to CCGPP Board member Ronald J. Farabaugh, DC, he noted that the "CCGPP has not adequately responded to concerns that it utilized the lowest possible form of evidence, the Level 5 opinion of the CCGPP panel, while not considering evidence that is more highly rated as Level 2 (nonrandomized Clinical Control Trials), Level 3 (observational studies with controls), and Level 4 (observational studies without controls). Can you please explain why the opinion of the panel members was used when scientifically superior levels of evidence that are rated higher were not considered?"

A number of other complaints were registered by organizations as well as individual practitioners. Chiropractic organizations in 21 states voted to ask that the CCGPP withdraw its flawed "Best Practices Lower Back Draft Document," according to a survey taken by the Wisconsin Chiropractic Association. Another two states stated they would support it only if significant changes were made.

The World Chiropractic Alliance issued a position paper rejecting the CCGPP document, stating that "WCA feels that the CCGPP Low Back Best Practices draft is methodologically flawed and poorly executed. It is does not reflect the practice objectives of analysis, adjustment, and management of vertebral subluxation. The literature reviews are dated, biased, and incomplete. WCA urges individual chiropractors and chiropractic organizations to reject this document, and request that CCGPP terminate their best practices' project."

The ICA called for the withdrawal the first chapter of the document. "In order to fulfill our responsibilities to our membership and to the future of the chiropractic profession, ICA's Board of Directors had no choice but to act to oppose this latest CCGPP initiative," stated President Dr. John K. Maltby.

The FSCO issued a statement that "the document, in its entirety, does not reflect the position of the FSCO or the practices of our membership in any way ... It is clear that the document and the opinions it contains address only the 'condition centered' model of practice. The practice of straight chiropractic is not condition centered, but rather, it is vertebral subluxation centered. The CCGPP draft does not attempt to gather and include information representing this key constituent of the profession. Since input from this segment of the profession has been ignored, the outcome is invalid."

Despite such widespread and vehement opposition, the CCGPP continued the document development process and is committed to having the results published and distributed to the insurance industry as well as all segments of the health care arena.