June 2008

ANJC blasts CCGPP process, actions

The Association of New Jersey Chiropractors (ANJC) has taken a strong lead in the fight against the "draft" guidelines on low-back conditions developed by the Council on Chiropractic Guidelines and Practice Parameters (CCGPP).

In a scathing letter to the CCGPP, the organization's board detailed the numerous and serious flaws in the guidelines as well as the process used to develop them.

In its announcement regarding the letter, the ANJC explained that, "rather than being based on available scientific literature, CCGPP is instead utilizing a consensus process in which the chiropractic treatment guidelines are based on the consensus opinion of 40 individuals. ... The ANJC feels strongly that the formal release of the CCGPP document in its current format could have severe repercussions to the chiropractic profession."

In addition, the New Jersey group, which was formed by the merger of six different state associations in 2005, challenged the CCGPP's decision to present the document to the California Workers' Compensation meeting in March.

The letter outlined several major areas of concern.

First was the supposed purpose of the CCGPP. Although the CCGPP "expressly and repeatedly" stated that its mission was to create a Best Practices document, not parameters or guidelines for care, the document it released contains several sections and tables with frequency and duration recommendations for the rendering of chiropractic care of low back disorders. The ANJC also noted that the document contains no justification or references in support of the recommendations.

"The ANJC specifically requests that CCGPP explain its rationale for deviating from its original stated purpose of creating best practices for chiropractic care," the letter noted, adding that "best practices, if properly executed, would be a dynamic process that allows change as new data and research is presented." That paragraph, in the letter, was placed in all capital letters for emphasis.

The next area of concern was the validity of the Delphi Consensus Process used by the CCGPP to arrive at its conclusions. The ANJC pointed out that this method relies on the selection of a panel of independent experts to come to conclusions after reviewing "seed statements" in a round after round approach.

"The Delphi process gives anonymity to the experts during the consensus process," the ANJC letter noted. "As such, instead of reflecting scientific evidence, the recommendations are merely the opinion of a small select anonymous group. No mention is made as to the criteria to be chosen as an expert, nor is information presented that would substantiate that the panel selected is best suited to represent the chiropractic community ... These recommendations therefore represent nothing more than the willingness of 36 individuals to agree to seed statements developed by CCGPP. The ANJC feels strongly that the use of this process to determine chiropractic frequency and duration guidelines for chiropractic care is severely flawed, blatantly unscientific, and an injustice to the profession."

The ANJC also strongly challenged the CCGPP's decision to "covertly" present the document to the California Workers Compensation meeting on March 19, 2008, "despite the fact that CCGPP has been well aware that the chiropractic profession opposed their development of treatment parameters. The ANJC questions why this draft was distributed and presented to outside agencies without being distributed for review by the chiropractic profession. The ANJC is concerned that if this document, purportedly supported by the majority or consensus of the profession, is released for public use, it will be widely circulated and improperly used by others with disastrous consequences to chiropractors nationally."

Another major area of contention was the unwillingness of the CCGPP to examine or consider numerous scientific studies that contradicted the opinion of the CCGPP panelists concerning frequency and duration of chiropractic care. It cited, as an example, a list of 200 studies containing data on frequency and duration for chiropractic care, compiled by the International Chiropractors Association. The ANJC called upon the CCGPP to "explain its rationale for utilizing the opinion of 40 panelists instead of the available scientific studies in formulating its frequency and duration guidelines for chiropractic care."

In closing, the ANJC stated that the CCGPP frequency and duration recommendations concerning chiropractic care "represent nothing more than the opinions of the 40 participants to a select group of unknown 'seed' questions. The consensus reached for these select questions are not based on scientific evidence, and do not reflect the standard of practice in NJ or any other state. Furthermore, the ANJC endorses that chiropractic care plans should be based upon the unique needs of each individual patient, and case progress determined by objective chiropractic assessments of neurospinal function and quality of life, not arbitrary charts or opinions."

This isn't the first time the ANJC has spoken out against the CCGPP. As noted in an article in the Sept. 2006 issue of The Chiropractic Journal, it was opposed to the guidelines group right from the beginning: "It is impossible to adequately review this document in the 60 days allotted. The CCGPP document took years to produce yet contains serious flaws and omissions. The ANJC opines that it would be irresponsible to release the document prematurely as it will set precedent with insurers and regulators. ... The ANJC rejects the draft CCGPP document on best practices for low back as presented."

The recent ANJC letter, which was quickly circulated throughout the profession via the Internet, is winning applause from other critics of the CCGPP efforts.

"It's heartening to see so many doctors and organizations, from across the broad spectrum of chiropractic practice, join the fight against the CCGPP guidelines," stated Terry A. Rondberg, DC, World Chiropractic Alliance president. "Early on, the WCA declared its opposition to the CCGPP, as it had to its predecessor, the Mercy guidelines and I'm confident that many other organizations will be stepping forward to challenge the CCGPP. We may not be able to stop them from publishing their guidelines, but we can make it clear to the world that they are not accepted or endorsed by the profession as a whole."

In addition to the World Chiropractic Alliance, the International Chiropractors Association, the Federation of Straight Chiropractors and Organizations and groups from more than 30 states have rejected the guidelines document and called for its withdrawal. Even the Congress of Chiropractic State Associations -- which initiated the CCGPP process -- has refused to endorse it as it is written.