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Dynamic Chiropractic – April 10, 2006, Vol. 24, Issue 08
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Dynamic Chiropractic

Developing a Chiropractic Best Practices Evidence Base With All Stakeholders in Mind

By Eugene Lewis, DC, MPH

The Council on Chiropractic Guidelines and Practice Parameters (CCGPP), an evidence-gathering body created by several national chiropractic organizations in 1995, has been frequently asked who it is that we serve.

The reply has always been that CCGPP exists primarily to serve chiropractic patients and prospective patients, as well as doctors of chiropractic. We are then asked why CCGPP would have anything to do with the notion that considers third-party payers as stakeholders; if our members have any sort of relationships with third-party payers; and naturally, whether there is risk of a conflict of interest that might threaten the integrity of the best practices project.

The council is comprised of volunteers who have put countless hours toward building a best practices evidence base. CCGPP members all have day jobs, with nearly everyone in private practice, but one of the advantages as a diversified group is the breadth of experience of CCGPP membership, so naturally, a small minority of our more than 135 members and advisors have worked with third-party payers in the past (and a few currently do). Some have co-authored articles with individuals who work for third-party payers. Some know very influential individuals in the insurance industry and have been very helpful in that regard.

This seems to be surprising to some. It is important to explain that, aside from representing a broad spectrum across the profession, as would be expected, there are other reasons for considering all of our stakeholders in the process. The CCGPP needs to have as much input from (and into) the third-party payer system as possible. From the outset, it was our intention to have a limited number of people who have relationships with the payer industry. In fact, input from all stakeholders is not only desirable, but also mandated by all international document evaluation instruments in order for the CCGPP finished product to be considered valid. Lack of this stakeholder input is one of the reasons other documents have received negative evaluations when those products were examined by independent authorities.

The CCGPP has members from education, from other health care professions, a member representing consumers, from the legal profession, and other perspectives as required. We see this diversity in our members as a strength as the best practices document, the Chiropractic Clinical Compass, is created and implemented.

Although we do not have a formal leadership seat on the CCGPP for a third-party payer representative, we do have some input from payers, speak at as many insurance meetings that we are able to attend, and try to build the necessary bridges one might imagine are critical to this process of reimbursement most of us participate in. After all, better than 90 percent of all doctors of chiropractic in the country receive at least part of their incomes through third-party payer sources.

To produce an effective best practices product, one that can be used as a mechanism to protect the profession against abuse by third-party payers, we must embrace the fact that third-party payers are bona fide stakeholders in this process. All of us in health care are in the same lifeboat together, whether we like that fact or not. I have made this same statement on numerous occasions when speaking to payer groups.

Anticipating the need for objectivity as part of the best practices process, it has been the policy of the CCGPP since its inception to have an ongoing screening process in place to examine the possibility of, and eliminate any conflict of interest with any of these relationships. That process remains in place today and is always open to inspection. All CCGPP members have signed conflict-of-interest and screening affidavits. They are aware of potential conflicts of interest, and we are very comfortable in saying that we feel there are no such conflicts.

Members of the CCGPP want to see this project succeed for the entire profession. Chiropractic has needed to identify a strong evidence base for many years to work from and to publicize to third-party payers and to other professions, and that is what we are assembling.

Since a number of CCGPP panel members also represent chiropractors in malpractice or regulatory agency cases, we are aware of the dire necessity for a knowledge base of the type being developed by the CCGPP on which testifying experts can depend, since this evidence may assist in this defense when chiropractors can be shown to be treating according to established evidence.

In 1993, with the Daubert1 case, the courtroom defense of expert opinion changed significantly. This case essentially stated that "scientific testimony requires that a determination of science exists," and the statement by the defendants in this now well-known case that the treatment given was valid because everyone else was providing the same mode of care was discarded. It was struck down by experts with better evidence, and several succeeding court cases punctuated the Daubert decision even more firmly.

Evidence has now evolved into widespread policy. Since there is no retreating to the former state, the chiropractic profession needs to take the kinds of bold steps with which the CCGPP is currently involved.

The CCGPP is not building guidelines or any other sort of restrictives. The council is only providing information that will expose other groups and prospective patients to the advantages of chiropractic, and to help chiropractors become more effective as they search for information for their patients. In this ever-competitive environment, our doctors need all of the tools available at their disposal, and the CCGPP exists solely to provide the evidence to support the most effective care in this vein. Not only that, the document also is intended for use by all chiropractors, as the council follows a model that is built around the art, science and philosophy of chiropractic, and tries to avoid being one-dimensional.

CCGPP has hired the Work Loss Data Institute as our publisher and distributor. The institute is well-known for its ability to penetrate the insurance industry with similar documents for other professions.

Chiropractors, consumers, payers, colleges, governmental organizations and all other stakeholders will have the opportunity to comment when the drafts are posted online, before any final publication is released. [Editor's note: A draft of the first chapter on best practices, focusing on the low back,2,3 will be posted online for stakeholder review at the end of April. Additional draft chapters will be released every six to 12 weeks and will remain available for comment at www.ccgpp.org for a period of 60 days.] We encourage readers to examine the information on this site to learn more about the document process and how they will be able to contribute their comments prior to publication in the last part of 2006.

We are simultaneously recruiting all other stakeholders for commentary, as all in the profession should value their opinion as well. Hopefully, this discussion has shed considerable light on reasons for that policy.


  1. Daubert, et al., v Merrell Dow Pharmaceuticals, Inc. Certiorari to the U.S. Court of Appeals, Ninth Circuit, #92-102. Argued March 30, 1993; decided June 28, 1993.
  2. CCGPP best practices document: stakeholder review. Dynamic Chiropractic, Jan. 1, 2006. www.chiroweb.com/archives/24/01/04.html.
  3. CCGPP urges stakeholder review of low back document. Dynamic Chiropractic, Feb. 13, 2006. www.chiroweb.com/archives/24/04/11.html.

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