[Editor's note: This is the second of a series of articles on the CCGPP best practice initiative. The first article, which provided background information on the initiative, appeared in the Nov.4 issue (www.chiroweb.com/archives/22/23/08.html).]
The best practice initiative undertaken by the Coucil on Chiropractic Guidelines and Practice Parameters (CCGPP) is progressing at a steady pace, with the introduction and first completed chapter of the document (lumbar spine disorders) scheduled for release in early 2005. The dedicated volunteers of the commission, who are researching and compiling the literature, strive to be as thorough as possible. The sheer volume of research gathered to date is very impressive and will no doubt result in reliable, evidence-based treatment options for all types of clinicians who want to serve their patients in an appropriate manner. This initiative focuses on the "process of care" instead of arbitrary treatment recommendations found in ordinary guidelines.
This article will attempt to answer the most common questions the CCGPP has received concerning the development of the best practice initiative. For further information, please visit our Web site, www.ccgpp.org.
Q: How did CCGPP members (AKA, the council) get chosen?
A: Members were appointed by the respective organizations that founded CCGPP. Those organizations are: American Chiropractic Association; Association of Chiropractic Colleges; Congress of Chiropractic State Associations; Consortium for Chiropractic Research (founding member, but not current member); Council on Chiropractic Education (founding member, but not current member); Federation of Chiropractic Licensing Boards; Foundation for Chiropractic Education and Research; Foundation for Chiropractic Tenets and Science (founding member, but not current member); International Chiropractors Association (founding member, but not current member); National Association of Chiropractic Attorneys; and National Institute of Chiropractic Research.
Q: How were the researchers (AKA, the commission) chosen?
A: Chiropractic colleges provided the majority of researchers. The CCGPP solicited from all schools; team leaders also selected others according to experience, education and needed skill sets.
Q: Is this "Mercy" all over again?
A: No, the CCGPP was appointed to look at all protocols, guidelines, parameters and research related, applicable and useful for the chiropractic profession, including information from outside the U.S.
Q: Will subluxation be included?
A: Yes, all research material pertaining to subluxation is being examined for publication.
Q: Why is the document condition-based?
A: The document is condition-based because the CCGPP was formed largely, but not exclusively, to address problems revolving around issues of reimbursement, and this industry is currently in a condition-based format.
Q: How will the CCGPP address techniques?
A: It will not address technique because of the exceptionally small amount of information available in the literature.
Q: Will the document address chiropractic philosophy?
A: Philosophy, certainly an underpinning of everything that chiropractors do, is not a focus of best practices and would be exceptionally difficult to place in that sort of framework.
Q: What opportunity will exist for input by stakeholders?
A: Pre-publication comment with advance notice, published online on our Web site (www.ccgpp.org), in chiropractic journals and made known by other methods, will solicit input from the chiropractic profession and from others, including patients, students, the insurance industry, governmental agencies and all other stakeholders.
Q: What is the focus of the best practices document?
A: The CCGPP is placing a special focus on the process of care, identification of risk factors and case complexity, techniques of response monitoring, with benchmarks for intervening when the response is below average. This focus helps all parties to recognize that there is a broad spectrum of individuals served in chiropractic offices, with varied presentations to be addressed.
Q: What if there isn't enough evidence on a topic?
A: Consensus will dictate the conclusion.
Q: What if we just waited to see if there was more evidence before publishing?
A: The demand for this document is overdue and waiting longer for any reason has been deemed unacceptable. Furthermore, although the chiropractic profession is in need of significantly more research funding, there is a surprising amount of information on many of our focus topics. The CCGPP has also applied for a number of grants, which we hope can pave the way for much more research in the profession, so we are addressing the issue directly.
Q: What will the CCGPP say about wellness care?
A: This is an important area for our profession and will be addressed. Since there is virtually no research in this area, consensus will also be the rule.
Q: What is the budget for this process?
A: The budget for 2004 is $475,000; it takes a considerable amount of funding to produce a quality product.
Q: What is the timetable for this process?
A: The completed document will be released in mid-2005.
Q: What's the difference between "best practices" and "guidelines"?
A: CCGPP operating definition of best practices and process:
- "Best practices" incorporate not only the most current explicit evidence-based practices, but also allow for filling the holes where the data are conflicting or absent (and those gaps are very large) by adopting formal consensus conclusions, which usually means there are a variety of equally appropriate ways of doing something. Best practices is the most contemporary approach and is employed by other health care professions, as well as those in many other non-health areas.
- "Guidelines" are a more narrow interpretation of existing information, often used to formulate so-called "stop-care points." They are frequently arbitrary, with little available information to support most guidelines, or may be subject to variable interpretation, depending on the reviewer. The CCGPP is not writing guidelines for practice.
Q: What is going to prevent the carriers, governmental agencies and others from taking this document out of context?
A: Obviously, the chiropractic profession cannot force anyone to use the best practices document in a certain manner. When receiving payment, chiropractic doctors do need to recognize that these groups are our partners, in a sense, whether this fact is liked or not. What the CCGPP can do is solicit industry input in advance, give our own critical responses in return, and make every effort to build bridges with these groups before, during and after publication (as described in the preceding response). We feel that having a "CCGPP Quick Response Team" ready for unexpected problems is one way to help meet this challenge quickly and effectively.
Eugene A. Lewis, DC, MPH
Chair, Council on Chiropractic Guidelines and Practice Parameters
Dr. Lewis can be reached through the CCGPP office in Lexington, Kentucky: (803) 808-0640 or