Over the past few years, many of you have heard the cries of our fellow chiropractic practitioners in California concerning revisions to the workers' compensation system.In 2004, the state legislature adopted the American College of Occupational and Environmental Medicine (ACOEM) guidelines for use in that system. Only those interventions recommended in the guidelines are now reimbursable under California law. The only exception available is that the guidelines may be supplemented by other nationally published guidelines.
In December 2007, Gary Globe, DC, MBA, PhD, who is serving as the California Chiropractic Association representative on the California Workers' Compensation Advisory Board, contacted the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) for assistance. Dr. Globe indicated that there was a brief window of opportunity for the chiropractic profession to provide a nationally published supplemental guideline to clarify weaknesses in the ACOEM guidelines pertaining to chiropractic care for low back and chronic pain conditions. However, for this opportunity to be realized, that supplement had to be available for the next regularly scheduled meeting of the California Workers' Compensation Advisory Board on March 19, 2008.
In September 2007, the CCGPP Rapid Response Team initially penned a letter to United Healthcare (UHC) demonstrating the inappropriateness of the insurer's newly adopted policy of noncoverage for chiropractic care of pediatrics and headaches. That letter subsequently was endorsed by numerous chiropractic organizations. In response to that letter, UHC ultimately retracted the pediatric policy and reworked the headache policy. Due to the rapidity and success of this response, Dr. Globe contacted the CCGPP for assistance with the California workers' compensation situation.
At its inception, the CCGPP was charged with the evaluation of any and all guidelines, parameters, protocols, best practices and standards of practice. This also means taking a stand for the profession when a problem or potential assault is noted. Therefore, the CCGPP accepted the California challenge and has undertaken a new initiative.
We are currently involved in a Delphi process to generate the consensus opinion of DCs from across the country regarding the care of low back pain, especially chronic pain. After conducting its extensive literature synthesis on low back conditions, initially posted on the Internet in May 2006, the CCGPP is acutely aware there is inadequate literature on various areas of common chiropractic practice. Many of the existing studies have a medical bias that needs to be tempered with a chiropractic lens.
The purpose of the Delphi technique is to elicit information and judgments from participants to facilitate problem-solving, planning and decision-making. It is structured to capitalize on the merits and minimize the liabilities of group problem-solving. Consensus derived from a rigorous Delphi process is considered to be expert evidence. While not as highly valued as some forms of research, it is nevertheless widely used and accepted, particularly in addressing areas in which high-quality research is lacking. Indeed, other national guidelines have used medical expert opinion to address issues of chiropractic care when more definitive literature was not available.
The purpose of the CCGPP conducting the present Delphi process was to look at the same literature base others have through a chiropractic expert perspective, and to clarify the role of chiropractic in these areas of care, especially as they are impacted by the workers' compensation system and their incorporation of external guidelines. We solicited seed panelists from chiropractic's national organizations such as the ACA and the ICA, and from the state associations through COCSA. As background material, those panelists were provided with the CCGPP low back literature synthesis, along with Dr. Gert Bronfort's recent study published in The Spine Journal.
After reviewing the ACOEM guidelines, the CCGPP Seed Committee developed 27 seed statements defining areas of concern within those guidelines. Those seed statements were then submitted to the panel for review and comment. After the first round of review, there was greater than 80 percent consensus on 24 of the 27 seed statements. On the three outstanding seed statements, the panelist comments were reviewed by the committee and utilized to revise those statements. Those revised seed statements were then submitted to the panelists for a second round of review and comment. After the second round, the three remaining outstanding seed statements again achieved greater than the 80 percent threshold for consensus that the committee had required at the outset of the project.
The Seed Committee is currently in the process of incorporating the acquired commentary into a final consensus report, the final version of which will hopefully be available by early June for use in the California workers' compensation process. That report will be posted on the CCGPP Web site, and the CCGPP Scientific Commission Chair, Dr. Cheryl Hawk, has a verbal commitment from the Journal of Manipulative and Physiological Therapeutics to publish the available literature syntheses chapters, inclusive of this consensus report, in the November/December 2008 issue.
The CCGPP has studiously avoided entering into the guideline-development process for a number of years, especially following the furor raised over the Mercy guidelines. They were widely condemned, particularly by those who never took the time to read them or learn how to properly apply them to obtain the care their patients needed. However, that was a long time ago. Given the pace of change in health care in the past decade and a half, the literature needed to be updated. Third-party payors, government agencies, other guideline organizations, patients, and yes, even DCs now want to know what kind of care is supported by evidence.
Our profession's refusal to address this issue has led to the inevitable result that MDs, insurers and bureaucrats are now deciding what reasonable chiropractic care should be, based on their interpretation of the currently available scientific literature. We must remember that we exist as a profession to provide a service our patients need and want, not to advocate for what benefits us the most. Need proof? Our market share has not increased (and some would argue it has declined) despite the greatest increase in the use of CAM in recent history. We continue to have little cultural authority, meaning in part that the public still does not clearly understand our role and areas of expertise in the health care market. Physical therapists are publishing widely accepted papers on indications for manipulation of the low back and have made it clear that they intend to take over chiropractic's traditional place in the health care market.
The good news is that there is a great deal of evidence for what we do, as revealed by the CCGPP low back literature synthesis, as well as the subsequent condition-related chapters. The crisis in California (where nearly one-quarter of U.S. doctors of chiropractic practice) has provided an opportunity to address what many of us consider to be misinterpretation of the scientific literature and to instead reinterpret the scientific literature viewed through a chiropractic lens. This Delphi process was in part developed by the CCGPP in response to what we heard at COCSA in Baltimore in 2006, where one of the primary concerns voiced by our critics during our round table discussion was that not every aspect of chiropractic practice has yet been subjected to randomized controlled trials.
Now some of those same critics have already begun to naively criticize this effort as "unscientific." Nothing could be further from the truth. The CCGPP conducted a multi-year scientific evaluation of the current literature based on internationally accepted standards, resulting in the aforementioned low back literature synthesis. We also included additional, newly released research, published in interim since the completion of the low back synthesis. This formed the framework for the subsequent Delphi consensus process, which is widely viewed as an appropriate, defensible and scientific methodology for addressing areas in which scientific literature is lacking.
The issue of "dosage" is a perfect example of the need for a scientific consensus process. Patients, insurers, DCs and others want to know the reasonable parameters of chiropractic care for a given condition. Is it short trials of treatment to see if it helps or 75 visits and yearlong contracts? Most published literature on this subject is based on treatment restrictions that do not realistically reflect actual practice, but instead necessary limitations imposed by clinical study protocols. Accordingly, the most appropriate and valid methodology for addressing the gaps between scientific studies and clinical practice is a rigorous consensus process. We chose to use the Delphi process because of its economy in terms of both costs and timeliness. We chose to ask every state association and national organization in the country to provide participants who were conversant with using published literature, represented a wide variety of practice styles, philosophies and locals, and were willing to work collegially to try to reach accord.
Is the end result what we wanted? No, if the goal is the ability of the individual chiropractor to practice unfettered by any constraints (and we are unaware of any other health care profession with such a privilege). But if the goal is to draft a guideline that reflects the mainstream of chiropractic practice, provides advice and benchmarks for extending trials of treatment and - most importantly, safeguards our patients' rights to demonstrably effective, conservative chiropractic care, we believe this is a good start.
We anticipate that this type of consensus process will eventually have national impact, as New York, Ohio and other states are also incorporating the ACOEM or other guidelines into their workers' compensation systems. As an example, the CCGPP was contacted in early March by the ACA to participate in its recently established Guideline Review Task Force, established in response to a request by the ACA delegate in Tennessee, Dr. Michael Massey. Blue Cross Blue Shield of Tennessee has requested a critique of the Milliman Care Guideline, 12th Edition, as it applies to chiropractic care. Once that review has been completed, task force members are hoping to again put together a professional coalition to sign onto the review, such as was done with the United Healthcare situation.
Ultimately, the CCGPP views this type of consensus development as one of the next phases of the progression from literature syntheses to the best-practices development process we have dubbed the "Chiropractic Clinical Compass." This is also another example of the CCGPP Rapid Response Team model, by which the fluidity of our organization is able to mobilize our teams of experts and effectively address an immediate issue.
Dr. Mark D. Dehen is a second-generation doctor of chiropractic practicing in North Mankato, Minn., where he does ergonomic consulting and injury prevention for local industries. Dr. Dehen is a past president of the Minnesota Chiropractic Association and the immediate past chair of the CCGPP.