The Need for Chiropractic Practice Guidelines: A Forensic Analysis - Part 2 of 3

Qualifying Statement

The working chiropractic guidelines are not intended to delineate universal, professional mandated regulations and actions. Instead, they are meant to serve as an outline for the training and knowledge that are generally necessary to guide the chiropractic clinician's approach to the patient. This means "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."¹ The application of a rigorous scientific and intellectual process methodology can provide a comprehensive and defensible standard of care. The use of guidelines makes sense in managed care, private health insurance, prepaid settings, and for reasons of malpractice defense.²

Foreword

The statement and purpose of chiropractic guidelines should focus on patient dialogue and outcome expectations. The use of clinical chiropractic practice guidelines should present a clear and resounding message. The best interests of our society, economy, businesses and families are served when the primary focus of our profession is the restoration of functional capacity and keeping life as normal as possible for the ill or injured patient.³ This process of the evidence means that the chiropractic professional is fully committed to identifying and applying those most efficacious chiropractic care paths, modalities, manual therapies, and special and diagnostic studies to maximize the quality and quantity of life for each patient. The guidelines should not dictate treatment for providers, but provide up-to-the-minute, unbiased, evidence-based information for optimal and timely decision-making. The purpose of this joint development chiropractic guidelines effort is to help treat, manage, improve and restore the health, well-being and productivity of ill and injured workers worldwide.⁵ The concepts and premises that justify and hold true for the development of the Work Loss Data Institute's Treatment Guidelines for the Workers' Comp 2004 and the Official Disability Guidelines 2004, and the revision of the American College of Occupational and Environmental Medicine Guidelines, are applicable to the development of the chiropractic guidelines. My impressions parallel the publishers' "Foreword 2004" regarding the work that the WLDI has done over the past year: "I cannot think of a better or more satisfying course to pursue."³

General Information on Guidelines

Guidelines are designed for a variety of groups and organizations, and all have a purpose. Most common guidelines are intended to determine the appropriate application of procedures or use of medications, with some designed to guide the evaluation and treatment of acute presenting complaints. Some guidelines address management of chronic, persistent, recurrent or recalcitrant problems, focusing on systematic evaluation and ongoing maintenance care.⁴ For example, the most common can be found in the National Guideline Clearinghouse (NGC, online at www.guideline.gov), sponsored by the Agency for Healthcare Research and Quality (AHRQ, online at www.ahrq.gov), the U. S. Department of Health and Human Services, in partnership with the American Medical Association (AMA, online at www.ama-assn.org) and the American Association of Health Plans-Health Insurance Association of America (AAHP, online at www.aahp.org). The NGC is a public resource for evidence-based clinical practice guidelines; almost every conceivable clinical and allied health care specialty has developed guidelines contained on this site. It provides a glossary of clarifying definitions and examples of terms used to describe common properties of evidence-based practice guidelines and abstracts (i.e., guideline summaries). In addition, the NGC contains a synthesis of selected guidelines that includes the scope of the guidelines with reference to chiropractic, such as the Washington State Chiropractic Association's Overview of Implementation of Outcome Assessment Case Management in the Clinical Practice 2001.

Reviewing the Medical Literature

Once the forensic process of selecting the high-quality medical scientific literature is obtained, upon what type of journals and high-quality scientific articles will the content editors rely? I have heard from many clinicians of all health care disciplines since my last article (Jan. 1 DC), and a recurrent theme follows. It is easy to mistrust that the new guidelines will be used against the chiropractic professional at all times, and ignored when they prove our point. I cannot assure you that various industries will not do just that. However, in future articles, I will outline the forensic selection methodology of how high-, medium- and low-quality scientific research articles are graded and applied to specific elements and tasks of conditions commonly seen in the chiropractic office. Since 2000, I have provided editorial guidance and reviewed hundreds of scientific articles for the WLDI projects, and can categorically state that there is a paucity of scientific articles for some elements of the essential functions of the chiropractic professional's job analysis. It is my firm conviction that the collaborative efforts between the WLDI and the Council on Chiropractic Guidelines & Practice Parameters (CCGPP) will set new standards for the chiropractic profession by presenting and summarizing the highest quality, most up-to-date scientific studies. I would like to acknowledge the WLDI and the CCGPP executive, steering and senior advisory committees, publishers, chairs, contributors and reviewers for their early planning stages, prior and continued hard work, dedication, and foundation of this exciting, evidenced-based project.

References

1. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence-based medicine: What it is and what it isn't. This article is based on an editorial from the British Medical Journal, Jan. 13, 1996 (BMJ 1996;312:71-2) and Patricia Whelan, publisher, Official Disability Guidelines Treatment in Workers' Comp 2004, 2nd ed., "Foreword 2004," pg. 10. Work Loss Data Institute, 169 Saxony Place, Suite 210, Encinitas, CA 92024.
2. Jeffrey S. Harris, M.D., MBA, MPH. Industrial indemnity. American College of Occupational and Environment Medicine's Committee on Practice Guidelines, Arlington Heights, Illinois, and Industrial Indemnity, San Francisco, Calif. JOEM 1997;39(1).
3. Patricia Whelan, publisher, Official Disability Guidelines Treatment in Workers' Comp 2004, 2nd ed., Foreword 2004, pg. 9. Work Loss Data Institute, 169 Saxony Place, Suite 210, Encinitas, CA 92024.
4. American Medical Association. H-410.000 Practice Parameters, H-410.965 Clinical Practice Guidelines, Performance Measures, and Outcome Research Activities. www.ama-assn.org/apps/pf_new/pf_online.