As you may or may not know, a new initiative is currently underway that has the potential to impact your practice in a positive and significant manner. But how do we know the resultant guideline will be any more or less credible than any other guideline? This article will help illuminate the difference between a "best practice initiative" and a "guideline," as well as explain how the process ensures that the current initiative is above reproach.
Most doctors have neither the time nor the scientific expertise to extensively assess the research literature on any given health topic. Fortunately, both guidelines and best practice documents are available to summarize the scientific literature for busy doctors. Guidelines and best practice documents are wonderful tools that allow a physician to quickly review the best evidence for various diagnostic and treatment procedures.
The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) is currently working on a new best practice document for the chiropractic profession, and it will be available to you in the near future. So, how can DCs use the new CCGPP best practice document to their advantage? Read it! Understand it! Some of the best minds in our profession toiled tirelessly to provide you with a useful summary of what is most likely to work best for your patients. It tells you how to document the necessity of supportive care, how to document exacerbations, and so much more. If we as a profession don't adopt the CCGPP's fair and valid best practice guideline, the insurance companies will use their own guidelines to assess our work, and it is very unlikely that they will be as balanced and fair as those put forth by our own scholars. In fact, right now, chiropractors in California are fighting with their legislature, which mandates that they follow restrictive guidelines reported to be very stringent and used by carriers to deny care.
The CCGPP has applied the principles of good best-practice construction and has employed the process recommended by the AGREE Collaboration (Appraisal of Guidelines for Research and Evaluation). With a clear, well-written best practice document, chiropractors can feel secure in knowing that health care brokers can be held to the standards we chiropractors have set, and not arbitrary or unfair rules they have established.
The difference between a guideline and a best practice document is primarily in the way the recommendations are handled. While both review the available evidence, "guidelines" generally provide treatment recommendations and numbers of visits, whereas a best practice initiative is based on three important elements: research, clinical decision-making, and patient values. The best practice document allows the physician to weigh the evidence, consider the clinical situation, and then select the treatment or diagnostic procedure that is best for that patient.
Many organizations produce guidelines, and often there are several guidelines on the same topic. Frequently, the recommendations are quite similar - but not always. The questions then arise: Which one do we use? How do I know this "guideline or BP document" will be any more or less valid than any other guideline? Indeed, not all guidelines or best practice documents are created equal, and the quality of construction can vary considerably. Attempts have been made in the past decade to construct an instrument that can assist in the evaluation of the quality of a document's construction process. Two early instruments include Cluzeau's Appraisal Instrument for Clinical Guidelines (the Cluzeau instrument) and the methodological appraisal instrument by Shaneyfelt, et al.
In 2000, Ian Graham, et al., evaluated 13 guideline appraisal instruments for validity and reliability. They evaluated assessment instruments according to their ability to assess 10 attributes put forth by the Institute of Medicine (IOM) as desirable guideline attributes,1 and concluded that the Cluzeau instrument was the most well-developed, followed by Shaneyfelt's. Additional reliability testing of the Cluzeau instrument by Cates, et al., served to support its validity.2 Many medical and chiropractic guidelines were assessed with the Cluzeau instrument.2
Additional improvements and modifications were made to the Cluzeau instrument, and the resulting AGREE instrument was recently introduced.3 The final version of the AGREE instrument contains 23 items grouped into six quality domains (scope and purpose; stakeholder involvement; rigor of development; clarity and presentation; applicability; and editorial independence), with a four-point scale to score each item. Guideline domain scores are calculated by summing all the scores of individual items in a domain and standardizing the total as a percentage of the maximum possible score for that domain. A global assessment is also rendered. This instrument has been internationally tested for reliability and validity and is widely used across Europe and in Canada. Currently, the AGREE instrument is arguably the global standard for guideline evaluation.4
Guidelines that lack quality construction and/or credible content have been and will continue to be rejected by the legal system and third-party payers. The AGREE instrument is useful in identifying where the flaws are in a guideline, so that they might be addressed and rewritten or revised. The CCGPP best practice document is being constructed by an impressive team of scientists and academicians within our profession. The CCGPP team has employed recommendations in keeping with good guideline / best practice attributes, as put forth by the IOM and measured by the AGREE instrument. These measures will help ensure that the new best practices document will be valid and acceptable to all stakeholders.
I encourage you to go to the CCGPP Web site (www.ccgpp.org) and learn more about the CCGPP and the new best practice document, and how you can support and donate to this project. A CCGPP representative will gladly travel to your state to present information and answer questions. Call CCGPP (803-808-0640) if you are interested in a presentation. Since funds are limited, all we ask is for your organization to pay the travel expense. Our time is donated to your association.
References
- Graham ID, Calder LA, Hébert PC, et al. A comparison of clinical practice guideline appraisal instruments. International Journal of Technology Assessment in Health Care 2000;16:1024-38.
- Cates JR, Young DN, Guerriero DJ, et al. Evaluating the quality of clinical practice guidelines. Journal of Manipulative and Physiological Therapeutics 2001;24(3):170-6. Assessment scores for various chiropractic guidelines are included in this paper.
- The AGREE Collaboration: Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument.
- The AGREE Collaboration [Cluzeau FA BJ, Brouwers M, et al]: Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. 2003;12(1):18-23.
Jeffrey R. Cates, DC, MS, DABCO
Oregon, Illinois
