CCGPP: Deceit and Consensus Opinion-When Will it End?

Dr. Joe Betz, B.S., D.C

ICA Board Member,

Idaho Chiropractic Association

CBP Fellow & Instructor

In their initial attempt to review the scientific literature and formulate an evidence synthesis, the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) asserted that visit frequency and duration parameters would not be developed in their work product. They made great effort to avoid the phrase “guideline” opting for “Best Practices” instead and avoiding developing parameters associated with typical guideline recommendations. This was their position until they decided to develop frequency and duration recommendations in California on the topic of chiropractic management of low back pain.

In California, the CCGPP didn’t rely upon the vast amount of high quality research published on the topic of low back pain. Instead, they formed a Delphi panel of chiropractors who arrived at a consensus for particular “seed statements” that were derived from a separate committee (non-democratically elected, of course).

The parameters they adopted stress the importance of incorporation of “active” treatments, frowning upon “passive” treatments, including the chiropractic adjustment, beyond 12 visits. Additionally, the patient is given 6 visits to show “satisfactory [emphasis mine] clinical gains utilizing commonly accepted outcomes assessment methods.” It is important to note that these parameters were based upon EXPERT OPINION only.

These types of “Consensus” projects are very common; but more and more are being frowned upon. According to a report by Culleton in 2009, “Traditionally, clinical practice guidelines were consensus-based statements, often riddled with expert opinion. It is now recognized that clinical practice guidelines should be developed according to a transparent process involving principles of bias minimization and systematic evidence retrieval and review, with a focus on patient-relevant outcomes.”¹

Despite the CCGPP’s assertion that consensus opinion is warranted, nothing could be further from the truth. There is a plethora of reports on the topic of Chiropractic management of Low Back disorders and on chronic pain of spinal origin. As you can imagine, consensus opinion has the ability to become a very biased tool when used in inappropriate situations.

Problematically, the CCGPP is recruiting the usual suspects for a similar adventure for an opinion consensus document on care for chronic pain conditions. Again, there is more than enough evidence upon which to base recommendations for chronic pain conditions. So, why is the CCGPP seeking opinions of researchers and clinicians? Expert and consensus opinion is for situations where there is no evidence.

It is my opinion that the CCGPP clearly has set an agenda. It is an organization that was out of control years ago. For example, the ICA critique of the Low Back document argued ad nauseum that the CCGPP was not representative of the profession at-large. ICA noted the ties of the Team lead with insurance companies and guideline distribution companies. ICA remarked that when finished, this document would become a tool used as a club to beat down Chiropractors that practiced outside of CCGPP frequency and duration parameters (which ICA also predicted would develop somehow).

In defense, the CCGPP maintained that they would fight the unfair interpretation of their document. Now that their money has dried up, I wonder who will be left to “defend” the CCGPP when this invariably happens.

I recently became aware of a lecture that was given by the CCGPP to the Federation of Chiropractic Licensing Boards (FCLB) in 2006. ² Within this lecture there is a section titled “Best Practices & Regulation: How does the Best Practices affect our Boards? How may the BP be applied by the Boards?”

The slides describe how the CCGPP documents can be used by the State Licensing Boards to define intent to commit fraud through over-utilization and breaching what the CCGPP would define as “appropriate care”. It has been my suspicion that the purpose of the CCGPP process has always been to contain and eliminate those Chiropractors that practice outside of what the CCGPP and related organizations that support the CCGPP, consider as “appropriate” treatment.

Unfortunately, based on the above document, I believe that the CCGPP will encourage the licensing boards to consider the following circumstances as fraudulent:

1) Care is beyond a defined frequency/duration;

2) Care for most everything beyond pain conditions (this includes methods used by mixers and straights);

3) Whether you take X-rays for detection of subluxation; and

4) The type of Technique you choose to practice.

This is purely speculative, but many of the ICA, the professions, and my predictions regarding the CCGPP have come to fruition thus far. I believe it only a matter of time until CCGPP tries to push these issues more and more as they initiated in their 2006 lecture to the Federation of Chiropractic Licensing Boards.²

The CCGPP process needs to be controlled by the organization that created it; the Congress of Chiropractic State Associations (COCSA). COCSA is the accountable organization. The members of the COCSA organizations are comprised of the state associations. Basically COCSA is a national association representing state associations. The majority of state associations have rightly opposed the work products of the CCGPP when they were reviewed, particularly the first version of the Low Back Disorder chapter. We understand the CCGPP has lost much of their financial support. Yet, they still exist and continue to produce these “consensus” projects.

If CCGPP was “commissioned” at the behest of COCSA, then that same organization should be able to “decommission” them as well. I urge all of you to do 3 things:

1. Contact your state association (join if you have not yet done so) and urge them to “decommission” the CCGPP at the next COCSA convention in November; 2009.

2. Join the ICA as a member and support the continued efforts through appropriate guideline development.

3. Support other research endeavors that advance the science of subluxation correction by joining CBP^® Non-Profit.

References

1. Culleton B. Development and limitations of clinical practice guidelines. Methods Mol Biol. 2009;473:251-61.

2. Best Practices Documents and Licensing Boards - A Quick Update. By Dr. David Taylor.http://www.fclb.org/Meetings/MeetingsHome/2006PortlandOregon/tabid/473/Default.aspx

CCGPP Council on Chiropractic Guidelines and Practice Parameters