The Chiropractic Report www.chiropracticreport.com Editor: David Chapman-Smith LL.B. (Hons.) March 2009 Vol. 23 No. 2 New Best Practices for Chiropractic Patient-Centered vs. Payer-Centered Care A. Introduction defined set of best practices to guide and explain quality patient-centered N NORTH AMERICA THE RE- care – and defend patients and clini- lentless upwards spiral of healthcare I cians against the inappropriate economic costs in the last quarter of the 20th cen- agenda of many third party payers. tury produced the current era of man- aged care. 2. This is the reason why the profession in North America has established the There is no question that the excessive Council on Chiropractic Guidelines cost of American medical care needed and Practice Parameters (CCGPP). The to be reined in. There is also no question Journal of Manipulative and Physiological that third party payers in managed care Therapeutics (JMPT) has now published have been ruthless in establishing rules some first products of this important and procedures based on financial tar- Council, namely: gets rather than reasonable patient care. a) A Best Practices Report on Chiropractic Money that should be going to patient Management of Low-Back Disorders by care is going to a bloated administration Globe, Morris, Whalen, Farabaugh and and managed care owners. In the US the Hawk,5 supported by a new literature ratio of physicians to administrators is review by Lawrence, Meeker, Branson now almost 1 to 1 (1 to 0.95)1. Professional Notes et al. 6 – which is specifically on chiro- LBP – Predictors of Chronic Disability Research is quoted and used selectively. practic management of low-back and Valuable evidence of effectiveness of Low-back pain (LBP) is the most preva- related leg disorders, and is one of three treatments from prospective studies, lent and costly work-related condition, research studies upon which the new from individual randomized controlled and most of the cost relates to the small best practices are based. trials (RCTs) and for subgroups of percentage of workers with acute injuries b) Literature reviews relative to chiro- patients, is excluded or diluted in broad who progress to chronic disability. practic management of: systematic reviews that typically make Accordingly risk factors that are early tentative conclusions only – allowing • Myofascial trigger points and pain syn- predictors of chronic disability – particu- 7 payers to assert there is insufficient evi- dromes – Vernon and Schneider. larly those that can be influenced – are dence. • Fybromyalgia – Schneider, Vernon, Ko, important. However there have been few 8 studies assessing these factors in a large Crucial differences in quality of care are Lawson and Perera. population-based sample. An impres- ignored. In the field of spinal manipula- • Tendinopathy – Pfefer, Cooper and sive new study from Turner, Franklin et tion for example, there are fundamen- Uhl. 9 al. at the University of Washington, does tally different levels of education and These are accompanied by a strong, so and reports that one risk factor/pre- skill for different health professions. This clear and authoritative editorial by John dictor of chronic disability is choice of is apparent from trials such as Meade et Triano, DC PhD, formerly of the Texas 2,3 healthcare provider – and that “workers al., where chiropractors received sig- Back Institute in Dallas, now Dean of whose first health visit for the injury was nificantly superior results for back pain Research, Canadian Memorial Chiro- to a chiropractor had substantially better patients than did physical therapists, practic College, Toronto, and widely outcomes”. 4 and Carey et al., where medical doctors regarded as a leading international 1885 workers back injury claims involv- given postgraduate training in spinal authority on the management of back ing at least four days of lost work time, manipulation proved unable to assess pain. Triano’s editorial is titled What and covered by the State Fund in Wash- and treat back pain patients success- Constitutes Evidence for Best Practice?1 ington from July 2002 through April fully. Yet systematic reviews bundle all and makes many wake up and helpful 2004, were interviewed by telephone the trials together to provide one overall statements such as: three weeks after submitting a lost work assessment of whether spinal manipula- “Under-treatment” is as much of a policy time claim for back injury. Significant tion is an effective treatment. baseline predictors of one year work dis- concern as “over-treatment”, is often ability were subsequently found to be: In this situation it is imperative that caused by economically-driven inter- continued on page 4 the chiropractic profession has its own pretation of evidence and guidelines Main Article continued from page 1 by third parties, and is now “a serious language – for example the differences The Chiropractic Report is an international review problem with evidence of association of between evidence-based and evidence- of professional and research issues published six increasing chronicity and expense”. informed care, between standards and times annually. You are welcome to use extracts guidelines and best practices, etc. from this Report. Kindly acknowledge the source. “Evidence-based” was never intended Subscribers may photocopy the Report or order to mean “evidence-enchained.” As 5. Later in the 1990s the same US additional copies (.80 cents each, plus shipping explained by Dr. David Sackett and other chiropractic organizations, again led – minimum of 20 copies) for personal, non- founders of evidence-based medicine, by COCSA, formed the Council on commercial use in association with their practices. However, neither the complete Report nor the good practice involves a blend of “best Chiropractic Guidelines and Practice majority or whole of the leading article may be external evidence” and “individual clini- Parameters (CCGPP), as an independent reproduced in any other form without written cal expertise” – and as Sackett has said organization with an elected Council permission. “neither alone is enough”.11 and appointed Research Commission, The opinions and statements in this publication are those of the individual authors alone, not the In this issue of the Report we look at and representative panels of expert and Editorial Board, World Federation of Chiropractic or these new publications and their impor- clinically experienced doctors of chiro- any other organization. tance in clinical practice – but first some practic asked to produce best practices Subscription: for rates and order form, see page 8. brief history of the CCGPP. reports for different fields of chiropractic • Visit www.chiropracticreport.com practice. The papers now discussed are • Call 416.484.9601 • Email us at [email protected] B. CCGPP - Background the first published best practices of the CCGPP, and related research reviews. Editorial Board 3. In January 1992 all the major chiro- Other evidence reviews and best prac- Alan Breen DC, PhD, England Raul Cadagan DC, PT, Argentina practic organizations in the US, led by tices are being developed for other areas Ricardo Fujikawa DC, MD, Brazil the Congress of Chiropractic State Asso- of practice – preventive and wellness Scott Haldeman DC, MD, PhD, United States ciations (COCSA) because it was seen care, extremities, the cervical spine and Donald Henderson DC, Canada Nari Hong DC, South Korea as the most representative of the profes- non-musuculoskeletal disorder. Gary Jacob DC, MPH, LAc, United States sion, held a conference at the Mercy The overall goal of the CCGPP is to Dana Lawrence DC, United States Center, San Francisco to agree upon the establish a fair basis for the provision Charlotte Leboeuf-Yde DC, PhD, Denmark profession’s first ever evidence-based Craig Morris DC, United States of chiropractic healthcare services, and Lindsay Rowe DC, MD, DACBR, Australia consensus guidelines for practice. This judgement of them by others – one Hossein Sabbagh DC, Iran led to the Guidelines for Chiropractic based upon credible evidence and Louis Sportelli DC, United States Quality Assurance and Practice Param- Aubrey Swartz MD, United States patient-centered care and not driven by Yasunobu Takeyachi DC, MD, Japan eters (thereafter known as the Mercy selective evidence and other agendas. Changes of mailing instructions should be sent to Center Guidelines) published by Aspen They are a shield for patients and pro- 12 The Chiropractic Report, 203–1246 Yonge Street, in 1993. viders for appropriate care – but also a Toronto, Ontario, Canada M4T 1W5, These Guidelines represented a major sword for inappropriate and undocu- telephone 416.484.9601, fax 416.484.9665. Printed by Harmony Printing Limited, 416.232.1472. step forward, demonstrating a matu- mented care. Copyright © 2009 Chiropractic Report Inc. rity that gave the profession new cred- ISBN 0836-144 ibility in many circles. One result was C. Triano Editorial appointment of two representatives of the profession, Dr. Scott Haldeman and 4. Dr. Triano is a recognized leader in b) Because of the policies of managed Dr. John Triano, to the US government’s spine care because of a prominent career care “under-treatment is a serious prob- AHCPR Panel that produced the first in both research and clinical practice. lem with evidence of associated increas- US national guidelines on management His doctoral degree is in spinal biome- ing chronicity and expense.” While of back pain in 1994. Another result was chanics. Following his participation on over-treatment is also a legitimate health that there was evidence-based support the US AHCPR Clinical Practice Panel policy concern, “the social and economic for many aspects of chiropractic practice, he, with Richard Deyo, MD MPH from impact of under-treated pain is a prob- including management of patients with Washington, was one of the two featured lem to patients and to society which is conditions sometimes labelled as contra- experts on the Time Life Medical video often ignored in deference to concerns of indications to chiropractic care by others Back Pain designed for public education.