"DC": Dr. Brook, considering the current political and economic health care environment, what is the value of the chiropractic profession for conducting standards of care studies?
"DC": Can you expand on the types of studies and issues that need to be examined in order to do a thorough job as far as the standard of care studies?
Dr. Brook: In terms of development of standards of care, one has to combine a process in which the literature is carefully analyzed in a quantitatively sophisticated method utilizing expert judgement. As any physician knows, the literature rarely answers definitively a single question. There are contradictory studies, there are groups of people that are excluded from studies, and the process that needs to be followed must combine expert judgement with the literature analysis. In our opinion, that expert judgement needs to be multidisciplinary because almost everything we do in medicine involves more than one type of practitioner, and developing a process to distinguish what works and what doesn't work requires the involvement of multiple specialties.
"DC": What makes the RAND Corporation specifically qualified to conduct this type of research?
Dr. Brook: RAND is a non-profit corporation with a public governing structure that does research in the public interest and produces products all of which are in the public domain. These criteria would seem to be useful in this activity. In addition to these generic criteria that RAND possesses, RAND for the last 20 years has had an extremely active group of individuals in the health area. This group has been distinguished by its multidisciplinary nature and involves physicians, social scientists, economists, statisticians, and other individuals whose expertise are called upon when practice standards are developed. We have also, for the last decade, been involved in developing methods by which valid standards or guidelines can be developed and all of these attributes, one hopes, would make it an organization to be considered in developing such guidelines.
"DC": Considering all the work that is being done by the other health care professions at this time and the work that is being done with the RAND Corporation in conjunction with the consortium and FCER, is the chiropractic profession ahead, behind, or running about even with what the other health care professions are doing?
Dr. Brook: Basically, at the moment I think it is a toss-up. The chiropractic profession did fund at RAND a multidisciplinary panel to develop indications for the use of manipulation. It is the first time that money to develop indications was funded by a professional group at RAND and in that regard I think that the chiropractic profession has demonstrated leadership. The chiropractic organization funded this panel even though it was multidisciplinary in nature and knew that the results of the process would be put into the public domain whether or not it supported its specific viewpoint. Other appropriateness work at RAND has been funded by foundations and the government. As you may know, we have just entered into a consortium agreement with academic medical centers and the American Medical Association to continue some of the work we have done and to improve it. In that regard, I think the chiropractic profession has been at least as involved as other organizations in funding a multidisciplinary approach to establishing practice guidelines. In terms of an individual specialty approach, I really can't comment on that subject, but I can tell you that organizations like the American Medical Association have put together books on the development of practice guidelines by individual specialties and I believe they have over 700 different entries into those books. I do not have firsthand knowledge about what the chiropractors have done individually as an individual specialty in developing guidelines. I would say, however, that I believe the future of guideline development requires a multispecialty approach and thus believe that the chiropractors have taken a major step forward by funding a multidisciplinary approach to setting guidelines for the use of manipulation.
"DC": We are beginning to see evidence within the third-party payer systems that there are standards or levels, if you will, that have been established for chiropractic care and the payment of such. Do you feel that the establishment of standards of care by the profession will help to correct or could possibly refute some of those internal standards that have been adopted?
Dr. Brook: I don't know the answer to this question because I haven't seen the standards to which you refer. I believe strongly that the standards, parameters, and guidelines by which our profession is examined, judged, evaluated, or whatever word you use, have to be in the public domain. So, I think it is to all of our interest that they be produced in the public domain. Now how they will be used will vary. I, as a physician, would like to believe that we can use an educational process to get these guidelines or standards adopted. On the other hand, I have read enough of the educational literature to realize that we may need to go beyond the strictly educational approach and I am sure people will use the standards for reimbursement. They may also be used for developing new programs of recertification or relicensure and for many other purposes. However, I hope their primary use becomes an educational one and I hope they are used in a constructive, self-improvement manner.
Include in multidisciplinary study, everywhere we have that -- put a print in including doctors of chiropractic.
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