The Joint Commission publishes Abstracts of Clinical Care Guidelines (ACCG) 10 times each year. While the commission does not endorse particular guidelines, its newsletter is designed to promote discussion of guidelines.
The April 1993 issue of ACCG reviews the Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy Guidelines), and the Practice Guidelines for Straight Chiropractic (Wyndham Guidelines). In addition, David M. Bell, J.D., "managing director in a law firm that emphasizes insurer consultation and litigation," provides a comparison of the two guidelines.
Each of the guidelines is summarized, followed by two reviews (pro and con). The first to be reviewed is the Mercy Guidelines. In each case, the opening paragraphs introduce the reader to the document:
Mercy Guidelines
"A commission of 35 chiropractors established by the Congress of Chiropractic State Associations (COCSA) has released a set of guidelines (parameters) for the practice of chiropractic. The guidelines, which are intended to be flexible and voluntary and are not standards of care, are part of an ongoing effort. With acceptance of chiropractic as a legitimate health care profession came recognition of the need for consensus within the profession on guidelines and overall quality assurance of care given by individual chiropractors. In 1989 and 1990 a number of conferences and workshops were held to define priorities and develop a consensus. The RAND Corporation was commissioned to evaluate the appropriateness of spinal manipulation for low-back pain and to develop specific indications and contraindications for chiropractic care, based on the RAND model for development of appropriateness criteria by a panel. The guidelines developed out of several rounds of drafting and critique by chapter teams, the commission steering committee, and the commission at large, culminating in the consensus conference at Mercy Center (Burlingame, Calif.) January 25-30. On April 11, 1992, the Federation of Chiropractic Licensing Boards expressly endorsed the recommendations. It has been anticipated that those wishing to incorporate the guidelines into their practices would be aware of them and have had an opportunity to adopt them by July 1, 1993.*References
"* The commission was chaired by Scott Haldeman, DC, MD, PhD, chairman of the Research Council, World Federation of Chiropractic, and associate clinical professor, Department of Neurology, University of California, Irvine. The 35 members, all graduate chiropractors, comprise 23 representatives of private practice in 14 states and provinces; 24 representatives with some affiliation with 10 colleges (8 full time, 12 with some research experience); and 18 representatives (either past or current) of 10 national, state, or other chiropractic associations. Sponsoring organizations and agencies are the Congress of Chiropractic State Association, Canadian Chiropractic Association, Federation of Chiropractic Licensing Boards, Foundation for Chiropractic Education and Research, Association of Chiropractic Colleges, Southeastern Chiropractic Federation, Texas Chiropractic Association, and National Upper Cervical Chiropractic Association."
Wyndham Guidelines
"In the interest of developing practice guidelines for chiropractors based on a credible consensus within the straight chiropractic community, the World Chiropractic Alliance initiated and organized the International Straight Chiropractic Consensus Conference in May 1992. The resulting guidelines, released early in 1993, cover all areas of practice of the straight chiropractic profession, which is defined as 'a limited, primary health care profession' with 'responsibility and authority... limited to the anatomy of the spine and immediate articulations, the condition of vertebral subluxation, and a scope of practice which encompasses addressing vertebral subluxations as well as educating patients and advising them about subluxations.' The guidelines are advisory and reflect the consensus of opinion arrived at during the consensus conference. They are not intended, nor should they be used, as a set of legally or ethically binding standards, but are instead intended as a method of guiding practitioners in the proper care of patients in keeping with the purpose and methods of straight chiropractic. *
References
"* Vertebral subluxation is a misalignment of one or more articulations of the spinal column or its immediate weight-bearing articulations, to a degree less than a luxation, which by inference causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential."
Vincent P. Lucido, DC, immediate past president of the American Chiropractic Association was asked by the ACCG Senior Editor Louise Kaegi to present the pro-Mercy review and Joseph P. Sasso, DC, president of the Federation of Straight Chiropractic Organizations presented the opposing position. Dr. Sasso presented the FSCO policy statement for his review. These are the concluding remarks of each reviewer:
Vincent P. Lucido, DC:
"To me, this is the ultimate benefit of the guidelines. They have made it necessary for me to examine my clinical practices in the light of the thinking of my peers and the scientific community. They will also help to make chiropractic physicians part of a responsible body of interdependent and mutually accountable professionals, instead of 40,000 individuals as a law unto themselves. The Mercy document will impress on the chiropractic physician the veracity of John Donne's declaration that 'no man is an island.'"
Joseph P. Sasso, DC:
"Since the Mercy document and standards have no relevance to the competent practice of straight chiropractic and, in fact, may cause the competent straight chiropractor to engage in extra professional exposure, it is the recommendation and opinion of the leadership of the FSCO that adherence to the standards proposed in the Mercy document constitute the incompetent practice of straight chiropractic. Therefore, it shall be the formal policy of this organization to resist any attempt to hold out membership to the standards contained in the Mercy document. Further, it shall be the policy of the FSCO to vigorously oppose any attempt lend the force of law to the Mercy document as the sole standard of care in any venue."David A. Pearson, PhD, professor and chair of the Department of Health Management and Policy, University of New Hampshire, Durham, presented the pro-review of the Wyndham Guidelines, with Alan Adams, DC, vice-president for professional affairs at Los Angeles College of Chiropractic providing the critical comments. Dr. Pearson's opening paragraph provided the best summation of his remarks, compared to Dr. Adams' closing paragraph:
David A. Pearson, PhD:
"These practice guidelines were developed at a consensus conference attended by 46 practitioners of straight chiropractic from the United States, Canada, France, Australia, and New Zealand. Participants at the conference consisted of doctors of chiropractic currently in practice, academics from chiropractic colleges, and researchers with DC degrees as well as PhDs. The guidelines clearly state that the basic objective of straight chiropractors is the correction of vertebral subluxation and the vertebral subluxations do not necessarily correlate with pain."Alan H. Adams, DC:
"Finally, one is left with the impression that Practice Guidelines for Straight Chiropractic was produced as an alternate to evidence-based practice guidelines represented in the document Guidelines for Chiropractic Quality Assurance and Practice Parameters. Unfortunately, the effort put forth by the straight chiropractic community is of dubious value because of questionable use of expert opinion, lack of explicit methods for consensus development, and poor documentation on the use of scientific evidence."David Bell, J.D. gives an interesting legal point of view in comparing the two documents. It is significant, that his is the only critical comparison included from the legal/third-party payer perspective. This is a sample of how he views the two guidelines:
Comparative commentary (on Mercy consensus and WCA consensus conferences): "From the perspective of one involved in insurer and third-party payment of claims, the recent publication of the Mercy Center Guidelines and the Wyndham Conference Guidelines provides valuable insight into the chiropractic profession, its approach to health care, and the willingness of its members to critically analyze its foundations and methods. On the one hand, the Mercy Center Guidelines not only appear to provide careful evaluations of chiropractic methods and practices but also demonstrate the profession's willingness to present its recommendations in a format that can be critically evaluated by others. In sharp contrast, the Wyndham Conference Guidelines are so vague, unsubstantiated, and defensive that their overall impact is to demonstrate a hurried "circling-of-the-wagons" reaction to the trends toward health care standards and guidelines."These guidelines will continue to be reviewed by third-party payers and governmental agencies across the U.S. Only time can tell what the true utility will be of each document."The strengths of the Mercy Center Guidelines also serve to highlight the corresponding weaknesses of the Wyndham Conferences Guidelines. For example, whereas the Mercy Center Guidelines emphasize well-designed controlled studies or clinical trials as the preferred evidentiary support for recommendations, the Wyndham Conference Guidelines apparently place greater emphasis on largely undefined and unreferenced "expert opinion, clinical experience, or effectiveness studies" (category "E" of "supporting evidence"). For example, in the chapter "Parameters of Care" no references are cited to justify the recommendation that for "Level Care," frequency of care should be daily to three times per week, with duration of care ranging from two to six months. In the chapter "Instrumentation," the authors make an unsupported and misleading assertion that "FDA approval (for 'medical devices') means the device has been shown to perform the function(s) that is/are claimed by the manufacturer."
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