Clinical Guidelines for Chiropractic Practice in Canada
Donald J. Henderson, D.C., F.C.C.S.(C)
All health care professions have recognized the need to develop practice guidelines that assure quality care - care that is both clinically effective and cost-effective. The process of establishing clinical guidelines is a lengthy and demanding one. It requires input from diverse groups who must review and assimilate the evidence for and against every aspect of a guideline recommendation.
Primary considerations in drafting practice guidelines are protecting the patient's best interest and ensuring that guidelines are realistic and reasonable for the practitioner to implement in daily practice. Guidelines should not represent a rigid prescription or standard given that individual clinical situations vary from case to case and given that continuing changes in practice are necessary in light of new research.
Once drafted, a set of guidelines must be subject to continuous review for accuracy, clarity and clinical commonsense. Eventually, those involved in this process should include not only the professionals subject to the guidelines but also consumers, third-party payers and other health care professions.
Background to The CCA Standards Project
At the May, 1990 Annual Meeting of The Canadian Chiropractic Association's Board of Governors, a motion was passed unanimously to establish national practice guidelines for chiropractic practice. On December 6, 1990 a letter from The Canadian Chiropractic Association (CCA) was sent to every chiropractic organization in Canada requesting their sponsorship and assistance. In response, virtually every provincial and national association, council, college and regulatory board has supported the effort to establish national guidelines.
A CCA sub-committee consisting of 25 chiropractors called the Guidelines Review Group was formed on April 15th, 1991 and began critiquing the literature and consulting others in the profession. Members of the Review Group represented either national or provincial chiropractic organizations whose participation and representation was considered essential to the success of the project. The Review Group drafted preliminary guidelines in 20 areas of chiropractic practice.
Details of the project were discussed in issues of The CCA News, and a brochure entitled "Establishing Guidelines for Chiropractic Practice" was circulated to the profession on two occasions. This communication helped facilitate understanding and acceptance of the process and, hopefully, will assist implementation in the future. It was felt that field practitioners should be kept informed and have the opportunity to contribute or make further inquiry through their respective provincial Association, regulatory Board or College -a focus that was consistent over the three-year period of the project.
A strict timeline was placed on the Guidelines Review Group, beginning with a meeting in Toronto on May 5th, 1991. By March 7th, 1992 initial drafts of the Guidelines Document were completed and a Guidelines Workshop was held on May 27th, 1992 held in conjuction with The CCA's Annual Convention in Regina. The draft document was circulated to all sponsoring organizations for their review. Status reports were delivered during meetings of provincial associations and regulatory boards.
Having completed its work, the Guidelines Review Group was disbanded in August 1992. It was superseded by a Guidelines Consensus Group or Commission. Again, there was representation from each national and provincial chiropractic sponsoring agency. Additionally, in response to a general announcement and returned field applications, fifteen members-at-large were added to the Commission including one lay member representing the public interest. This group represented a good cross-section of the chiropractic profession - there was a mix of gender, age, years in practice, practice styles, clinical and academic experience, region of practice and college of graduation. Of the organizational representatives, there was a balance of chiropractors from the provincial associations as well as the licensing bodies whose experience comes from protecting the public interest.
It was the task of the 35 members of the newly formed Commission to re-evaluate the Review Group's draft guidelines document studying text and providing further clinical support for suggested guideline revisions. The Commission as a whole was to impartially appraise and incorporate text changes proposed by any source (sponsoring organizations or field practitioners) so long as this was supported by the indexed literature or a consensus of expert opinion. This re-evaluation, which took place over a seven-month period, was preliminary to a four-day consensus meeting to vote on and establish guidelines.
Concurrent American Guidelines Project
During the development phase of The Canadian Chiropractic Association's national guidelines initiative, a similar project had been underway in the United States commissioned by the the Congress of Chiropractic State Associations. A consensus conference held on January 25-30, 1992 at the Mercy Center in Burlingame, California led to the publication of its proceedings in late 1992. This historic document provided a wealth of resource material for The CCA Commission's consideration. Indeed with minor revision and permission, some of the chapters have been reproduced within this document. Further, the consensus method used at the Mercy Conference served as a model for the Canadian conference.
The Glenerin Consensus Conference
This conference was held over four long days from April 4-7th, 1993 at the Glenerin Inn in Mississauga, Ontario, and brought all 35 Commission members together in round-table format. The guideline recommendations were debated and voted upon in the plenary sessions. The consensus method used at the conference ensured participation by those who would be most directly affected by the decisions reached - practising chiropractors. Each chapter was concluded during the plenary sessions then signed off on the last day.
In two instances, original chapter areas were merged with another because this was considered appropriate. Three hundred and five guideline recommendations were voted upon with nearly all votes achieving a consensus level greater than 90%. There were no minority opinions; quite remarkable given the sensitivity of some of the issues. When all chapters were signed off the Conference was adjourned on the fourth day allowing the Guidelines Steering Committee the right to make minor editorial changes leading up to the document's publication.
Three years after The CCA initiated the project it was finally complete. There had been as much professional participation as possible. More than a few hundred people were involved in shaping the document.
The conclusions reached by those involved are not final, since continuous evaluation is implicit in the process of establishing and implementing practice guidelines. For this reason, The CCA has a Practice Guidelines Committee in place and is committed to working to keep this document current and reflective of the literature and quality chiropractic care. Within a two to three year period, another consensus conference should be convened to review these Glenerin guidelines.
While every effort was made to consider all authoritative and scholarly sources, it is acknowledged that these guidelines will not be perfect. Nor is it expected that everyone will agree with each guideline or recommendation. If clinical research or legal decisions express a contrary point of view, this should be taken into account in future revisions. All individuals or groups wishing to challenge or amend a guideline statement, rating, or anything else in the following chapters are encouraged to write to The CCA Practice Guidelines Committee - for further particulars see p. 179 Those wishing to challenge the appropriateness of the guidelines, but having little or no research to support their point of view, are actively encouraged to perform or support new clinical research.
It is timely that, as the chiropractic profession approaches its centennial celebrations in 1995, a national clinical guidelines document is presented to both the membership and public. Chiropractic becomes one of the first of the health care professions to have nationally based clinical guidelines affirmed in print.
Many participants deserve acknowledgement. The names of those who worked on the Steering Committee, the Review Group, the Guidelines Commission (Consensus Group) and all consultants, are given elsewhere. They spent countless hours away from office and family researching, writing, reviewing and attending meetings and deserve special thanks.
There should also be particular acknowledgement of the hard work and support of Dr. James L. Watkins, Theresa Barton, Lauri Dunlevy, and Stephanie Austin at The CCA office, Beverly Fuller at the Canadian Memorial Chiropractic College, and Serena Smith at The Chiropractic Report. Special thanks is given to the members of The CCA Board of Governors for their guidance and commitment that saw this project proceed to a completed product.
Finally, there should be acknowledgement of the support and encouragement of all participating organizations, particularly The Canadian Chiropractic Association and The Canadian Chiropractic Protective Association who provided the necessary funding. Without their firm support and encouragement this undertaking would still be in the "good idea" phase.