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Chiropractic Problems with the Biased and Discredited 'ODG Guidelines'
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Exposing the Bias of the Discredited ODG Guidelines in relation to 

Chiropractic Care and Utilization Review

REPORT TO THE EXECUTIVE DIRECTOR OF THE KENTUCKY

OFFICE OF WORKERS CLAIMS FROM THE TREATMENT

GUIDELINES COMMITTEE OF THE 2006 UTILIZATION REVIEW STUDY

Frankfort, Kentucky December 1, 2006

 Attachment 3 A

LOW BACK PROBLEMS: Chiropractic Care

Kentucky OWC Treatment Guidelines Subcommittee

Chiropractic Report

November 15, 2006

Preface

The current trend in the healthcare field is development of “best practices, evidence-based” guidelines. Previous attempts at guidelines as cookbooks or prescriptions for care had disastrous effects in patient management. In general, good guidelines are now considered as data sets to serve as background information to assist the physician in deciding the proper course of care based the best available evidence and their clinical experience. "Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough [emphasis added]. Without clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best external evidence, practice risks becoming rapidly out of date, to the detriment of patients (Sackett).”

An attempt to provide the best external evidence and yet retain the simplistic approach of cookbook guidelines is represented by the Official Disability Guidelines (ODG), with their confusing new approach of recommendations of automatically approvable care. We find the ODG to be laudable in its attempt list the evidence for provider scrutiny, but its cookbook conclusions are particularly problematic and a source of potential misuse and abuse. The medical necessity of care should be based on the documentation of benchmark outcomes found in the patient’s file, not in a guideline document that recommends arbitrary numbers of treatments. The greatest weakness of the ODG is this arbitrary assignment of treatment numbers, with no attempt to differentiate between mild, moderate, and severe conditions. Therefore, any reference to specific numbers of treatments over specific periods of time is inherently inaccurate compared to the actual facts of each injured workers' case. The development of quality for therapeutically necessary care requires triad of elements; Structure, which leads to Process, which leads to Outcome. Outcomes are universally measured to establish the appropriateness and medical necessity of care, yet are not referenced as benchmarks in the ODG guidelines. Our past experience with the misunderstanding or misuse of cookbook-style guidelines by claims managers, nurse reviewers, and outside peer review consultants gives us great concern that ODG will be used inappropriately by replacing the effort needed to understand the uniqueness of each patient, with arbitrary hard and fast numbers provided by the ODG easy reference. "Rigid standards and guidelines, which frequently are interpreted rigidly, must be avoided to allow for individual considerations and scientific innovation" (Triano).

ODG Background:

The editorial advisory board of the ODG is comprised of 78 people, including 62 doctors of medicine, 2 doctors of Osteopathy, and 2 doctors of chiropractic. Neither the American Chiropractic Association, representing the largest number of doctors of chiropractic in the world, nor, any of the profession's recognized researchers, were represented on the panel.

The prestigious Rand Institute evaluated ODG and four other guidelines at the request of the state of California, and ODG was not found to be a valid guideline for any of the low back treatment issues evaluated. Rand’s conclusion was, “The ODG guideline set was rated comprehensive and valid for both carpal tunnel surgery and shoulder surgery; the other two topics were of ‘uncertain validity”. And finally; “Seven of the 11 Rand panelists felt that ‘The five selected guidelines [including ODG] are not as valid as everyone would want in a perfect world.; They do not meet or exceed standards; they barely meet standards. [and] California could do a lot better by starting from scratch.”

Chiropractic Treatment Guideline Concerns:

While the ODG cites numerous references to support their recommendations; the process is reliant on a medically dominated committee's interpretation of the data. We have no confidence that a committee dominated by 62 medical physicians and only 2 DCs who do not represent the majority of practicing chiropractors or even chiropractic researchers, can produce a credible recommendation for chiropractic care. None of the papers cited in ODG supports the use of their rigid recommendations for the typical injured worker. ODGs “Codes for Automated Approval”, assigns procedure codes (CPT) to a diagnosis (ICD9) code with a recommendation for “maximum occurrences”, based on the self-admitted “ideal protocol”, for use in decisions to approve treatment. These specific “ideal protocol” numbers beg for misuse and abuse by those overseeing care based on the ODG. As previously seen by the outmoded guideline attempts to arbitrarily limit care, the ODG could be interpreted to avoid the much more laborious but appropriate determination of medical necessity by measuring patient progress. We challenge the supporters of ODG to produce credible references suggesting the appropriateness of 10 visits for a cervical disc, 18 for a lumbar disc, or 14-16 visits for post-surgical care. In our opinion, these numbers are overly conservative and will lead to unnecessary specialist referral, diagnostic imaging, pain relief prescriptions and surgical intervention in the injured worker population; contrary to the stated goals of the Utilization Review Committee.

Again, we return to the Rand Report for support of our objection to the adoption of ODG as the guideline for chiropractic care:

From the Rand report’s, “Clinical Evaluation Summary: Panelists’ Assessment of Comprehensiveness and Validity’, we find that ODG was rated “Appropriate” in only 2 of 6 criteria for Physical Therapy and Chiropractic. Rand’s conclusion on ODG on Lumbar spine physical therapy (passive care) and chiropractic care is found in Table S.5 (Panelists’ Assessment of the Comprehensiveness and Validity of Content Addressing the Quantity of Physical Modalities): “Lumbar spine physical therapy = Validity uncertain”; and, “Lumbar spine chiropractic = Validity uncertain”. We find guidelines with such weak validity unacceptable for treatment of an entire segment of the injured worker population.

ODG lists all passive modalities as “Not Recommended”, even though Rand found their validity, “uncertain”; and ODG omits the literature studying these passive modalities when used as an adjunctive treatment to the chiropractic manipulation. In contrast, however, the CCGPP (Chiropractic Committee on Guidelines and Practice Parameters) Best Practices Document, when studying the research specific to chiropractic practice (94% of manipulation in the USA is provided by chiropractors), found that these passive modalities were "Recommended" in conjunction with spinal manipulation. While ODG accurately states, “Successful outcomes depend on a functional restoration program, including intensive physical training, versus extensive use of passive modalities.”, they distort the phrase, “extensive use of passive modalities” into a conclusion of, “Not Recommended”, thereby totally eliminating not just extensive use, but any use, of these resources.

Also of particular concern is the confusion created by differing treatment recommendations found in the Disability Guideline (DG) and the Treatment Guideline (TG), sections of the ODG. The DG section suggests 18 visits over 6- 8 weeks for a typical nonradicular lumbar sprain/strain; while the TG section suggests “End manual therapy at 4 weeks” after what appears to be just 3 visits. [page 415 TG] An example provided in the very beginning of the TG section is that of a typical computer screen presumably available to a case manager, that indicates the treatment protocols for low back pain includes only 3 visits over a 4 week period, ending all manual therapy at 4 weeks. More troublesome is the fact that the “radiculopathy” section completely omits chiropractic management and the various conservative spinal manipulative techniques that are supported by the literature, decades of clinical experience and the chiropractic-specific CCGPP Best Practices Low Back Literature Review. While the chiropractic profession certainly encourages the shift towards active care, the ODG could easily be interpreted to suggest that no chiropractic care is appropriate after 3 visits or 18 visits, no matter the patient’s satisfaction and progress.

The chiropractic panelists are also concerned over the potential of ODG to restrict treatment to only limited spinal conditions for a limited course of care. For example, the ODG provides no mention of chiropractic management for the subacute, chronic and permanently injured worker.

Lastly, the ODG actually recommends a referral for both high cost diagnostic tests and referral to an orthopedic surgeon without even the benefit of a trial period of chiropractic care; an obvious bias resulting from a medically dominated ODG panel.

The WC system in Kentucky has experienced a dramatic increase in both drug expenditures and hospital based costs. If the ODG guidelines are adopted, especially for chiropractic care, the Commonwealth will likely experience an even greater shift toward increased drug and surgical costs for the most prevalent injuries suffered by workers by forcing those workers into higher cost medical management.

Best practice guidelines should be a source of information to provide the physicians with choices based on the best available medical evidence, but treatment guidelines based on rigid numbers and case averages is a concept already outdated and laden with potential conflict between physicians and case managers; with delays and uncertain care-paths for the injured worker. We have developed guidelines which supplement the data set of the Best Practices Document of the CCGPP, and rely on patient progress measured by outcome benchmarks with parameters for benchmarking that will control unnecessary or inappropriate care.

(The process of extracting, studying, referencing, and researching was limited by the time constraints of the committee process, so the chiropractic members of the subcommittee respectfully request an opportunity to further refine this guideline in consultation with the LRC and the Kentucky State Board of Chiropractic Examiners before its final adoption.)

Respectfully submitted,

Michael R. Hillyer, D.C.

Andrew P. Slavik, D.C.