Evidence-Based Care and Clinical Practice Guidelines
Clinical practice guidelines allow DCs to keep their knowledge and skills current, ensuring standards of care. Easier said than done?
By David J. Brunarski, DC, MSc, FCCS(C)
The Institute of Medicine defines clinical practice guidelines (CPGs) as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances."1
The intent is to guide evidence-based clinical practice, but in practical terms; their widespread use would facilitate patient access, improve the quality of patient care and outcomes, as well as maximize efficiency, effectiveness and cost-benefit ratios.2
The National Guideline Clearinghouse (NGC) is the free-access database funded by the U.S. government's Agency for Healthcare Research and Quality. A clinical practice guideline must meet the following criteria to be included in the NGC:
- The guideline must contain systematically developed recommendations, strategies or other information to assist health care decision-making in specific clinical circumstances.
- The guideline must have been produced under the auspices of a relevant professional organization (such as the Canadian Chiropractic Association and the Canadian Federation of Regulatory Education and Accrediting Boards).
- The guideline development process must include a verifiable, systematic literature search and review of existing evidence published in peer-reviewed journals.
- To remain current, a guideline must have been developed, reviewed or revised within the past five years.3
The history of health care guidelines in the modern era began with the introduction of surgical anaesthesia. Guidelines were necessary then, as they are now, because they specified the most effective techniques to minimize negative side effects and improve patient safety. The NGC lists close to 400 contributing organizations and over 2,400 guidelines. The Web site receives nearly 1.5 million visits every month.4
The most scientifically rigorous guidelines are developed through a multidisciplinary process that incorporates validity, reliability, reproducibility, clinical applicability, flexibility and clarity. Despite a guideline's intention to treat with best practices, adherence to guidelines has been reported to be variable across all health care providers and jurisdictions, and guidelines seem to have little impact on changing physician behaviour.5-6
Although most clinicians espouse tacit support for guidelines in terms of their utility, educational value and potential to improve the quality of care they provide, many clinicians still complain that CPGs are impractical, unlikely to be appropriate for their individual patients, impose limits on the doctor's autonomy, and could even increase the risk of litigation or disciplinary action if not followed explicitly.7
Reviews of guideline use report that clinicians often feel guidelines are too complex and confusing. Concerns focus on what many perceive to be an overly complicated guideline development process and lack of a standardized grading system, which limit comparison between different guidelines and undermine trust in the applicability of the recommendations in actual practice situations.8-13
The most common barriers to evidence-based practice and the successful implementation of CPGs include:
- Clinicians who are more comfortable relying on their own experience-based knowledge in deference to the inherent uncertainty of the scientific evidence.
- Guidelines that discourage certain treatments or behaviours are considered to be proscriptive. Some health care providers believe this could negatively impact a clinician's autonomy and decision-making; effectively disrupting the doctor-patient relationship.
- Ten percent of clinicians are unaware of the existence of guidelines affecting their sphere of practice. Even when aware of the guidelines, many lack enough familiarity with the process to effectively apply the recommendations in their practices.14-15
Many of the neuromusculoskeletal conditions chiropractors treat are chronic conditions with high prevalence, co-morbidity and prolonged economic burden. It is difficult for most clinicians to be familiar with all of the existing standards of care and their supporting scientific evidence. Knowledge transfer is not a linear process, but evolves over time and can leave gaps in patient care. So, what happens when there are challenges to a chiropractor's clinical knowledge, skill, attitudes and competencies by government, third-party payers and preferred provider plans?
Clinical practice guidelines are effective and efficient knowledge translation tools that doctors of chiropractic can use to keep their knowledge and skills up to date. The Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards formed a joint task force in 2002 to oversee the development of chiropractic clinical guidelines.16 Originally intended for Canadian chiropractors, the neck pain guideline17 and the whiplash guideline18 in particular have received international critical acclaim.19 The headache guideline is currently in press.20 The Canadian chiropractic clinical guidelines adhere to the most rigorous methodological standards of guideline development and, on average, are "larger and more encompassing than guidelines in other areas."21
- Field MJ, Lohr KN. Clinical Practice Guidelines: Directions for a New Program. Committee to Advise the Public Health Service on Clinical Practice Guidelines. Institute of Medicine. Washington: National Academy Press, 1990.
- Manchikanti L. Evidence-based medicine, systematic reviews, and guidelines in interventional pain management, part 1: introduction and general considerations. Pain Physician, 2008 Mar-Apr;11(2):161-86.
- National Guideline Clearinghouse. www.guideline.gov
- Manchikanti L, Singh V, Helm II S, Schultz DM, Datta S, Hirsch J. An introduction to an evidence-based approach to interventional techniques in the management of chronic spinal pain. Pain Physician, 2009 Jul-Aug;12(4):E1-33.
- Lopez-Olivo MA, Suarez-Almazor ME.Developing guidelines in musculoskeletal disorders. Clin Exp Rheumatol, 2007 Nov-Dec;25(6 Suppl 47):28-36.
- Busse JW, Guyatt GH, Bhandari M, Cassidy JD. User's guide to the chiropractic literature-1B: how to use an article about therapy. JMPT, 2003 Oct;26(8):525-32
- Kotzeva A, Sola I, Carrasco JM, et al. Perceptions and attitudes of clinicians in Spain toward clinical practice guidelines and grading systems: a protocol for a qualitative study and a national survey. BMC Health Services Research, 2010;10:328.
- Francke AL, Smit MC, de Veer AJE, Mistiaen P. Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review. BMC Medical Informatics and Decision Making, 2008;8:38.
- Bishop PB, Wing PC. Knowledge transfer in family physicians managing patients with acute low back pain: a prospective randomized control trial. Spine J, 2006 May;6(3):282-8.
- Djulbegovic B, Trikalinos TA, Roback J, Chen R, Guyatt G. Impact of quality of evidence on the strength of recommendations: an empirical study. BMC Health Services Research, 2009;9:120.
- Bishop P, Badii M, Wing P. Implementation of clinical practice guidelines in workers compensation board patients with acute mechanical back pain: a prospective randomized trial. Spine J, 2002 Sept;2(5, Supplement):62-3.
- Dahm P, Yeung LL, Gallucci M, Simone G, Schunemann HJ. How to use a clinical practice guideline. J Urol, 2009 Feb;181(2):472-9.
- Schuemann HJ. GRADE: from grading the evidence to developing recommendations. A description of the system and a proposal regarding the transferability of the results of clinical research to clinical practice. Z Evid Fortbild Qual Gesundhwes, 2009;103(6):391-400.
- Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud P-AC, Rubin HR. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA, Oct 20, 1999;282(15):1458-65.
- Carlsen B, Glenton C, Pope C. Thou shalt versus thou shalt not: a meta-synthesis of GP's attitudes to clinical practice guidelines. British Journal of General Practice, 2007;57:971-8.
- Bridge G. The Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory Boards clinical practice guidelines development initiative (the CCA/CFCRB-CPG) Development, Dissemination, Implementation, Evaluation and Revision (DevDIER) Plan. J Can Chiropr Assoc, 2004;48(1):56-72.
- Anderson-Peacock E, Blouin JS, Bryans R, et al. Guidelines Development Committee (GDC), The Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory Boards, Clinical Practice Guidelines Development Initiative ( The CCA-CFCRB-CPG) Chiropractic Clinical Practice Guideline: Evidence-Based Treatment of Adult Neck Pain Not Due to Whiplash. J Can Chiropr Assoc, 2005;49(3):158-209.
- Shaw L, Descarreaux M, Bryans R, Duranleau M, et al. A systematic review of chiropractic management of adults with whiplash-associated disorders: recommendations for advancing evidence-based practice and research. Work, 2010;35:369-94.
- Personal communication with Elanor White, President, Canadian Chiropractic Association.
- An evidence-based guideline for the chiropractic treatment of adults with headache. JMPT (in press).
- Status report on the activities of the CCA / FCCRB clinical practice guidelines project. March 2011.
To review the current Canadian clinical practice guidelines, go to www.chiropracticcanada.ca/AboutUs/ClinicalPracticeGuidelines.aspx.
Dr. David Brunarski, former associate editor of DC Canada, graduated from CMCC in 1977 after completing his undergraduate educa-tion at the University of Alberta. He is president of the Ontario Chiropractic Association and practices full time in Simcoe, Ontario. To learn more, visit www.dynamicchiropractic.ca/drbrunarski.