Canadian Chiropractic Guideline Initiative: progress to date

Post on September 18, 2014 by André Broussard, D.C.

André Bussières, DC, MSc, PhD
J Can Chiropr Assoc. 2014 Sep; 58(3): 215–219.

 

Background

The Canadian Chiropractic Guideline Initiative (CCGI) is operating at full speed. On behalf of the dedicated clinicians, researchers, academics, and leaders in the chiropractic profession contributing to the success of the CCGI, it gives me great pleasure to share our progress to date.

Achieving our long term goal to improve on the delivery of chiropractic care and patient health requires a wide range of expertise and commitment by all levels of health care. It is important to acknowledge the work of a large number of dedicated people involved in the Committees and Working Groups of the CCGI (see details below).

The Clinical Practice Guideline Initiative was launched by the Canadian Chiropractic Association (CCA) and the Canadian Federation of Chiropractic Regulatory and Education Accrediting Boards (CFCREAB or Federation) over a decade ago to develop clinical practice guidelines (CPGs) to improve delivery of chiropractic care in Canada. CPGs aim to describe appropriate care based on the best available scientific evidence and broad consensus while promoting efficient use of resources. For details, see: Bussières A, Stuber K. The Clinical Practice Guideline Initiative: A joint collaboration designed to improve the quality of care delivered by doctors of chiropractic. J Can Chiropr Assoc. 2013; 57(4):219–84.

To accomplish its complex tasks, the Guideline Initiative is made up of a Guideline Steering Committee, a Guideline Advisory Committee, a Guideline Development Group, an External Review Group, a Guideline Implementation Group, an International Scientific Advisory Committee, research associates and graduate students (Appendix 1). Committee members originate from several countries and represent a range of clinical and scientific disciplines or specialties. The first annual report dated December 2nd 2013 described the structure, methods and procedures of the Guideline Initiative. The following presents the key elements contained in the semi-annual report dated June 2014.

On March 29–30th 2014, the Guideline Steering Committee along with 5 key members representing each guideline working group (Guideline Advisory Committee, Implementation Group and Development Group) gathered in Toronto for a strategic planning session. Each representative contributed valuable insight from different vantage points which helped the group accomplish its target goal of creating a robust new vision, mission and strategies for the project.

The new statements and strategies are as follows:

  • Vision
    Enhance the health of Canadians by fostering excellence in chiropractic care.
  • Mission
    Develop evidence-based clinical practice guidelines and best practice recommendations, and facilitate their dissemination and implementation within the chiropractic profession.

Strategies

  1. Transform the culture of the profession to one that is guided by evidence-informed practice.
  2. Engage stakeholders to sustain the Canadian Chiropractic Guideline Initiative.
  3. Produce, adapt or endorse recommendations relevant to chiropractic practice to enhance patient care, based on the best available evidence.
  4. Create and apply innovative knowledge translation strategies to influence chiropractic practice.

A motion to pass the newly created vision, mission and strategies was unanimously adopted and passed at the end of the meeting. A small sub-group from the GSC met on April 17th to develop the tactics (activities) and metrics (evaluation measurements) that will be prioritized to accomplish the vision and mission. Tactics and metrics were approved by the GSC in May 2014.

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Overview of the Roles and Responsibilities of Committees and Working Groups of the CCGI:

The various committees and working groups regularly meet online to discuss tasks related to the respective mandates. Face-to-face meetings occurs once or twice a year as needed.

  • Guideline Steering Committee (GSC)
    The 6 member-committee established governance policies. The GSC provides overall direction, approves the budget and monitors progress of the CCGI.
  • Guideline Advisory Committee (GAC)
    The 9-member committee provides guidance on the overall direction and monitors progress made by the CCGI. In addition, GAC members may advise on individual projects undertaken by working groups.
  • Guideline Development Group (GDG)
    The 15-member committee held its first face-to-face meeting in Toronto on January 10–11, 2014. The scope, key questions (Analytical Framework and systematic review/best evidence synthesis) and timeline for the low back pain (LBP) Assessment guideline were determined during a series of calls after the meeting. Considering ongoing work in this field, the GDC will appraise, and adapt and/or adopt upcoming recommendations on the management of LBP and other musculo-skeletal conditions. Details are provided below.
  • Guideline Dissemination/Implementation Group (GIG)
    The 17-member committee regularly meets to advance a series of projects to support specific dissemination activities. To ease its work, four subgroups were created: practitioner; patients; schools; leader/decision makers. Each subgroup is developing strategies to help disseminate key findings of the updated CCA-CFCREAB Neck Pain guideline (Bryans R, Decina P, Descarreaux M, Duranleau M, Marcoux H, Potter B, et al. Evidence-based guidelines for the chiropractic treatment of adults with neck pain. J Manip Physiol Therap. 2014;37(1):42–63).
  • External Review Group
    Composition of the External Review Group will include members of the recognized chiropractic specialties.
  • North-Atlantic Research Consortium (NARC)
    A collaborative agreement between the CCA (Canada), and chiropractic professional organisations in Denmark, Norway, Switzerland and the UK was signed in 2011. This agreement aims to facilitate collaborations between involved countries on education, research and clinical practice guidelines. Two researchers from Denmark are members of one of the working groups of the Guideline Initiative and a researcher from Norway assists with another project. NARC members met at the 2014 ECU conference. Additional representatives were invited to participate. Graduate students may participate in specific research projects of the Guideline Initiative. This has the advantage of helping build research capacity within respective countries while provide the CCGI with additional resources and expertise.
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Achievements since October 2012

(aligned with the four new strategies outlined above)

Strategy 1: Transform the culture of the profession to one that is guided by evidence-based practice

  1. Identifying Opinion Leaders:
    Stakeholders of the CCGI received an invitation to complete a survey to identify potential opinion leaders (OLs) to help disseminate key messages from guideline recommendations. A committee met in June 2014 to select over twenty OLs who will receive training in the fall 2014 and the winter of 2015. OLs will help disseminate key messages to practitioners and stakeholders.
  2. Medium and long term plans:
    Harmonization of Continuing Education (CE) across jurisdictions in Canada and establishing partnerships with teaching institutions is deemed important to take advantage of existing strategies and programs and to create opportunities for sharing and disseminating best practices and guideline recommendations. Development of a national continuing education program will be recommended to help standardize accreditation of quality CE activities. Furthermore, routine data collection to inform practice patterns and variations, identify evidence-practice gaps, and help determine if and how best practice influence patient care and patient health is recognized as important. This may be accomplished using available/tailored electronic health technologies to provide quality objective data on day-to-day chiropractic patient encounters.

While these two projects are necessary for the wellbeing of the profession and patient, and serve to help integrate the profession into the health care system, their accomplishment largely depends on the commitment of stakeholders, including regulatory boards, professional associations, and academic institutions.

Strategy 2: Engage stakeholders to sustain the Canadian Chiropractic Guideline Initiative

  1. Develop a sustainability plan:
    The Guideline Steering Committee will aim to stabilize and diversify funding of the CGI. Multiyear funding from stakeholders will be sought.
  2. Ensure stakeholders have opportunities to engage:
    Semi-annual reports tied back to strategy are provided to stakeholders in June and December. Engagement at national meetings will create the appropriate structures to ensure transparency.

Strategy 3: Produce, adapt or endorse recommendations relevant to chiropractic practice to enhance patient care, based on the best available evidence

  1. Gap analysis on content areas:
    The Guideline Development Group (GDG) will help identify gaps in the current availability of clinical practice guidelines and best practice. Specifically, GDG members will compare findings with a list of ongoing systematic reviews, best evidence synthesis and clinical practice guidelines. A priority list will be developed and circulated among stakeholders. The GDG will then adapt/endorse/develop key recommendations based on this prioritization.
  2. Assessment of LBP:
    The Bone and Joint Canada initiative aims to recommend a model of care for the management of LBP within the next 3–6 months. In addition, national LBP guidelines are currently being updated (e.g., NICE in the UK and TOP in Canada). The CCGI is closely monitoring work undertaken by the different groups. Results will be considered by members of the GDG prior to disseminating to Canadian chiropractors.

Strategy 4: Create and apply innovative knowledge translation (KT) strategies to influence chiropractic practice

Specific knowledge translation interventions of the CCGI are further described in a Commentary in the current issue (see page 206).

  1. National E-BASE-survey:
    An IRB approval was received by McGill for a survey aimed at identifying Canadian chiropractor’s attitudes and skills toward evidence-based practice. Similar studies were conducted by Dr. Mike Schneider DC, PhD amongst US chiropractors (phase 1 of an R21 grant study) and by Dr. Matthew Leach in Australia amongst Complementary and Alternative Medicine (CAM) providers. The study was launched in December 2013. Over 7000 invitations were sent out across the country through the CCA, the provincial chiropractic jurisdictions and the JCCA. Return rate was less than 10% despite three reminders. Significant technical challenges were encountered (password to register received in junk mail for a number of participants). Data analysis will be conducted in summer of 2014.
  2. Ontario Chiropractic Observational and Analysis Study (O-COAST): improving quality of care through better understanding of current chiropractic practice.
    Principal investigators, Sil Mior DC, PhD, André Bussières DC, PhD and Simon French BAppSc(Chiropractic), MPH, PhD obtained funding from the Ontario Chiropractic Association (OCA) and from Queen’s University in early 2014 to document the reasons people seek care from Ontario chiropractors, the problems/diagnoses identified by chiropractors and the treatment they provide. The results of this project will be used to leverage further funding to undertake a national Canadian study in the future. We believe the proposed research will be the first in Canada to document what happens in chiropractic practice, providing the foundation for ensuring that people who seek the care of a chiropractor are provided with the most effective and safest approach. A meeting of the steering committee occurred with representatives of the OCA and CCA in March 2014. The study was launched in June 2014.
  3. Scoping review on Research utilization, evidence-based practice, and knowledge translation in chiropractic:
    Over 3618 citations were retrieved from the search, of which 53 matched the eligibility criteria. Descriptive and content analysis were completed in June 2014. Findings will inform on what has been done thus far on these topics (research utilization, evidence-based practice, and KT in chiropractic). A manuscript will be submitted for publication in the fall.
  4. Information hub on best practices:
    The new responsive website of the CCGI is hosted under the CCA while remaining independent (http://chiropractic.ca/guidelines-best-practice/). The Web-site was developed in collaboration with members of the Guideline Dissemination/Implementation Group (GIG) and the CCA. Material and tools to accompany guidelines are being developed for three target audiences: 1) practitioners (guidelines and tools, methods to help implement CPGs, useful links to high quality information); 2) patients (shared decision making tools, self-care, and key recommendations to stimulate discussion with clinicians), and 3) decision makers (to help identify important issues to consider for implementing guidelines within respective jurisdictions).
  5. Neck Pain guideline implementation study:
    Members of the GIG are developing a proposal to test the implementation of a theory-based tailored KT intervention. The feasibility study is expected to begin in the fall of 2014.
  6. Chiropractic Practice-Based Research Network (PBRN):
    A CIHR planning grant was submitted by Dr Bussières along with 10 co-investigators (a national and international multidisciplinary research team) in October 2013. The aim of this project is to bring together clinicians, patients, decision-makers and researchers to recommend strategies for the creation of a PBRN infrastructure so that research can be conducted to improve the delivery of appropriate, high quality chiropractic care to Canadians with musculoskeletal complaints. A first meeting is planned for the end of 2014. Details of the proposed PBRN may be found in a commentary published in the JCCA (Bussières A, Côté P, French S, Godwin M, Gotlib A, Graham ID, Grondin D, Hawk C, Leboeuf-Yde C, Mior S, Stuber S. Creating a Chiropractic Practice-Based Research Network (PBRN): Enhancing the management of musculoskeletal care. J Can Chiropr Assoc. 2014; 58(1):8–15.

We hope that you will be as excited as we are by the rich potential of the Canadian Chiropractic Guideline Initiative and look forward to hearing from you about ideas for collaboration and other activity in this critical area for the future of the chiropractic profession. Please visit our website at (http://chiropractic.ca/guidelines-best-practice/).

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Appendix 1. Clinical Practice Guidelines Initiative (2013–2017)

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Articles from The Journal of the Canadian Chiropractic Association are provided here courtesy of The Canadian Chiropractic Association

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