canadian chiropractic guideline initiative (ccgi) introduction & implications for clinicians,...
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Canadian Chiropractic Guideline Initiative (CCGI)Introduction & implications for clinicians, patients & our profession
CCGI Introduction
• Our Vision:– Enhance the health of Canadians by fostering
excellence in chiropractic patient care• Our Mission:– Develop evidence-based CPGs and best practice
recommendations– Facilitate dissemination & implementation within
the chiropractic profession
CCGI Introduction
• Funded by a majority of Professional Associations & Licencing Boards
• CPG Projects:– Neck Pain due to Whiplash (2010)– Headache (2011)– Neck Pain not due to Whiplash (2014)– Back Pain (2014-2015)– Other MSK Conditions (2016-2017)
Top 10 (+1) Causes of Disability (Global Burden of Disease – Vos et al. 2012)
1. Low back pain2. Major depressive
disorder3. Iron-deficiency
anaemia4. Neck pain5. Chronic obstructive
pulmonary disease
6. “Other” MSK disorders
7. Anxiety disorders8. Migraine9. Diabetes10.Falls11.Osteoarthritis
Musculoskeletal Disorders (MSDs) result in enormous social, psychological & economic burdens (IOM 2011)
Scope of the CCGIReasons for consulting chiropractors in North America
42%
25%
13%
6%4%
4% 3% 2%
Back pain
Upper/Lower extremity problems
(Coulter 2005)
Location of Patient Treatment Areas
30%
20%9%
8%
28%
6%
Neck region
Low back regionMultiple
sites
Back re
gion
Extremities
Other
(Waalen & Mior 2005)
Evidence-Informed Practice & Clinical Practice GuidelinesCanadian Chiropractic Guideline Initiative
WHAT DO YOU THINK OF WHEN YOU HEAR:Evidence-informed practice?Evidence-based medicine?Evidence-informed healthcare?
Evidence-Informed Practice (EIP)
Clinical expertise
Patient values &
preferences
Best research evidence
Clinical context
CLINICAL DECISION
Evidence-Informed Practice (EIP)
• Definition:– The conscientious, explicit and judicious use of
current best evidence in making decisions about the care of individual patients
• TAKE HOME POINT: – All three aspects of the model are equally
important!
WHY WOULD YOU USE EVIDENCE-INFORMED PRACTICE?
Why use EIP?• ↑ chance of positive patient outcomes• ↑ patient satisfaction• ↓ risk of harm to the patient• Facilitate effective and honest communication
with patients• Improve cultural authority of chiropractic• Enhance integration and communication in
multidisciplinary environments – Evidence is a common language!
Reality of EIP Integration
• LOTS of new, useful research is published every month, but is consistent uptake and integration happening?
• Will we like what we see?
EIP Misconceptions
• EIP/research = allopathic medicine• EIP is a rulebook/cookbook• There is no ‘chiropractic’ research • Researchers don’t understand practice
realities and want to tell us what we can’t do vs. what we can/should do
• Volume of new research is too large, making it impossible to stay current
WHAT ARE SOME BARRIERS TO IMPLEMENTING EIP IN YOUR PRACTICE?
WHAT ARE POTENTIAL SOLUTIONS?
Challenges in EIP Uptake
• Clinicians• Patients• Practice• Health care policy
Clinician Challenges
• Lack of time and/or motivation
• Personal beliefs regarding research:– Doesn’t reflect my
practice/patients– Statistics too complex– Too much information!– Don’t know where to
look
Clinical Practice Guidelines
What is a Clinical Practice Guideline?
• CPGs are a comprehensive collection of:– Current best evidence regarding etiology,
diagnosis & treatment of a condition– Expert opinion & consensus– Practice-based recommendations
• Who puts these together?– Researchers, clinicians and patient reps – people
we should listen to!• It’s a massive undertaking!
CPG Development
Clear Question
Literature Search
Study Selection
Critical Appraisal
Data ExtractionAnalysis
Recommendations
Dissemination
Update & Revise
Hierarchy of Evidence
Evidence-Informed Practice (EIP)
Clinical expertise
Patient values &
preferences
Best research evidence
Clinical context
CLINICAL DECISION
CPGs – Key Points for Clinicians• ‘Living EIP document’ = updated regularly• A tool to support clinical reasoning– NOT standards of care/practice– NOT a substitute for a practitioner’s experience
• Contain practice recommendations linked to best evidence
MSDs: Associated Co-Morbidities
• MSDs are known to be associated with other health issues (ex. cardio vascular disease, depression, etc...).• Addressing them together:
Can be more efficient (time and money)Adds a broader health-related meaningCan improve patient compliance!
Summary & Take Home MessagesEIP = rational integration of best available
research, your clinical experience/expertise and what the patient wants
Summary & Take Home MessagesCPGs help guide decision-making regarding
diagnosis, treatment and patient management Patients should always be treated as
individuals who can have multiple health problems and risk factors – humans are complex!
Visit us today!
The Canadian Chiropractic Guideline Initiative Website is NOW ONLINE!
Your essential guide to the latest news on guidelines and best practice
www.chiroguidelines.org
Additional resources• www.chiroguidelines.org
• Evidence Informed Practice Program - EIP modules
• Centre for Evidence-Based Medicine
• Evidence UP DATES: Free Tools for Evidence-Based Clinical Practice
• JAMA Evidence
• Evidence-Based Medicine Tool Kit
• Grey Matters: A practical search tool for evidence-based medicine
• Centre for Evidence-Based Medicine (Toronto)
Helping practitioners and patients make the right choice for optimal care
GIG Group MembersProject lead: André Bussières
• Clinician1) Kent Stuber (lead)2) Jeff Quon (lead)3) Fadi Al Zoubi4) Sandy Sajko5) Simon French (KT Expert)6) Alex Pessoa (collaborator)• Decision Makers1) Diane Grondin (lead) 2) Simon Brockhusen (collaborator)3) André Bussières (KT Expert)4) Michele Maiers (collaborateur)5) John Triano• Chiropractic programs1) Tony Tibbles (lead)2) Danica Brousseau (lead)3) Tue Jensen4) Aliki Thomas (KT Expert)5) Craig Jacobs (CMCC collaborator)6) Joe Lemire (UQTR collaborator)7) Caroline Poulin (UQTR collaborator) 8)I sabelle Pouliot (UQTR student)• Patients1) Sara Ahmed (lead)2) Shawn Davies3) Monika Kastner (KT Expert)4) Nadia Richer (UQTR collaborator)
Physical activity: Bob Grisdale (lead)Website- Vic Weatherall (lead)Reviewer: Bryan Budgell
Any questions?
References• Coulter ID & Shekelle PG. Chiropractic in North America: Descriptive analysis. J
Manipulative Physiol Ther 2005; 28(2): 83-89. • Fineout-Overholt E, Mazurek Melnyk B, Schultz A. Transforming Health Care from the
Inside Out: Advancing Evidence-Based Practice in the 21st Century. J Professional Nursing. 2005;21(6):335-44.
• Kawchuk G, Newton G, Srbely J, Passmore S, Bussières A, Busse JW, Bruno P. Knowledge Transfer within the Canadian Chiropractic Community. Part 2: Narrowing the Evidence-Practice Gap. J Can Chiropr Assoc 2014; 58(3):206-14 (In Press).
• Lizarondo L, Grimmer-Somers K, Kumar S. A systematic review of the individual determinants of research evidence use in allied health. J Multidisciplinary Healthcare. 2011;4:261-72.
• Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996; 312(7023):71–72.
• Vos T, Flaxman AD, Naghavi M et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2163–96.
• Waalen JK, Mior SA. Practice patterns of 692 Ontario chiropractors (2000-2001). J Can Chiro Assoc 2005; 49(1): 21-31.