by John Weeks, Publisher/Editor of The Integrator Blog News and Reports

The American Chiropractic Association (ACA) released a list of five tests and procedures commonly ordered but not always necessary in chiropractic care as part of the national Choosing Wisely campaign launched by the American Board of Internal Medicine Foundation (ABIM) and Consumer Reports, according to an August 15 announcement.

After reports emerged that 30 percent or more of services provided in the U.S. medical industry are unnecessary, the ABIM and Consumer Reports launched the Choosing Wisely campaign to address the costly and harmful problem, and to encourage “conversations between patients and their clinicians about what care is really necessary and appropriate.”

Through the initiative, medical professionals and healthcare groups own up to their role in delivering unnecessary services by identifying the top five tests and procedures in their field that evidence shows are not always necessary. The campaign, which began in 2012, has nearly 100 organizations participating.

According to an ACA media conference held on August 15, participation in Choosing Wisely is expected to move chiropractors more deeply into the patient-centered care movement and bolster the field’s “cultural authority.”

The ACA’s journey began three years ago with two ACA members in Rochester, New York who were interested in addressing quality issues in the profession. They “developed as list of ‘dos and don’ts’ for local chiropractors,” said John Ventura, DC, chair of the ACA’s Committee on Quality Assurance and Accountability.

The grassroots effort to improve chiropractic services responded to an emerging need within the field. During Tuesday’s media event, one of the profession’s top policy leaders, Christine Goertz, DC, PhD, described her conversations with multiple insurer and employer executives. Goertz, a member of the Board of Governors of the Patient Centered Outcomes Research Institute, spoke of informally quizzing executives on why chiropractors were not being used as “the first line of defense” for pain management, given research on chiropractic’s value for low back pain. She found responses quickly turning to the variability and uncertainty in chiropractic practices. Over-utilization of chiropractic services is an issue, she said, and some question how to find a good provider.

Participation in Choosing Wisely emerged as a potent step of good faith for the profession. Ventura, a member of the quasi-governmental National Quality Forum’s Musculoskeletal Steering Committee for the Musculoskeletal Measure Endorsement and Maintenance project, approached the campaign on behalf of the ACA in 2015.

The response from the medical leadership at the sponsoring ABIM was not friendly. Ventura was told that Choosing Wisely only worked with “allopathic physicians.” The ACA pointed out that physical therapists were participating. In response, the ABIM said they would look into it. Then, according to Ventura, they never got back to the ACA. This rejection happened a second time before, finally, a fortuitous meeting between ACA member Brian Justice, DC and an ABIM founder served as an end-run around the obstacle course the Choosing Wisely leaders had created—an ACA application would be considered if tendered.

The ACA then began an extensive committee process, with review from members and approval by its Board of Governors, to identify its list of five services and tests, which are now on the Choosing Wisely site. The five things patients and physicians should question are:

  1. In the absence of red flags, do not obtain spinal imaging for patients with acute low-back pain during the six weeks after the onset of pain.
  2. Do not perform repeat spinal imaging to monitor patients’ progress.
  3. Avoid protracted use of passive or palliative physical therapeutic modalities for low-back pain disorders unless they support the goal(s) of an active treatment plan.
  4. Do not provide long-term pain management without a psychosocial screening or assessment.
  5. Do not prescribe lumbar supports or braces for the long-term treatment or prevention of low-back pain.

In its announcement, ACA President David Herd, DC, PC said the ACA and its members should “support evidence-informed care as well as shared decision-making between patients and their doctors.” The ACA is both the first chiropractic group and first integrative healthcare organization to join the campaign.

ACA personnel explained that the role of Consumer Reports will be to develop and disseminate patient education materials to create a more informed client base to engage their chiropractors on whether these services or procedures are important at a specific point of care.

Comment: Take a minute to honor the patience and perseverance of chiropractors amidst the abuse they received when they decided to apply to Choosing Wisely. Historically accused of fraud and charlatanism, they come knocking at the initiative with a desire to reform their own practices, and were turned away multiple times. Picture a supplicant on prayerful knees taking regular lashes while slowly moving toward a citadel. “Allopaths,” it’s time to stop the rearguard fighting.

Kudos to the ACA for taking on this important self-regulatory work, and for their patience in gaining acceptance. This is one in a set of chiropractic initiatives where chiropractors are playing the long game, including in projects by the the Best Practices Academy and Spine IQ, with which Goertz also plays a lead role.  The chiropractic field is attempting to march the egalitarian gauntlet that opens before all professions wishing to enter the front door of a value-based system.