Evidence Based Medicine and Best Practices
The Doctors at Arlington Chiropractic Clinic support and follow these guidelines published by the American Chiropractic Association.
RESOLVED, that the American Chiropractic Association considers the attached "Evidence Based Medicine and Best Practices" as official policy:
The American Chiropractic Association (ACA) supports Evidence Based Medicine and Best Practices that are predicated by an objective review of the most current and valid evidence available in literature and other sources. Information yielded from a thoughtful review of the literature is intended for use in designing the most beneficial course of care for an individual patient. The ACA respects provider clinical expertise and recognizes the importance of individual provider competence in combination with the most current evidence based practices to fit the needs of a patient. The unique nature of each patient and a provider's right to choose a quality course of treatment for each individual is also supported.
The ACA supports the definition of evidence based medicine as:
"Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer."
Source: Sackett, D.L. et al. (1996), Evidence based medicine: What it is and What it isn't. BMJ 312 (7023), 13 January, 71-72.
In response to medical literature of poor standards and extreme bias, the creation of practice guidelines is shifting to rely solely upon randomized clinical trials (RCTs), which have strong clinical evidence. This is problematic because the patient base often included in RCTs is taken from very restrictive groups of individuals. When guidelines are based on evidence that is representative of a narrow group of patients and those guidelines are applied unequivocally, a disconnect occurs, and patients do not receive the best treatment. Another unfortunate consequence of relying strictly on RCTs is that there is a lapse in time between valuable advances in therapies and completed RCTs. Providers should have the most proven up to date methods at hand to treat their patients, either by science or by clinical experience or a combination thereof. Best Practices, in contrast to restrictive clinical guidelines, allow for the integration of research and clinical expertise while respecting the unique nature of individual patients and are preferred due to their patient centered focus as opposed to guidelines that are meant to impose restrictions or limits on providers.
While RCTs are, without doubt, highly valuable clinical evidence, they have limitations and weaknesses when applied across the board. Because of this, it is important to take into review a variety of other clinical evidence information including case studies, cohort studies, literature reviews and historical performance for applicability and value when developing guidelines and patient care plans. Third party payers and providers have an obligation to the public to remain aware of new evidence that is released which may affect patient care.
The ACA is aware of over-utilization and questionable utilization of care that occurs in the health care delivery system. The ACA does not support those who engage in these actions nor does the ACA support guidelines developed by third party payers that draw upon out of date literature and impede the doctor-patient relationship through excessive management of providers. The ACA supports patient-centered healthcare that draws upon a provider's expertise and the available research while effectively and cost-consciously treating the patient.
(Ratified by the House of Delegates, September 2004)
