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and without proper justification. Should the reviewer reference any literature or guideline source, the reviewer should document and explain specifically how that reference applies to the treatment in question, and the reference should be directly quoted from the source used, and include the exact wording and page number.

Careful application of literature is necessary to ensure the efficacy of a chiropractic review. It is essential that any such application consider all of the specific factors and circumstances surrounding the individual case. The reviewer is expected to accurately and specifically include remarks regarding any and all complicating factors and individual circumstances which may have affected the treatment provided, thereby precluding the validity and application of a generic reference to a specific case. All complicating factors and special circumstances may not be apparent in the case documentation. As such, in order to have all of the information regarding the case, the reviewer should make every attempt to consult with the attending chiropractor in order that he/she can consider all factors and circumstances regarding the case. Any additional information the reviewer obtained from this consultation should be noted in the review.

The quality, consistency and reliability of chiropractic peer review varies greatly. There are many external forces which affect this, not the least of which is the fact that in the chiropractic profession, few, if any peer reviews are performed for the primary purpose of ensuring quality patient care. In most instances, the reviewer has a relationship with a peer review organization or insurer, and many understand that their future relationship is dependent upon their ability to provide reasons with which the insurer can deny reimbursement. The reviewer has no ethical or fiduciary relationship with the patient, but often has financial incentive and motivation to undermine the case for the benefit of the insurer, without regard for the actual necessity of the care.

In addition, the criteria used for peer review determinations is not consistent and national, state and local governments more often than not fail to provide regulations for the determination of chiropractic necessity. As such, the system and environment in which chiropractic peer review occurs encourages peer review abuse, as there are no adverse consequences for this type of unethical conduct.

Recent evidence points to the fact that a review of records by an individual practitioner has poor inter-examiner reliability and is not a reliable method for determining a treating doctor’s compliance to standards of care.

The methods for conducting peer reviews outlined here have been devised for the purposes of correcting this problem. The tenets outlined above provide the opportunity for consistency in peer review based on fair standards. A chiropractic practitioner should


_________________________________________________________ Council on Chiropractic Practice Clinical Practice Guideline Number 1 Vertebral Subluxation in Chiropractic Practice – 2003 Update & Revision

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