ACOEM is a Cost / Benefit Analysis

Sunday, October 24, 2004 | 0

The American College of Occupational and Environmental Guidelines (ACOEM) continue to be a significant source of controversy and dialogue among work comp professionals, and in particular, the Guide's legal affect relative to treatment rights of injured workers.

ACOEM, this month, released its very first issue of a newsletter which, it says, is intended to "complement and address issues dealing with the 2nd edition of the College's Occupational Medicine Practice Guidelines."

To be published quarterly, the inaugural issue dated Fall 2004 addresses issues of vital concern to the workers' compensation legal practitioner: acute vs. chronicity; recommendation vs. requirement; and perhaps most important to legal pros who would be arguing against ACOEM treatment guides in favor of some other evidence based treatment recommendation, "The Organizing Principle Behind the Development [of the] Guidelines."

Critical to the legal practitioner is an understanding by the authors of the Guidelines that treatment protocol not found in the Guides may still be valid on a "value" basis.

"In the absence of high-grade evidence, available scientific information must be analyzed in the context of current clinical practice in order to determine the 'value' of accepting a given intervention or causal hypothesis," the newsletter states. "Value may be determined by generally considering the current standards regarding treatments or tests, and more specifically based upon an analysis of the benefit or potential benefit of an intervention, weighed against the cost."

In other words, say the authors, in any given medical treatment plan, an inherent cost/benefit analysis is performed to determine the relative efficacy of any single modality.

Costs, however, are not measured solely in monetary terms, say the authors. "Examples of non-monetary terms range from the direct risk of harm that might result from unnecessary surgery or other invasive procedures, to the chance of addiction or side-effects from unnecessary medication, to the risk of untoward dependency upon a passive palliative treatment or relationship with a provider that is not leading to any improvement in overall functional status."

Likewise, the assessment of benefit is not measured solely in economic terms, and the overriding principle in the Guides is the best interest of the injured worker.

The authors note a specific process that was followed in the development of the guides, and knowing that process will assist the legal practitioner deal more effectively with ACOEM based arguments. The process/principles, in order, are:

1. Decide what treatment, test or theory needs to be evaluated;
2. Gather evidence (medical literature) on the topic;
3. Assess the quality of that evidence;
4. Compare that evidence to other forms of "evidence" such as consensus based norms;
5. In cases where the literature supports the clinical consensus, deciding whether there is a need for any further scientific analysis;
6. If there is no supporting literature:
a. should it be adopted due to high likelihood of benefit, or favorable cost/benefit ratio,
b. left up to a case by case determination,
c. rejected on a cost/benefit analysis (monetary or physical basis);
7. Solicit input from other practitioners who are knowledgeable regarding the tests, treatments, or hypotheses and are considered representative of their specialty; 8. Establishing a method for periodic review of the evidence to ensure continuing validity of the initial assessment; 9. Amendment of the Guidelines "to reflect any changes that occur due to the development of an improved foundation of quality scientific literature."

In other words, what the authors are stating is that ACOEM, while a useful and necessary foundation of work for ensuring continuity in treatment, are not the final word. The authors recognize that there is a fountain of ongoing research and scientific review of various treatment protocol that may in fact be valid.

A raging debate among work comp practitioners is whether the Guides are applicable past the first 90 day "acute" phase, and on into the "chronic" phase. The newsletter says "unequivocally 'yes'."

Chapter 6 deals almost exclusively with chronic pain, note the authors, and Chapter 15, dealing with stress, are issues that are common to those suffering from long-standing conditions, but the principles of ACOEM make it applicable to any phase of injury treatment. "That the Guidelines mostly focus on the first critical 90 days following injury should in no way be interpreted to mean that issues outside of that range are not addressed. The Guidelines apply at any point following an injury that the principles it espouses, or the information it includes, are applicable to the care of an injured worker."

"Guidelines fill the gap between the use of certain treatments which may be as yet unproven and the quiet certainty of conclusive scientific proof," ACOEM says in its Fall newsletter.

The newsletter, say the authors, will provide periodic supplemental information to the Guides, and for that reason, may be a necessary subscription item for the work comp practitioner. Subscriptions to the newsletter are $105 per year for ACOEM members, $125 per year for non-members, and may be purchased by contacting ACOEM at:
APG Insights
ACOEM Communications Dept.
1114 N. Arlington Heights Road
Arlington Heights, IL 60004
Telephone: 847-818-1800
Fax: 847-818-9266
Web: www.acoem.org.

By David DePaolo

-------------------

The views and opinions expressed by the author are not necessarily those of workcompcentral.com, its editors or management.