Comments on Medical Treatment Guidelines

Sunday, December 5, 2004 | 0

The following is a reproduction of a letter sent by Phil Denniston, President and Chief Executive Officer of Work Loss Data Institute, to Andrea Hoch, Administrative Director of the Division of Workers' Compensation, concerning the controversy over selection and determination of appropriate treatment guidelines. Presently in their 9th edition and in the process of being updated, Work Loss Data Institute's guidelines were one of the specific guidelines that were reviewed and considered by RAND researchers as well as the Commission on Health Safety and Workers' Compensation (CHSWC) for adoption of utilization guides. The editors felt that the opinions stated in this letter would be of interest to our readers as California grapples with implementing treatment guidelines that are appropriate for industrial care.

Dear Ms. Hoch:

I am concerned that the CHSWC Recommendations to DWC on Workers' Compensation Medical Treatment Guidelines will result in a return to "anything goes" in California workers' compensation.

Specifically, CHSWC is recommending "adopting an interim utilization schedule... replaced with respect to spinal surgery by the American Academy of Orthopedic Surgeons (AAOS) guidelines... and guidelines for specified therapies, including podiatry, chiropractic, physical therapy, occupational therapy, acupuncture, and biofeedback." I think it should be obvious that guidelines written by spinal surgeons will probably recommend spinal surgery, and guidelines written by acupuncture providers will recommend acupuncture, whether or not these recommendations are supported by strong medical evidence, because that is what these providers do for a living.

Of course, the CHSWC recommendations rely on the RAND study, which, based completely on the opinions of 11 clinicians, found that all the guidelines required substantial improvement.

This panel of clinicians, which included 2 orthopedic surgeons, one of whom is Chairman of the AAOS Occupational Health and Workers' Compensation Committee, concluded that the recommendations in ACOEM and ODG for lumbar spinal fusion surgery were of "uncertain validity", and the AAOS guidelines were "valid" for spinal fusion surgeries.

What evidence is this based on?

As a medical editor who worked on both the ACOEM and the ODG guidelines, I can attest that those guidelines are based on the highest quality medical evidence, as defined by AHRQ.

Spinal fusion is a surgical procedure that is very much overused in workers' compensation. Approximately $15 billion was spent on spinal fusion in the U.S. last year, and based on our analysis, about 90% of these operations were not supported by the results of high quality medical studies.

In addition to wasting money, many patients are having to suffer through an unnecessary surgery which is highly invasive and even life threatening, when there are other therapies that would be more likely to help them return to functionality.

According to the Rand study, "two panelists advocated using ACOEM together with ODG in order to address clinical and utilization issues..." and said, "the ACOEM guideline could be somewhat strengthened by adding complementary sections from the ODG guideline."

With respect to the other therapies above, ODG has normative data on number of visits and duration of treatment for physical therapy and chiropractic for each condition where the medical evidence supports use of these therapies.

Respectfully submitted,
Phil Denniston
Editor-in-Chief
Work Loss Data Institute
phil@worklossdata.com

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