Casillas, ACOEM, Mercy and ODG
Saturday, April 8, 2006 | 0
The following discussion from the WorkCompCentral Professional Forums started out as a review of the recent WCAB panel decision in Casillas (see side bar) but then shifted towards a critique of medical treatment guidelines. The discussion is republished here, edited for clarity, succinctness, spelling and grammar.
Those of you who regularly participate in the discussion threads on this forum ought to check out the Casillas panel decision that I posted on the Legal forum and that WCC covered in a news story about overcoming ACOEM. After years of authorizing post-Award chiro care, employer sent a further authorization request through U/R and their U/R DC reviewer opined that chiro care is not consistent with ACOEM and is ineffective for treating chronic injuries. The WCJ agreed and found that the applicant should get NO MORE chiro care at all. The WCAB reversed and relied upon the report of panel QME DC who cited Mercy Hospital Consensus treatment guidelines as evidence that periodic chiro appropriate. Hopefully, this case will be designated a significant panel and signals a move away from ACOEM as the "Bible".
This case is now published as both a panel decision in the CWCR and as a "noteworthy" decision in the CCC. As such it is citable but not binding authority on any judicial level.
Perhaps the most significant part of this case is that the WCAB actually wrote the decision and therefore the commissioners put some thought and effort into the opinion, not that they do not think about the decisions where they adopt and incorporate, but we get more of a glimpse into what issues the Commissioners consider significant:
1 They did not conclude that ACOEM does not apply because the treatment was beyond 90 days and specifically held that ACOEM did apply unless rebutted.
2 The Board relied upon the Mercy Guidelines to either rebut or supplement ACOEM. This is interesting because the Mercy Guidelines have been rejected by virtually every Chiropractic association that has considered the guidelines since they were published. They have been rejected because the guidelines limit medical care to reasonable levels. If chiros as an industry had followed the Mercy Guidelines, we probably would not have the caps on care from SB 228.
3 The Mercy guidelines are probably not admissible as they do not meet the criterion under LC 5703 to be an admissible treatment guideline. This issue appears to have been missed by the defense and the Board.
4 The WCAB limited the treatment to the recommendations of the QME for treatment of acute flare-ups only and not maintenance or regular care.
I suspect that most defendants could live with opinions such as Castillas as it provides some reasonable limitations on the amount of care based on at least some kind of data. In my practice, since I do not have any problem with reasonable and rational levels of care, whether medical or chiropractic, this case has been useful in arguing against some of the more abusive treaters who continue treatment unabated by time or lack of results.
<<
More importantly, in my lay opinion, the commissioners opined that ACOEM could be used past 90 days to support acute exacerbations of chronic pain. This concept will not go over well with most of the UR doctors who routinely cut-off manipulative care at 6 visits per the one-month limitation of ACOEM. It would seem, now, that a significant exacerbation of chronic pain would warrant an additional month of manipulation, per ACOEM, which should be sufficient to quell the effects of any exacerbation.
"In short, we do not find the ACOEM guidelines to specifically preclude continuing chiropractic care for acute exacerbations of applicant's symptoms."
<<
Chapter 8 alone contains 67 references to support the recommendations made in this section on "frequency and Duration of Care." Many of these references are to scientific peer review investigations that were published in some of the highest quality journals on the planet, i.e., Spine, The New England Journal of Medicine, RAND, etc. Although Mercy has its flaws, it certainly would seem to build on "scientific medical evidence."
The most common definition of evidence based medicine is "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." (Sackett D)
According to the above mentioned definition and the National Guideline Clearinghouse the Mercy Guidelines are not evidence-based, as they are not the conscientious, explicit, and judicious use of current best evidence. The Mercy Guidelines have not been updated since 1993, which is why they have been removed from the NGC. According to the NGC the guideline is current as long as it was developed, reviewed, or revised within the last five years.
In any event, it may be reasonable in some cases to use the initial care section of the ACOEM Guidelines to apply to acute flare-ups absent Mercy, as ACOEM is silent in this matter. However, if acute means a condition lasting less than 3 months a lapse of at least 90 days should occur between applying the initial care section of the ACOEM Guidelines. Furthermore, extending the time between flare-ups should be necessary to show a trend towards maximal self-actualization and decreased health care utilization.
<<According to the above mentioned definition and the National Guideline Clearinghouse the Mercy Guidelines are not evidence-based, as they are not the conscientious, explicit, and judicious use of current best evidence... >>
I would agree that Mercy is out of date and certainly not without its flaws; however, it certainly would constitute as evidence based.
With respect to Chiropractic care, ACOEM has by no means judiciously used the current best evidence to reach its conclusions: For example, where are these randomized controlled trails sited in ACOEM? Chiro Randomized Controlled Trials
1) Aure OF, Nilsen JH, Vasseljen O. - Spine 2003 28(6):525-31; discussion 531-2
2) Triano JJ, McGregor M, Hondras MA, Brennan PC. - Spine. 1995 Apr 15;20(8):948-55.
3) Giles LGF, Muller R. - Spine 2003;28(14):1490-1503
4) Muller R, Giles LG. - J Manipulative Physiol Ther. 2005 Jan;28(1):3-11.
5) Hoiriis KT, et al. - J Manipulative Physiol Ther. 2004;27(6):388-98.
6) Koes BW, Bouter LM. - BMJ. 1992 Mar 7;304(6827):601-5.
7) Niemisto L, et al. - Spine. 2003 Oct 1;28(19):2185-91.
Furthermore, ACOEM, unlike the Massachusetts, Colorado, and Mercy guidelines hasn't even bothered to site an appropriate treatment frequency, which has allowed UR docs to run amuck.
And, with regard to making the National Guideline Clearinghouse list, neither has ACOEM. National Guideline Clearinghouse
So, if ACOEM is the "standard," than Mercy is certainly in the same league with respect to manipulative care.
ACOEM has refused to let the NGC publish their guidelines. On the other hand, the Mercy Guidelines were removed by the NGC. Massachusetts and Colorado Guidelines are not scientifically based, as their literature has not been graded.
If you want to use EBM Treatment Guidelines that are nationally recognized and that are scientifically based that bother to site the appropriate treatment frequency and duration for manipulation regarding acute and chronic pain patients use the Official Disability Guidelines. I have trumped ACOEM every time with these guidelines.
Where are these randomized controlled trails sited in ACOEM?
Question is where are they sited in the Mercy, Massachusetts or Colorado Guidelines? One thing is for sure; they are sited in the ODG:
The following discussion from the WorkCompCentral Professional Forums started out as a review of the recent WCAB panel decision in Casillas (see side bar) but then shifted towards a critique of medical treatment guidelines. The discussion is republished here, edited for clarity, succinctness, spelling and grammar.
Those of you who regularly participate in the discussion threads on this forum ought to check out the Casillas panel decision that I posted on the Legal forum and that WCC covered in a news story today about overcoming ACOEM. After years of authorizing post-Award chiro care, employer sent a further authorization request through U/R and their U/R DC reviewer opined that chiro care is not consistent with ACOEM and is ineffective for treating chronic injuries. The WCJ agreed and found that the applicant should get NO MORE chiro care at all. The WCAB reversed and relied upon the report of panel QME DC who cited Mercy Hospital Consensus treatment guidelines as evidence that periodic chiro appropriate. Hopefully, this case will be designated a significant panel and signals a move away from ACOEM as the "Bible".
This case is now published as both a panel decision in the CWCR and as a "noteworthy" decision in the CCC. As such it is citable but not binding authority on any judicial level.
Perhaps the most significant part of this case is that the WCAB actually wrote the decision and therefore the commissioners put some thought and effort into the opinion, not that they do not think about the decisions where they adopt and incorporate, but we get more of a glimpse into what issues the Commissioners consider significant:
1 They did not conclude that ACOEM does not apply because the treatment was beyond 90 days and specifically held that ACOEM did apply unless rebutted.
2 The Board relied upon the Mercy Guidelines to either rebut or supplement ACOEM. This is interesting because the Mercy Guidelines have been rejected by virtually every Chiropractic association that has considered the guidelines since they were published. They have been rejected because the guidelines limit medical care to reasonable levels. If chiros as an industry had followed the Mercy Guidelines, we probably would not have the caps on care from SB 228.
3 The Mercy guidelines are probably not admissible as they do not meet the criterion under LC 5703 to be an admissible treatment guideline. This issue appears to have been missed by the defense and the Board.
4 The WCAB limited the treatment to the recommendations of the QME for treatment of acute flare-ups only and not maintenance or regular care.
I suspect that most defendants could live with opinions such as Castillas as it provides some reasonable limitations on the amount of care based on at least some kind of data. In my practice, since I do not have any problem with reasonable and rational levels of care, whether medical or chiropractic, this case has been useful in arguing against some of the more abusive treaters who continue treatment unabated by time or lack of results.
<<
More importantly, in my lay opinion, the commissioners opined that ACOEM could be used past 90 days to support acute exacerbations of chronic pain. This concept will not go over well with most of the UR doctors who routinely cut-off manipulative care at 6 visits per the one-month limitation of ACOEM. It would seem, now, that a significant exacerbation of chronic pain would warrant an additional month of manipulation, per ACOEM, which should be sufficient to quell the effects of any exacerbation.
"In short, we do not find the ACOEM guidelines to specifically preclude continuing chiropractic care for acute exacerbations of applicant's symptoms."
<<
Chapter 8 alone contains 67 references to support the recommendations made in this section on "frequency and Duration of Care." Many of these references are to scientific peer review investigations that were published in some of the highest quality journals on the planet, i.e., Spine, The New England Journal of Medicine, RAND, etc. Although Mercy has its flaws, it certainly would seem to build on "scientific medical evidence."
The most common definition of evidence based medicine is "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." (Sackett D)
According to the above mentioned definition and the National Guideline Clearinghouse the Mercy Guidelines are not evidence-based, as they are not the conscientious, explicit, and judicious use of current best evidence. The Mercy Guidelines have not been updated since 1993, which is why they have been removed from the NGC. According to the NGC the guideline is current as long as it was developed, reviewed, or revised within the last five years.
In any event, it may be reasonable in some cases to use the initial care section of the ACOEM Guidelines to apply to acute flare-ups absent Mercy, as ACOEM is silent in this matter. However, if acute means a condition lasting less than 3 months a lapse of at least 90 days should occur between applying the initial care section of the ACOEM Guidelines. Furthermore, extending the time between flare-ups should be necessary to show a trend towards maximal self-actualization and decreased health care utilization.
<<According to the above mentioned definition and the National Guideline Clearinghouse the Mercy Guidelines are not evidence-based, as they are not the conscientious, explicit, and judicious use of current best evidence... >>
I would agree that Mercy is out of date and certainly not without its flaws; however, it certainly would constitute as evidence based.
With respect to Chiropractic care, ACOEM has by no means judiciously used the current best evidence to reach its conclusions: For example, where are these randomized controlled trails sited in ACOEM? Chiro Randomized Controlled Trials
1) Aure OF, Nilsen JH, Vasseljen O. - Spine 2003 28(6):525-31; discussion 531-2
2) Triano JJ, McGregor M, Hondras MA, Brennan PC. - Spine. 1995 Apr 15;20(8):948-55.
3) Giles LGF, Muller R. - Spine 2003;28(14):1490-1503
4) Muller R, Giles LG. - J Manipulative Physiol Ther. 2005 Jan;28(1):3-11.
5) Hoiriis KT, et al. - J Manipulative Physiol Ther. 2004;27(6):388-98.
6) Koes BW, Bouter LM. - BMJ. 1992 Mar 7;304(6827):601-5.
7) Niemisto L, et al. - Spine. 2003 Oct 1;28(19):2185-91.
Furthermore, ACOEM, unlike the Massachusetts, Colorado, and Mercy guidelines hasn't even bothered to site an appropriate treatment frequency, which has allowed UR docs to run amuck.
And, with regard to making the National Guideline Clearinghouse list, neither has ACOEM. National Guideline Clearinghouse
So, if ACOEM is the "standard," than Mercy is certainly in the same league with respect to manipulative care.
ACOEM has refused to let the NGC publish their guidelines. On the other hand, the Mercy Guidelines were removed by the NGC. Massachusetts and Colorado Guidelines are not scientifically based, as their literature has not been graded.
If you want to use EBM Treatment Guidelines that are nationally recognized and that are scientifically based that bother to site the appropriate treatment frequency and duration for manipulation regarding acute and chronic pain patients use the Official Disability Guidelines. I have trumped ACOEM every time with these guidelines.
Where are these randomized controlled trails cited in ACOEM?
Question is where are they sited in the Mercy, Massachusetts or Colorado Guidelines? One thing is for sure; they are cited in the ODG:
A copy of the decision can be downloaded here
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