California Demonstrates Great Leadership

Major Overhaul Planned for MTUS

The California Department of Industrial Relations Division of Workers’ Compensation (DIR DWC) continues to demonstrate its commitment to improving the quality of medical care available to ill or injured workers in the state by announcing that all MTUS Guidelines will be updated to Reed Group’s ACOEM Practice Guidelines.

On February 23rd and 24th, then again on March 2nd and 3rd, the DIR DWC hosted several breakouts during the State’s Workers’ Compensation Education Conferences in Los Angeles and Oakland respectively. As expected, the team spent a considerable amount of time discussing updates to the enactment of California’s drug formulary. Dr. Raymond Meister (Medical Director, DIR DWC), Jackie Schauer (DIR DWC Legal Unit), and John Cortes (DIR Legal Counsel) also spent time discussing updates to MTUS via Senate Bill 1160’s expedited process.

Initial MTUS Guidelines Updates (As Discussed in Great Detail at Each Conference)

– ACOEM 2004 Neck and Upper Back Complaints (Updated to ACOEM 2016 Cervical and Thoracic Spine Disorder Guideline)

– ACOEM 2004 Shoulder Complaints Chapter (Updated to ACOEM 2016 Shoulder Disorders Guideline)

– ACOEM 2007 Elbow Disorder (Updated to ACOEM 2013 Elbow Disorders Chapter)

– ACOEM 2004 Forearm, Wrist, and Hand Complaints (Updated to ACOEM 2016 Hand, Wrist, and Forearm Disorders Guideline)

– ACOEM 2004 Low Back Complaints (Updated to ACOEM 2016 Low Back Disorders Guideline)

– ACOEM 2004 Knee Complaints (Updated to ACOEM 2015 Knee Disorders Guideline)

– ACOEM 2004 Ankle and Foot Complaints (Updated to ACOEM 2015 Ankle and Foot Disorder Guideline)

– ACOEM 2004 Eye (Updated to ACOEM 2017 Eye Disorders Chapter)

New Guidelines To Be Added

– ACOEM 2017 Hip and Groin Guideline

– ACOEM 2016 Occupational/Work Related Asthma Guideline

– ACOEM 2016 Occupational Interstitial Lung Disease Guideline

MTUS Updates Beginning Spring of 2017 via Expedited Process

– ODG 2015 Chronic Pain Medical Treatment Guidelines (Updated to ACOEM 2017 Chronic Pain Medical Treatment Guideline)

– CA MEEAC Opioids Treatment Guidelines (Updated to ACOEM 2014 Opioids Treatment Guideline)

– ACOEM 2004 General Approaches Guidelines (Updated to ACOEM 2016 General Approaches)

MTUS Updates To Be Made via Expedited Process Upon Completion of Guidelines by Reed Group/ACOEM

– ACOEM 2004 Stress Related Conditions (Updated to ACOEM 2017 Behavioral Health Guideline)

– ACOEM 2017 Traumatic Brain Injury Guideline

RAND Corporation and The National Academy of Medicine Measures of Quality EBM

The major updates to the MTUS coincide with the RAND Corporation’s report “Implementing a Drug Formulary for California’s Workers’ Compensation Program” and recommendations for the treatment guidelines and the formulary to incorporate the evidence-based standards of care that best meet the needs of California’s injured workers. The RAND report also recommended that there be consistency between the MTUS guidelines and the adopted ACOEM-based drug formulary. Perhaps the most important reason for California’s wholesale adoption of Reed Group’s ACOEM Practice guidelines is RAND’s determination that the ACOEM guidelines have a more rigorous, transparent development process. (Click HERE to view the complete PowerPoint presentation, Slide 4 provided below.)

The ACOEM Practice Guidelines are the only commercial nationally recognized content source that meticulously complies with all eight (8) Standards for Developing Trustworthy Clinical Practice Guidelines established by the National Academy of Medicine (NAM, formerly the Institute Of Medicine, IOM). The defined standards are:

  1. Establishing Transparency
    • The processes by which the clinical practice guideline is developed and funded should be detailed and explicitly and publicly accessible.
  2. Management of Conflict of Interest
    • Prior to selection of the guideline development group, individuals being considered for membership should declare all interests and activities potentially resulting in conflicts of interest with development group activity, by written disclosure to those convening the group activity.
  3. Guideline Development Group Composition
    • The guideline development group should be multidisciplinary and balanced, comprising a variety of methodological experts and clinicians, and populations expected to be affected by the clinical practice guideline.
  4. Clinical Practice Guideline-Systematic Review Intersection
    • Clinical practice guideline developers should use systematic reviews that meet standards set by the Institute of Medicine’s Committee on Standards for Systematic Reviews of Comparative Effectiveness Research.
  5. Establishing Evidence Foundations for and Rating Strength of Recommendations
    • For each recommendation, the following should be provided: An explanation of the reasoning underlying the recommendation, including:
      • A clear description of potential benefits and harms.
      • A summary of relevant available evidence (and evidentiary gaps), description of the quality (including applicability), – quantity (including completeness), and consistency of the aggregate available evidence.
      • An explanation of the part played by values, opinion, theory, and clinical experience in deriving the recommendation.
      • A rating of the level of confidence in (certainty regarding) the evidence underpinning the recommendation.
      • A rating of the strength of the recommendation in light of the preceding bullets.
      • A description and explanation of any differences of opinion regarding the recommendation.
  6. Articulation of Recommendations
    • Recommendations should be articulated in a standardized form detailing precisely what the recommended action is and under what circumstances it should be performed.
  7. External Review
    • External reviewers should comprise a full spectrum of relevant stakeholders, including scientific and clinical experts, organizations (e.g., health care, specialty societies), agencies (e.g., federal government), patients, and representatives of the public.
  8. Updating
    • The clinical practice guideline publication date, date of pertinent systematic evidence review and proposed date for future guideline review should be documented within the guideline.
    • Literature should be monitored regularly following the clinical practice guideline publication to identify the emergence of new, potentially relevant evidence and to evaluate the continued validity of the guideline.

ACOEM Practice Guidelines Meet The National Guideline Clearinghouse Inclusion Standards

The National Guideline Clearinghouse (a public agency for the AHRQ and public resource for summaries of evidence-based clinical practice guidelines) measures compliance to the above-mentioned standards. A prominent workers’ compensation news media outlet announced on Tuesday, March 7th, that the ACOEM Practice Guidelines were accepted by the clearinghouse, confirming they meet all of the newly updated inclusion criteria.

The National Guidelines Clearinghouse also made national workers’ compensation news in June of 2016 after announcing that the other commercial nationally recognized guidelines provider, ODG published by Work Loss Data Institute, had been removed from its database after it was determined that the ODG content and development process did not meet evidence-based medicine standards. Some examples provided of the unmet standards include:

– Explaining how ODG selected studies for their evidence-based review

– Including the number of studies identified

– Including the number of studies evaluated

– Providing a summary of inclusion and exclusion criteria

According to the NGC and AHRQ, evidence from the selected studies must also be synthesized in a detailed description or evidence table, which ODG did not provide for all of its treatment recommendations.

California’s patient-centric decision to replace all of its existing guidelines with the most current versions of the ACOEM Practice Guidelines is the first step in the much-needed direction towards patient advocacy. In addition to taking a position that places the doctor-patient relationship as paramount, the State also decided to take a leadership position with adopting a drug formulary model that differed from the news-mainstay and savings-focused Texas model. By moving away from the draconian yes/no drug list approach of yesteryear to a modern formulary model that eradicates assertions of a cookie-cutter, one-size fits all approach, the California ACOEM-based formulary elevates the importance of each individual patient’s medical condition and where they are in their respective treatment path, is not only the right thing to do, its smart medicine.

Will California’s innovative approach to improving medical care for injured workers pay off?

The sense is that while learnings will present themselves along the way, we are now much closer to making significant progress in workers’ compensation. The future will tell if other States follow California’s lead to put patients’ health and well-being at the center of their adopted standards for drug formularies and medical treatment guidelines.

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