Category Archives: Evidence-Based Medicine (EBM)

Content Out of Context

The adoption of evidence-based medicine (EBM) by state jurisdictions tends to polarize workers’ compensation stakeholders – sometimes for good reason. Many justify that it is the political machine driving the opposite perspectives. This may very well be part of it, but lack of understanding combined with the improper use of the scientifically based standards by certain system verticals is almost certainly a recipe for varying points of view and disagreement.

Evidence-based Medicine is Not Always Unequivocal

Proponents for the adoption of EBM in workers’ compensation generally agree that the content is a path leading to improved medical care for injured or ill workers. Various metaphors (e.g., speed bump, guard rails, etc.) have been appropriately used to describe the content’s ability to steady the tempo of decision-making around care considerations ensuring that safety and efficacy remain priorities in the care and claim continuum. These metaphors, however, miss an important attribute that is evident in a well-developed medically responsible EBM standard – it may not always be unequivocal.

Today, non-clinical professionals often view EBM as absolute standards for the appropriateness of care rather than scientifically based guidance to inform medical decision-making. The use of the content in worker’s compensation as a rigid basis for approving or denying reimbursement for treatment is in large part responsible for maintaining this perception. While this application of EBM, when informed by clinical consensus, may be an acceptable use of the content, it is not its sole purpose and the original intent for the guidance.

Certain recommendations for, or against, specific protocols can be very straightforward and have clear guidance that is actionable for clinical professionals, and non-clinical personnel alike. However, ensuring appropriate clinical interpretation of the recommendations by considering each individual patient’s unique medical needs prevents the use of the content from being out of context and avoids perpetuating a cook-cutter approach in medicine.

The original intended application of EBM was to strengthen weak standards in clinical practice and to increase confidence in clinical decision-making. If the application of the content was more prominent in clinical settings used by medical professionals in workers’ compensation, would the industry view EBM as unequivocal standards, versus trustworthy guidance useful to aid in the care of the individual patient as it was initially intended to be?

The Over-simplification of Complex Concepts

Publishers of EBM continuously walk a fine line between creating tools and widgets, that deliver the content in concise actionable formats and potentially over-simplifying complex medical concepts that become diluted and dangerous when made to fit into an overly simplistic delivery. This, along with prospectively rigid applications previously mentioned, leads to distrust of the content and breeds opposition among the stakeholders for whom EBM is intended to support.

Opposition among providers outside of the Occupational Medicine specialty for EBM always surprises me. I have had the privilege of interviewing numerous providers who oppose the use of EBM over the last ten years. Their perspective has a common thread that echoes the issues identified above. And while medical providers are often accused of rejecting the use of EBM standards due to avoidance of oversight and accountability, a more sensible source of their opposition may be due to the oversimplification of the complex medical concepts delivered via poorly engineered EBM tools and inadequately credentialed users of the content.

A recently posted blog by a long-term, well respected, proponent of EBM documents a young Air Force physician’s disillusionment of medicine due to EBM, among other things. The young physician states that EBM sucks the intellectual challenge and creativity, or as he puts it “the fun” out of the art of medicine. He further shares that following the guidelines is the “easy path” and that there is neither “encouragement nor reward for taking the extra mental step” to determine if the guidance fits the patient’s needs, or if a variance is medically appropriate.

I have several thoughts about why the young physician’s disillusionment of medicine may be misplaced. However, the acknowledgement of the lack of reward for varying from EBM guidance, when warranted, in pursuit of the best medical care and health outcome for his patient is telling of a system’s over-simplification of the complex medical scenarios he must work to resolve.

A rigid, over simplistic application of guidelines will only shorten the cycle for reimbursement, but can risk stifling a good doctor’s willingness to invest the time to identify the best treatment plan that will produce the best health outcomes for their patient. This rigid approach to medicine will breed and reward poor practice habits in the clinic and potentially result in a higher medical spend long term. Conversely, a doctor unwilling to investigate the best course to recovery for their patient irrespective of the hurdles encountered may be subject to criticism for prioritizing other interests ahead of their patient’s needs.

The data is clear. The impact that EBM has on improved health outcomes in workers’ compensation is overwhelmingly positive. Adverse patient and provider experiences are more accurately contributed to the inappropriate rigid use of the content in a system that is engineered to focus more on reimbursement versus quality medical care and improved health outcomes.

The pursuit to simplify and streamline solutions has become part of our cultural fabric. Just as technology has made it possible for our society to make advancements in medicine, it will eventually become a vehicle to better deliver these advancements. For now, however, we rely on the appropriate application of EBM standards by qualified professionals in the clinic and beyond allowing for flexibility when warranted.

Patient Engagement in Workers’ Compensation

This article was published on WorkCompCentral’s Work Comp World. Click here to link to the article.

The call to increase patient engagement to inform the development of standards and policies is gaining traction. The development of these standards ultimately helps improve health outcomes in workers’ compensation, and other health care influenced industries. Efforts to consistently collect and incorporate patient perspectives into the scientific process is becoming a priority for many. This is welcome news to all patients and patient advocates!

How important is patient input to ensuring the best possible health outcomes for ill or injured workers?

Understanding the importance of patient involvement in the composition of evidence-based Guideline Development Groups (GDG), The National Academies of Sciences, Engineering, Medicine (formerly the Institute of Medicine (IOM), included the requirement of patient input as one of its eight Standards for Developing Trustworthy Clinical Practice Guidelines in 2011. The standard directs guideline developers to incorporate patient involvement, at least, when formulating clinical questions and reviewing Clinical Practice Guideline (CPG) drafts. Former patients, patient advocates, or patient / consumer organization representatives qualify to participate in the GDGs under this requirement.

Accordingly, the requirement of patient involvement is included in AHRQ’s National Guideline Clearinghouse’s (NGC) assessment of submitted guidelines’ adherence to the academy’s standards of trustworthiness. Patient and public perspectives, along with multidisciplinary group participation and methodologist involvement, is measured by the NGC when grading the content developer’s GDG composition.

The newly energized push for patient engagement is prompting content developers aiming to align with National Academy standards to improve methods for soliciting, receiving, and incorporating patient and public input into the content development process. The American College of Occupational and Environment Medicine (ACOEM) accepts patient, and other stakeholder, input through an online portal to assist the development of its evidence-based medicine practice guidelines.

Patient Engagement beyond Content Development

Notable recent activity from the Food and Drug Administration (FDA) includes assembly of a Patient Engagement Advisory Committee (PEAC). A statement issued by the FDA explains the committee exists to support its efforts to broaden engagement with patients and deepen patient involvement in the administration’s regulatory activities.

More specifically, the initiative will seek patient perspectives for use across medical device design, clinical trial process, and post market evaluation. Additional guidance on patient preferences, such as tolerance of risk and patient point of view on benefits, will be used by the FDA to assess device benefit-risk profiles.

The administration can consider the systematically gathered patient preference information, in conjunction with its assessment of scientific evidence that demonstrates a device’s probable benefit outweighing its likely risks, to form its complete grouping of clinical and non-clinical testing.

Workers’ Compensation Continues its Efforts for Patient Engagement

Very few venues exist in workers’ compensation that facilitate direct engagement between industry vendors and patients. Perhaps the most visible platform today is WorkComp Central’s Comp Laude® Awards & Gala. Event participants advertise that Comp Laude’s most memorable moments typically occur when patients are involved in panel discussions. Event organizers have voiced their excitement about the overall positive impact patients have on the industry get-together.

Stemming from the mission and vision of the event’s late founder David DePaolo, Comp Laude® created a scholarship intended to create a path for direct engagement between the industry and its patients. The scholarship provides travel funds and covers lodging expenses along with conference registration for the patient and a guest. Several vendors, among them ReedGroup, are honored to have the opportunity to be sponsors of the scholarship fund.

Many have criticized the workers’ compensation industry for its numerous shortcomings, myself included. While it is important to acknowledge the industry has more work to do in the pursuit to increase patient engagement to improve health outcomes, it is equally important to acknowledge the progress gained by organizations whose corporate point of view regularly advocates for patients and their well-being. For this, the industry should be complimented.

A Case for National Standards for State Workers’ Compensation

Would you be surprised to know that the definition of “Employee” and “Contractor” varies from one state to another? Would you be shocked if I told you that more state Workers’ Compensation agencies operate without a full-time, or part-time, Medical Director on staff than those that do?

Speaking with a prominent regulator, and Workers’ Compensation expert, at the #IAIABC103 conference in Portland, OR last week, rekindled my interest in determining what establishing national standards could do for a system where variances from one jurisdiction to the next seem endless.

The sources of variability in definitions and standards are numerous. Among the most prevalent, RESOURCES (expertise, budget, time etc.). Is it reasonable to suggest that the varying availability of resources from state-to-state present limitations for regulators in their pursuit to appropriately research prospective public policy that will improve system outcomes?

Take evidence-based medicine (EBM) for example…

Admittedly, EBM is a very complex concept that few people truly understand and appreciate (Note: This is particularly true, and ironic, in the Workers’ Compensation industry where misaligned incentives makes it nearly impossible for stakeholders to share a common goal). EBM goes beyond the review of literature and authoring of content. The path taken to form conclusions, interpreting scientific literature and answering defined clinical questions ultimately constitutes the content as evidence-based. Without an informed guide to point out technical deficiencies and/or important considerations, the outcome for the agency looking to adopt may result in the selection of a consensus-based resource, or worse, a resource with an undetermined basis.

Serving a Thanksgiving Meal on a Fast-food Budget

In Workers’ Compensation, state officials routinely struggle to serve a Thanksgiving meal given little more than a fast-food budget. This type of limitation in resources hinders small markets from properly researching and vetting EBM tools when considering a source for adoption.

In a best-case scenario, the adopted solution goes through uncontested for quality and trustworthiness, due to a lack of understanding, and provides a standard of care where there previously was none, albeit lesser in quality. Worst-case scenario, the inadequately vetted solution becomes a liability to patient health and is a source of significant system friction and cost due to errant research findings by the agency adopting it. With proper informed due diligence, which requires RESOURCES, both scenarios are entirely avoidable.

Stakeholders in the Workers’ Compensation system throughout the country are actively expanding the conversation on the necessary attributes in EBM treatment guidelines and drug formularies for state adoption. Increased scrutiny is placed on determining if guidelines and formularies are built atop a basis that aligns with public standards defined by the National Academies of Sciences, Engineering, Medicine (formerly the Institute of Medicine). Interestingly, these standards, and the non-profit entity that measures alignment among content sources (i.e., AHRQ’s National Guideline Clearinghouse), are deemphasized and lessened in value by small market states who do not have properly experienced personnel evaluating the standards’ merits. This should prompt action by every person with an interest in Workers’ Compensation – employees, employee attorneys, employers, physicians, carriers, et al.

Good Public Policy is Never Easy and Rarely Inexpensive

Select state agencies have expressed concerns with limited options for adopting EBM content and tools due to absent resources such as a Medical Director, Pharmacy and Therapeutics Committee, and staff with expertise in the area of scientific research. A state’s “limitations” supersedes its “needs” under these restrictive circumstances. The more limited the resources, the less available options for these agencies to consider for adoption.

It is my sincere belief that small market agencies, much like their large market counterparts, work extremely hard to educate themselves on evidence-based medicine treatment guidelines and drug formularies, as well any other area they seek to reform, and aim to make the right decisions. In the end, they are left to act using the resources they have at their disposal, whether plentiful or scarce.

Perhaps a national standard for the evaluation and adoption, better yet a definition of EBM for Workers’ Compensation, as an example, would help afford better options for small markets managing with modest resources.

Removing Friction from California’s Workers’ Compensation System

The California workers’ compensation system has been buzzing with activity since the passage of AB 1124 in 2015 requiring the Administrative Director of the Division of Workers’ Compensation to establish a drug formulary as part of the state’s Medical Treatment Utilization Schedule (MTUS). The addition of the formulary, in concert with the impending updates to various treatment guidelines (following the new expedited process set forth in SB 1160), in MTUS will improve the system by:

  • increasing the use of evidence based care administered to patients therefore reducing the inappropriate prescription of dangerous drugs and inappropriate medical treatment;
  • reducing system friction by providing a common standard to base medical decisions for injured workers at every step in the care and claim continuum.

California Code of Regulations and Presumptive Weight

Perhaps my day-to-day exposure to regulations and legislative text is what drives my “geeking out” on the code. I have actually heard highly influential people say, “no one pays attention to the labor code”, or “no one cares about what the regs state”. Comments such as these just don’t make any sense.

Admittedly, regulation text can miss the mark if stakeholder input is not considered. Real-world experience and wisdom must inform the process that is expected to turn the gears of the workers’ compensation industry. Absent sound and constructive input from the marketplace, regulations run the risk of being detached from the day-to-day needs of the system and all of its stakeholders.

In California, the Division of Workers Compensation’s Administrative Rules emphasize the state’s commitment to injured workers and their employers by defining what may well be the most critical of expectations – that the best available evidence be used to guide clinical decision-making. The state’s commitment to injured workers and their employers is again emphasized by the thorough analysis that was conducted to inform their selection of the content source that powers the MTUS’ treatment guidelines and drug formulary.

The outcome of the state’s thorough analysis of multiple treatment guidelines and drug formularies lends great weight to the state’s assignment of the MTUS (and the platform that provides the foundation for the MTUS, the ACOEM Practice Guidelines and Drug Formulary) as being the “go-to” source when treating ill or injured workers in the California market:

§ 9792.21 Medical Treatment Utilization Schedule.

(c) The recommended guidelines set forth in the MTUS are presumptively correct on the issue of extent and scope of medical treatment. The MTUS constitutes the standard for the provision of medical care in accordance with Labor Code section 4600 for all injured workers diagnosed with industrial conditions because it provides a framework for the most effective treatment of work-related illness or injury to achieve functional improvement, return-to-work, and disability prevention. The MTUS shall be the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers.

Assigning this weight to the MTUS prioritizes the use of its treatment guidelines and drug formulary above all other sources. In doing so, MTUS becomes California’s primary language of communication for all workers’ compensation system stakeholders. Understanding that on occasion secondary sources may be needed to form a comprehensive foundation for evidence base care, California’s Division of Workers’ Compensation defines a very clear path (through its Medical Evidence Search Sequence) for introducing standards not found in the MTUS. This path should only be taken after the MTUS is considered (see charts below).

More Than Claims and UR Tools

California’s endeavor to establish the tools contained in MTUS as the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers is based in the realization that in order to meaningfully improve the friction in the workers’ compensation system, MTUS must be the guiding source for treatment from day-one.

The treating physician’s initial interaction with the injured worker is paramount to accomplishing favorable health outcomes. The dialog between doctor and patient not only sets appropriate (or inappropriate) medical expectations, it ultimately shapes the trajectory of the claim – smooth going, or friction-filled. This is the point where evidence based care is most effective and necessary.

Retrospective efforts to get a run-a-way claim train back on track are perceived as detrimental to employee benefits by employee advocacy groups. Deviating from or challenging a doctor’s orders, even when informed by the highest-grade of evidence-based medicine, can be an invitation for friction. Disparate standards of care introduced outside of the established path (Medical Evidence Search Sequence) further widens the gap among stakeholders and adds friction to the process.

Opponents of Sound Patient-Centric Medicine

Sound patient-centric medicine will always have opponents – opponents by commission and opponents by omission.

Misaligned interests are present in numerous verticals of the industry. Opponents by commission are identifiable by their persistent off-center messaging in the marketplace. Their message intends to deemphasize what the State has created as a standard; they work to obfuscate what is otherwise a clear path to scientifically based standards for optimal care. Their interest is driven by personal gain, forgetting that a conflict-free, good working system that produces optimal health outcomes benefits everyone.

In some cases, opponents do not see themselves on the opposing side of sound medicine. Opponents by omission are parties that remain neutral when confusion is intentionally sown into the marketplace by the aforementioned. I often question, are opponents of sound patient-centric medicine unware, or are they indifferent to the friction they invite by their lack of action?

California’s success in removing friction from its workers’ compensation system hinges on all of the state’s stakeholders committing to work from the same standards and speaking the same language. Anything short of this type of cooperation is both counter-productive and an affront toward the collective effort to produce improved health outcomes for California’s injured workers.

Aides from Dr. Raymond Meister, CA DWC Medical Director

*Complete presentation deck is available at http://ccwcworkcomp.org/ccwc/assets/File/2017%20Conference/PPT%20Presentations/4_1%20Implementation%20of%20SB1160.pdf.

MTUS Online Education

http://www.dir.ca.gov/dwc/CaliforniaDWCCME.htm

Inspiración en el Sistema de Compensación de Trabajadores Lesionados

La inspiración lleva a la gente a hacer cosas increíbles, a veces cosas atípicas. En raras ocasiones, la inspiración mueve a la gente en su núcleo y activa el comportamiento y la creencia, que no es característico para ellos. Cada cuatro años, la inspiración moviliza a millones de ciudadanos en esta nación para que se reúnan detrás de unas cuantas personas que ellos creen que los van a inspirar.

Las instituciones religiosas, organizaciones no comercial (educativas, basadas en las salud, políticas, etc.) y empresas de comercialización del sector privado con éxito usan como arma la influencia de la inspiración para reclutar el apoyo y la inversión necesarios para cumplir sus misiones definidas. Efectivamente, las organizaciones de ventas más exitosas construyen sus imperios sobre una base de inspiración, inyectando a sus representantes copiosas cantidades de la euforia adictiva.

Si la inspiración es de hecho un tan poderoso conducto de acción, ¿existe una parte constructiva que pueda desempeñar en el mundo de el sistema de compensación de los trabajadores lesionados? Un mundo sostenido por cuerpos rotos, muchas veces oscurados por la moral derrotada, y en casos raros, confiscados por un carácter en bancarrota.

Estudio tras estudio, pilas sobre pilas de datos científicos, se ha verificado la realidad de que los elementos no fisiológicos (psicosociales) tienen un impacto significativo en el retorno a la función de lesión / enfermedad fisiológica. Mientras que los pagadores, proveedores, reguladores, empleadores y abogados debaten sobre la conveniencia, y la necesidad médica de los protocolos de tratamiento diseñados para abordar los elementos fisiológicos, los psicosociales muchas veces no se observan mientras que conducen al paciente por un camino rico en sedación, pero pobre con mejoría funcional.

Sentado en un centro de convenciones lleno de gente, con 2,000 otros trajes, me inspiró recientemente un panel formado por un presidente americano de dos períodos, un proveedor / líder del cuidado de la salud de Baltimore, y dos adictos en recuperación de medicamentos recetados. Su peregrinación a la salud provocó una fuerte creencia de una realidad alternativa del systema de compensación de los trabajadores lesionados; una realidad donde los esfuerzos colectivos de las partes interesadas / accionistas en el sistema realmente podrían ayudar a las personas heridas o enfermas volver a la función severed y esfuerzo productivo y revertir una epidemia que demuestra ser más proficientes en matar que los accidentes de vehículos de motor y armas de fuego.

Me pregunto a mí mismo, ¿podría este mismo tipo de inspiración ayudar a impulsar al famélico de motivación, el quien esta roto en cuerpo y en la mente, regresar a una vida productiva después de una lesión o la enfermedad en el lugar de trabajo?

¿Cómo respondería a la inspiración el arduo ensamblador de gabinetes, padre de cuatro hijos, ganador primario de su hogar, con tres dedos cortados (el que experimenta dolor constante porque se niega a ingerir los narcóticos recetados)?

Tal vez estoy exageradamente sensacional; tal vez no…

Why Standards Matter

I had the privilege of attending the AASCIF conference for the first time, hosted in Oklahoma City this year. I was honored to have so many in the state compensation insurance fund community express support of our organization’s efforts to elevate evidence-based medicine (EBM) and advocate for the improvement of the quality of medical care to injured workers.

One conversation left a lasting impression. A well-known workers’ compensation veteran verbalized discomfort with some of my topical write-ups on EBM, trustworthy clinical guidelines, and my willingness to name certain commercial guidelines publishers in hopes of encouraging accountability. They echoed the conflict-free mantra, “There is enough room for all EBM treatment guidelines in workers’ compensation.”

A thought immediately consumed me:  My point of view is based on standards that are not defined by me, or my employer (also a commercial guidelines publisher), but standards that were developed independently by a non-interested not for profit entity at the request of the U.S. Congress looking to establish best methods used in developing clinical practice guidelines. The goal was to ensure such guidelines have information on approaches that are objective, transparent, scientifically valid, and consistent – the ideal basis of accountability for the clinical guidelines industry.

What is at Stake?

The statistics are sobering. Treating providers experience challenges in the clinic. A 10-year study conducted by a medical consultation firm found that nearly a fifth (~21%) of medical diagnoses in workers’ compensation claims involve errors costing the injured worker prolonged disability and household financial distress.

Workers’ compensation only covers a portion of the earned income and there is usually a ceiling, typically 66% of pre-tax earnings up to the state’s average weekly wage. Lost time from work for the injured worker due to injury or illness means loss of income. According to a study by the Washington State Department of Labor and Industries (2015), injured workers with less than 3 months of lost time lose an average of 3.5% of earning capacity over a 10-year period. Conversely, lost time of 3 to 12 months produces losses of income of approximately 11.6%; 28% loss in earnings is experienced after a 3-year absence due to workplace injury or illness.

Another study published in January 2017 looked at ~1.9 million short-term disability and workers’ compensation claims investigating for absences where prescribed opioids were contrary to a leading EBM drug formulary’s recommendations. The study estimated 57,000 (~3%) claims were found to have had an opioid prescribed that was either moderately or strongly not recommended in the formulary. The study also discovered approximately 133,000 (~7%) claims where prescribed opioids were contrary to the formulary recommendations for disorders of the peripheral nervous system including ulnar nerve lesions and carpal tunnel syndrome.

The challenges experienced in the care and claim continuum are plentiful and very difficult to navigate. Employees, employers, insurers, and medical providers deserve content measured and deemed trustworthy according to non-bias standards to guide injured workers through these challenges and on to recovery.

Thought-Leaders Stand Up

With the deep knowledge base and hands on experience of how quickly a workers’ compensation claim can go into free fall toward catastrophic health and recovery outcomes for the injured worker, why aren’t more “thought-leaders” taking a closer look at the status quo to identify inadvertent, or unintended, consequences and voice opportunities for improvement in their respective areas of expertise? Why is accountability viewed as a negative for industry report and the cost to the individual worker is almost intentionally ignored?

There may be enough room for all EBM treatment guidelines in workers’ compensation. However, there should never be room for vendors to profit from poorly constructed products that are dangerous to the well-being of injured workers and subsequently cost employers a lot more time and money.

Leading “comp-sters” have a duty to encourage accountability in the spirit of preserving the heart of the Grand Bargain, where the employee and the employer are center of the discussion. In cases where benefits and quality of medical care suffer from intendedshortcuts, or vendors falsely representing the basis of their products, accountability should not be viewed as bad for the industry rather it should be viewed through the eyes of an injured worker trusting they will get better.

The Truth Regarding Outcomes in Texas and the Guideline Never Discussed

The Texas workers’ compensation system is again the center of national discussion. Republican House Representatives in Louisiana are proposing the adoption of the binary drug list that Texas made popular resulting from the material reduction in cost and overall decrease of prescription drugs made available to injured workers in the state. However, employee and patient advocates struggle with correlating lower costs and medication prescriptions to a healthier workforce. Denying medical care, without the support of quality scientific evidence, does not guarantee better care and therefore may not result in overall health outcomes.

Texas Commissioner Ryan Brennan submitted a write up published by WorkCompCentral (subscription is required) encouraging the use of the Texas-model formulary by other jurisdictions. While the success of cost savings and reduced medication prescriptions to injured workers in the state is well documented, Commissioner Brennan’s claim that the drug list is responsible for the state’s improvements in return-to-work may not be as cut and dry. The dual adoption of individual commercial return-to-work and treatment guidelines in the state sets a stage worthy of scientific discourse and dramatic findings of deranged recommendations.

Texas’ Choice for Return-To-Work Standards

Texas’ legislated mandate to use return-to-work guidelines is an element of their workers’ compensation system that is usually discussed out of context, or is all together ignored. Leading up to the passage of House Bill 7, which includes the requirement that the Texas DWC adopt return-to-work guidelines in 2005, the state completed a thorough analysis of both ODG, providers of the Texas treatment guidelines and binary drug list, and Reed Group’s Medical Disability Advisor, now MDGuidelines. The state found the Medical Disability Advisor content to be more reliable and based on actual observed claims data wholly tagged by ICD codes and moved forward with adopting the content source to guide return-to-work decisions for injured workers in the state.

Commemorated in the Division of Workers’ Compensation Biennial Report to the 85th Texas Legislature, signed by Commissioner Brennan, Texas’ return-to-work outcomes are driven by the legislative reforms focusing on returning employees to work such as the return-to-work guidelines, return-to-work reimbursement program for employers, improvements in return-to-work outreach efforts, and other return-to-work specific programs. The report also correlates the rebound in return-to-work rates to the state’s economy in 2012 and 2013.

This information is critically important as state regulators and legislators reference the popular report Impact of a Texas-Like Formulary in other States by the Workers Compensation Research Institute and attempt to replicate outcomes experienced in the Texas system. The improvement in duration of disability and return-to-work is not the product of a binary drug list rather a result of a very comprehensive return-to-work effort mandated through legislative reform.

The following is an excerpt from the biennial report available online:

“Not only has the percentage of injured employees who returned to work and remained employed improved since the 2005 legislative reforms, but the amount of time the average injured employee who received TIBs [Temporary Income Benefits] is off work after an injury also decreased from a median of 28‐29 days in 2004‐2005 to 19 days in 2013. The reduction in the number of days off work per claim not only allows employers to quickly restore productivity levels after a work-related injury, it also allows injured employees to regain their wage-earning capacity quicker, helping them avoid severe economic losses as a result of a work-related injury.”

ODG Recommends Return-To-Work for SIDS & Other Pediatric Conditions

ODG claims to have a comprehensive data consortium undergirding its return-to-work guidelines data set as well. So why did Texas choose the Medical Disability Advisor over ODG? The publisher does not describe established standards for exclusion, fails to provide information about diversity with regard to industry or geographic location, and it cites the use of public databases (i.e., CDC NHIS and OSHA) where ICD codes are likely questionable or unavailable.

ODG also asserts its comprehensive guidelines cover every reportable condition and procedure, including over 10,000 ICD-9 codes, 65,000 ICD-10 codes, and 11,000 CPT procedure codes. Rather than screening these codes and providing information about conditions that affect working-age individuals, ODG’s website provides return-to-work summary guidelines for conditions not relevant to the working population:

  • Sudden Infant Death Syndrome (ICD-9 code 798.0)
  • Instantaneous Death (ICD-9 code 798.1)
  • Fussy Infant/Baby (ICD-9 code 780.91)
  • Infant Botulism (ICD-9 code 040.41).

Oddly, a search of ODG’s website using the term “infant” returns numerous conditions for which disability duration data does not exist and return-to-work guidelines are all together inappropriate. These recommendations call into question the source(s) of the numbers provided in the summary guidelines tables.

There is no doubt Texas made the right decision to adopt the Medical Disability Advisor, now MDGuidelines, as its standard for return-to-work over the ODG return-to-work content. The outcomes are irrefutable and a clear result of legislative reforms from 2005, not the savings-focused binary drug list made popular by the state.

However, the realization that the same entity that defines treatment standards for injured workers in Texas also publishes outlandish return-to-work guidance for deceased infants, should prompt severe concern for the quality of the science undergirding every recommendation stemming from the ODG library – treatment and return to work guidelines and drug formulary.

This prompts the question: Do the ODG treatment guidelines and drug formulary meet the definition of evidence-based medicine in the Texas Labor Code?

Texas Labor Code, Section 401.011 (18-a)

“Evidence-based medicine” [EBM] means the use of the current best quality scientific and medical evidence formulated from credible scientific studies, including peer reviewed medical literature and other currently scientifically based texts, and treatment and practice guidelines in making decisions about the care of individual patients.”

The labor code specifies “the use of current best quality scientific and medical evidence formulated from credible scientific studies.” While the State’s definition of EBM is not all together complete, the verbiage indicates the need for the content source to incorporate a transparent systematic review process.

Systematic review ensures the use of the “best” scientific evidence from “credible” sources; it is a core element of evidence-based medicine.

Good-working Systematic Review

As an example, the development of guidelines from the American College of Occupational and Environmental Medicine (ACOEM) utilizes Cochrane systematic reviews, in addition to other scientific systematic reviews that meet or exceed the Institute of Medicine’s (now known as the Academy of Medicine) Committee on Standards for Systematic Reviews of Comparative Effectiveness Research. The ACOEM Guidelines rely on systematic reviews conducted in accordance with the highest standards to provide current guidance on the relevant clinical questions.

Here is how it works: The Research Team conducts exhaustive systematic literature reviews for each guideline topic, and/or research question. In order to identify all high- and moderate-quality original research studies, the literature search is broad and comprehensive.

ACOEM searches PubMed, CINAHL, Cochrane Central Registry of Controlled Trials, and Scopus for primary sources of original research. ACOEM also conducts extensive supplementary searches using review articles, systematic reviews, and reference lists of the included and excluded studies. It searches other databases likely to contain references of high quality medical literature, including Google Scholar to identify potential quality, impactful literature that includes the grey literature.

Search strategies and methods are recorded in detail, including specific databases, search terms, number of studies found (e.g., regarding treatment efficacy searches including RCTs and crossover trials). A Search Results section, in paragraph form, is also included as a footnote for each evidence table.

  • The Search Results section includes:
  • Databases searched (that there were no limits on publication dates, limited to English language)
  • Search terms used
  • Number of studies found from all the databases searched
  • Total number of articles screened

– number meeting inclusion and exclusion criteria

– number critically appraised

  • Total number of studies included of high or moderate quality.

Also identified in tables, are studies of low quality.

In formulating the final recommendations, the numbers of studies and the strength of those studies, are all included in summary statements under the “Rationale for Recommendation” section.

The US Agency for Healthcare Research and Quality’s (AHRQ) Verdict on Texas’ Treatment Guidelines

In June of 2016, Mary Nix, AHRQ Health Science Administrator, stated in a WorkCompCentral interview, “Work Loss Data Institute [publisher of the Texas treatment guidelines a.k.a. Official Disability Guidelines/ODG] didn’t fully explain how it selected studies for its evidence-based review, including the number of studies identified, the number of studies evaluated, and a summary of inclusion and exclusion criteria. Another Requirement WLDI didn’t meet was to synthesize evidence from the selected studies in a detailed description or evidence table.”

In a separate interview with Business Insurance during the same month in 2016, Nix stated, “We were not able to … assure that the systematic evidence review was conducted for each of the topics that they cover in the ODGs”.

The following is a list of the types of evidence reviewed by ODG as documented in their methodology document available on line:

STUDIES:

  1. Systematic Review/Meta-Analysis
  2. Controlled Trial – Randomized (RCT) or Controlled
  3. Cohort Study – Prospective or Retrospective
  4. Case Control Series
  5. Unstructured Review

OTHER:

  1. Nationally Recognized Treatment Guideline (from guidelines.gov)
  2. State Treatment Guideline
  3. Other Treatment Guideline
  4. Textbook
  5. Conference Proceedings/Presentation Slides
  6. Case Reports and Descriptions

None of the “Other” materials reviewed and used by ODG meet the selection criteria for inclusion of any methodology literature-scoring model.

Recommendations for medical care should not be created based on single studies, or sources. Rather, recommendations should be based on the preponderance of evidence systemically gathered, reviewed, graded, summarized and evaluated. These steps are important to ensure the process is reproducible and the recommendations, when established, are valid and supported by the best quality scientific evidence meeting inclusion criteria from credible scientific studies.

The influence of Texas’ return to work standards on outcomes cannot be more apparent. While the evidence that the content underpinning their treatment standards do not meet their Labor Code’s definition of evidence-based medicine is overwhelming. It is a strange case indeed, when states such as Louisiana are specifically seeking to replicate the adoption of tools proven to have no scientific merit in hopes of achieving outcomes driven by sources and initiatives unique to Texas.