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| Evidence-Based Guidelines Help Create a Solid Foundation for Practice Decisions in Occupational Medicine
The past year has seen significant movement across the country in developing scientifically based guidelines to address problems within workers’ compensation systems. In December 2003, the American College of Occupational and Environmental Medicine (ACOEM) set forth specific guidelines, backed by scientific findings, for treatment of injured workers. These guidelines were developed by occupational medicine physicians and other specialists involved in the medical care of workers to guide health care providers. Also in December 2003, the Work Loss Data Institute released the second edition of the Official Disability Guidelines (ODG), which make recommendations for care based on literature reviews and organized by ICD-9 codes (diagnosis codes). And, in April 2004, the State of California passed massive workers’ compensation overhaul legislation that defines standard of care as treatment in accordance with the ACOEM guidelines.
Both the ODG and ACOEM guidelines drew heavily on work begun in 1992 by the State
of Colorado, which was the first state to develop evidence-based workers’ compensation practice guidelines. In the following article, Kathryn Mueller, MD, MPH, and Edward Whitney, MD, MSPH, who have been involved in developing evidence-based practice guidelines, share information about the process they used—and how these guidelines
can improve care to workers.
The value of creating practice guidelines for the treatment of workers has been recognized for some time. But prior to 1990, guidelines were likely to be based on general medical opinion. More recently, the trend has been toward developing evidence-based guidelines.
Kathryn Mueller, MD, MPH, has witnessed this trend first-hand. As a member of the Board
of Directors of the American College of Occupational and Environmental Medicine (ACOEM), she was involved in the development of the occupational medicine guidelines published by ACOEM earlier this year. These guidelines were based on a scientific literature review conducted by the Work Loss Data Institute, an independent research organization and publisher of the Official Disability Guidelines. With the state of California having recently led the way in giving regulatory status to the ACOEM guidelines, several other states are considering adopting them as well.
As Medical Director of the Colorado Division of Workers’ Compensation, Mueller also served on a taskforce that was mandated in 1992 to develop evidence-based practice guidelines. One of the key steps taken by the Colorado taskforce, which developed 10 guidelines, was to create multidisciplinary teams. Mueller stresses the importance of using such an approach. “In an ideal world, you would look at all the pertinent literature and select the highest quality, evidence-based studies that address a given guideline. In reality, you often find that there are not any high-quality studies in the specific area you are reviewing,”
she says. “Given these limitations, you need the involvement of
all of the relevant specialists for each guideline. They can bring a well-rounded perspective to the discussion of the available evidence in order to make an appropriate recommendation.”
In 2000, the Colorado Division of Workers’ Compensation enlisted the expertise of an epidemiologist, Edward Whitney, MD, MSPH, to assist in making revisions to the guidelines. (Revisions are to
take place approximately every 10 years.)
“Dr. Whitney brings the dual perspective of
a scientifically trained researcher who is
also a medical professional, which has
been extremely valuable to our work,”
says Mueller. Whitney is not a voting member
of the taskforce; his role is to gather, analyze, and grade relevant studies and report his findings to the group.
In updating the guidelines, the taskforce has focused on adding statements of evidence whenever possible—as well as a notation on the level of evidence: “Some” (at least one adequate scientific study), “Good” (multiple adequate scientific studies or one high-quality scientific study), or “Strong” (multiple relevant and high-quality scientific studies).
If relevant studies are not available, recommendations are made by consensus—defined by the guidelines as “the opinion of experienced professionals based on general medical principles.” Consensus recommendations are designated in the guidelines as “Generally well accepted,” “Acceptable,” or “Well-established.” Finally, procedures that do not meet the standard of reasonable care are labeled “Not recommended.”
Gaining sponsorship
Mueller advises that when it comes to implementing guidelines, the goal should not be for insurers to monitor doctors on an
ongoing basis, but for the majority of practitioners to shift to
a practice pattern that fits the guidelines. To effect this kind
of change, Mueller recommends developing advocates among
the medical leaders in the community—which she believes can best be done by involving them in some aspect of the develop- ment process.
She also recommends getting a good picture of practice patterns in the community by gathering input from practitioners. “They can identify the hot spots—those areas where health care providers really aren’t following the best practice patterns,” she says.
Most important, the underlying principle in developing guidelines must be to determine what’s best for the patient—and this motivation must be made very clear to everyone involved in the process, says Mueller. “If people have the impression that the goal is to cut costs, they aren’t going to trust the recommendations,” she says. Even in dealing with legislators who are likely to be looking at the bottom line, Mueller advises taking “the high road.” “It can be difficult,” she acknowledges, “but I think you simply need to say: ‘All we want to do is practice good medicine. We’re presenting you with information about what’s best for the patient—so that you can make an informed decision.”
Addressing common issues
While no two workers’ compensation systems are alike. Mueller notes some critical areas that states are likely to face—and that practice guidelines can help address.
“A serious problem that many workers’ compensation systems face is that cases are not managed correctly from the outset.
If you do not correctly assess the patient’s condition and educate
the patient at the start of the case, it’s almost impossible to rectify the problem later.” To address this issue, the ACOEM guidelines provide a step-by-step outline of initial procedures in an easy-to-read format that may serve as a good model for other workers’ compensation systems.
Another issue workers’ compensation systems may encounter is the lack of specific diagnoses. A study of the California system conducted by the Colorado Workers’ Compensation Institute,
for example, found that approximately 30 percent of claims did not have specific diagnoses. “This is completely inappropriate in workers’ compensation cases,” says Mueller. “Guidelines need to be very clear about what physical findings and/or test results are required to establish a diagnosis.”
In addition, many states may find value in developing guidelines that underline the significant role psycho/social factors can play
in a worker’s response to treatment. “The concept of identifying psycho/social issues is something providers frequently ignore, especially in high-volume practices,” she notes. Both the Colorado and California guidelines specify conducting a psycho/social evaluation with patients experiencing delayed recovery. “While we don’t yet have full compliance with the guidelines, they have helped raise awareness. We are seeing practitioners addressing psycho/social issues more quickly than they were before.”
Improving the practice of medicine
Mueller has found that providers in Colorado are very pleased with the workers’ compensation practice guidelines developed by the taskforce. “Many doctors have told us they can provide better care now within the workers’ compensation system than they can within the general health care system,” she says.
As a clinician, Mueller also has discovered the guidelines to be helpful in communicating with patients. As an example, she relates her interaction with a patient suffering from low back pain. “The patient questioned me on why I was not putting her on bed rest for a week. She believed the only reason I was sending her back to work was because her employer had told me to do so. But I was able to reassure her by showing her the actual guideline. I could point to it and say: ‘Here is the recommendation of doctors, not insurers or employers. Bed rest is simply bad treatment for you.”
In addition, creating scientifically based guidelines performs a useful service for practitioners in this “information age,” Mueller says. “As health care providers, our professional duty is to be using scientific standards. You should always be saying ‘What does science tell me?’, not ‘What did I do with the last 20 patients and how did my patients like that treatment?’ But the difficulty for practitioners is that it’s nearly impossible for an individual to read and analyze the vast amount of material available on a given medical topic. Evidence-based guidelines provide the scientific foundation that individual practitioners can’t develop for themselves.”
Whitney points to another benefit of producing evidence-based guidelines. “One of the issues we are concerned with is adherence,” he notes. “Scientific support is one of the variables that gives guidelines credibility—making it more likely that practitioners will implement them.”
Making the Case for Evidence-Based Medicine
As defined in 1996 by one of its founders, David Sackett, evidence-based medicine is “the integration of individual clinical expertise with external evidence from systematic studies.” Edward Whitney, MD, MSPH, notes that while the concept had been around for years, evidence-based medicine did not emerge as a formally recognized approach until the early 1990s when opinion leaders began making the case for it. Their position was strengthened when several widely accepted treatments, which were based on general medical and biological principles, were scientifically disproven by random trial studies.
Whitney gives the following example to illustrate:
Before 1990, medical experts theorized that premature ventricular contractions, if left untreated, could increase one’s risk for sudden cardiac death, which accounted
for thousands of fatalities per year in the United States. To address this concern, many practitioners supported the use of a particular drug therapy that was shown to be effective in suppressing the contractions.
It seemed to be a reasonable approach—so much so that some experts argued it would be unethical to conduct a random trial to test the theory, since such a study would assign some patients to receive placebos rather than the drug therapy. Despite these protests, a randomized trial was conducted in 1990—and it found that, far from helping reduce the risk of sudden cardiac death, the drug therapy actually increased it. The research made national news—and became a watershed event in gaining acceptance for evidence-based medicine.
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Guidelines Help Emphasize Value of Psychological Evaluations in Workers’ Compensation Arena
A review of several recently published practice guidelines suggests that the use of psychological tests in evaluating
workers’ compensation patients is gaining increased support. The American College of Occupational and Environmental Medicine (ACOEM) guidelines recently adopted in California, for example, specifically recommend that patients who
are not showing normal recovery within the expected timeframe receive a psychological evaluation. The State of Colorado's Division of Workers' Compensation guidelines and the Official Disability Guidelines also support the use
of psychological assessments.
Kathryn Mueller, MD, MPH, associate professor at the University of Colorado Health Sciences Center, has
been involved in developing both the ACOEM and Colorado guidelines—and has observed the influential role guidelines can play in raising awareness among practitioners on the benefits of psychological evaluation
(see main article above). She also notes the importance of ensuring that practitioners use solidly researched tools, such as the BBHI™ 2 (Brief Battery for Health Improvement 2) test, a brief psychomedical inventory designed for use by medical practitioners.
“The BBHI 2 instrument is well-supported—and it’s well-suited for use with workers’ compensation cases,”
Mueller says. “Unlike assessments that measure a single factor such as depression, the BBHI 2 test evaluates a number of additional factors that are particularly relevant in treating workers, such as functionality, level of pain, emotional distress, and defensiveness.” The BBHI 2 test is derived from the widely used BHI™ 2 (Battery for Health Improvement 2) instrument, a comprehensive assessment that can be used for in-depth follow-up evaluations.
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For more information…
Kathryn Mueller, MD, MPH, is an associate professor at the University of Colorado Health Sciences Center, an attending physician at National Jewish Medical and Research Center, and residency director for the University of Colorado occupational medicine residency program.
She is also medical director of the Colorado Division of Workers’ Compensation and secretary/treasurer of the American College of Occupational and Environmental Medicine (ACOEM). Dr. Mueller received her MD from the University of Nebraska Medical School and
her Masters in Public Health from the Medical College of Wisconsin.
She is board-certified in Occupational Medicine.
Edward Whitney, MD, MSPH, is a graduate of the University of Colorado School of Medicine who practiced adult ambulatory medicine
in Colorado and in California until 1995, when he returned to the University of Colorado Health Sciences Center to study epidemiology
and public health. Since 1999, he has worked full time at the Colorado Division of Workers’ Compensation, where he has conducted studies of adherence to the division’s Medical Treatment Guidelines. To support
the goal of including evidence statements in the revised guidelines,
Dr. Whitney has conducted critical reviews of published medical literature.
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BBHI™ 2 Test Helps Psychologists Improve Outcomes in Work Hardening Program
As practicing psychologists with the work hardening program at Aurora Rehabilitation Centers, Michael DiMarco, PsyD, and Randall Daut, PhD, are taking a non-traditional approach to mental health therapy.
“In our program, the psychologist is involved with every client from the onset as standard protocol,” says DiMarco. “The more common approach is for psychologists to see clients only if a problem becomes evident at some point during treatment.
But we don’t want to wait four or five weeks to discover barriers that may hinder the patient’s progress. An injury can have a profound impact on a person’s life. There’s a domino effect—the worker is pulled out of the normal routine and may be worried about a loss of income, which can lead to stress, depression, or anxiety, which, in turn, may cause problems at home or on the job. We want to start addressing these issues as soon as possible.”
Taking an interdisciplinary approach
A specialty service offered by Aurora Health Care, the work hardening program treats clients at three locations in the Milwaukee metro region. Initially housed within hospitals,
the service was later moved to free-standing clinics to better reflect the program’s focus on wellness and prevention. DiMarco joined the staff two years ago and helped develop the service for two of the sites.
In addition to DiMarco and Daut, the care provider teams include a physical therapist, an occupational therapist, an athletic trainer, and a vocational rehabilitation counselor.
Most referrals come from physiatrists, orthopedic specialists, and neurosurgeons.
The desired outcome of the program is that the client will be able to return to the same job or a similar job. Impressively,
the clinics have achieved this goal 86% of the time to date. Treatment lasts from two to six weeks, depending on the severity of the injury and the worker’s needs.
The treatment protocol includes:
- An initial assessment by each member of the care team, including the psychologist
- An onsite evaluation of the client’s work environment, conducted by the vocational rehabilitation counselor and the occupational therapist
- A simulation of work activities at the clinic
- An individualized, multidisciplinary treatment plan
- Client education
Psychologists add value on many fronts
DiMarco and Daut are involved with clients throughout the treatment process. They evaluate a range of psychosocial, behavioral, and cognitive issues that may influence the patient’s rate of progress. They then share this information with the rest of the team to help them better understand the client’s pain complaints and adjust their teaching style to the individual’s needs.
In addition, the psychologists communicate with the client on
a variety of topics. For example, they may attend the physical and occupational therapy sessions to help the client visualize what’s happening “under the skin,” which can help reduce an individual’s fear of re-injury and more readily adopt the exercise plan. They also educate clients on pain management techniques and discuss how to incorporate behavioral changes—such as proper body mechanics, time management, and pacing of activities—into their lifestyles. In addition, their counsel may include advising the client on how to communicate with supervisors and co-workers about needed adjustments in the workplace to avoid a repeat injury.
BBHI 2 test supports best practice standards
One of the tools DiMarco and Daut have found highly useful
in their multi-faceted approach to treatment is the BBHI 2 (Brief Battery for Health Improvement 2) test, a brief, self-report assessment of psychomedical factors. The clinics began administering the instrument in the fall of 2003 as part of an overall initiative launched by DiMarco and Daut to implement best practice standards at the clinics.
“We were looking for a contemporary assessment that more closely represents our population,” says DiMarco. “What most impressed us about the BBHI 2 test is that it does not pathologize symptoms into psychiatric diagnoses per se. The instrument is normed on a medical population rather than a psychiatric population. This allows us to understand psychological symptoms associated with individuals coping with medical conditions. Aurora Health Care wants us to be competitive and cutting-edge; well, the BBHI 2 test is cutting-edge—because it is directly applicable to physical rehabilitation patients.”
The clinics administer the BBHI 2 assessment to every client at intake to get a quick snapshot of psychomedical factors and help determine appropriate interventions. DiMarco and Daut have observed the test to be valuable in gathering information that patients might not want to share in the clinical interview—or simply might not know how to explain. DiMarco also points out that the instrument has good face validity, with a primary focus on physical symptoms, which helps patients understand why the test is relevant to them.
“The BBHI 2 test has proven to be a real asset in enabling us to achieve our goal, which is to help people resume their lives as soon as possible,” says DiMarco. “It allows us to quickly identify underlying issues so that the team can begin addressing them from the outset, which can reduce the time the client needs to
be in the program.”
“The BBHI 2 test provides a cost-effective, efficient tool to help us gain critical insights about our clients,” says DiMarco. “It measures Somatic Complaints, Pain Complaints, Functional Complaints, Depression, and Anxiety, which are particularly relevant in our work, since patients with pain often experience these symptoms—and patients with these symptoms tend to heal more slowly. The test is especially useful in pre-surgery and post-surgery evaluations to track these issues.” DiMarco also appreciates that the BBHI 2 test alerts the examiner to potential issues that could have been pre-existing, such as substance abuse or sleep problems. The psychologist can use the generated data during a clinical interview to determine the accuracy of reported symptoms and timelines.
An aspect of the test that Daut considers particularly beneficial is that it asks patients to assess their medical care. “Responses to this question have helped alert me to problems in patients’ relationships with the health care system,” he says. “If left undetected, negative attitudes about health care can significantly affect a patient’s progress. When these attitudes are detected early, we can enhance progress significantly.”
In addition, DiMarco notes the instrument’s value in generating objective, measurable data to augment the clinical interviews, which is very important in dealing with insurers and decision-makers in the workers’ compensation system. He also finds that the test results facilitate communication with patients. “When we show clients how the problem areas they endorsed in the BBHI 2 test are reflected in the psychologists’ reports, it demystifies how we are deriving our impressions,” he says.
“The BBHI 2 test has proven to be a real asset in enabling us to achieve our goal, which is to help people resume their lives as soon as possible,” says DiMarco. “It allows us to quickly identify underlying issues so that the team can begin addressing them from the outset, which can reduce the time the client needs to
be in the program.”
Michael DiMarco, PsyD, is a clinical health psychologist who concentrates his practice on individuals coping with chronic health conditions. Areas of specialization include pain management,
work injury, cancer, stroke, sexual dysfunction, obesity and HIV/AIDS. Dr. DiMarco received his doctorate in clinical psychology with a specialization in health psychology from the Illinois School of Professional Psychology-Chicago.
Randall Daut, PhD, operates a private practice and has been
involved with Aurora Health Care’s work hardening program for the past 15 years. He received his doctorate from the clinical psychology program of the University of Wisconsin-Madison. He has served as president of the Wisconsin Psychological Association and as a surveyor of pain clinics for the Commission on Accreditation of Rehabilitation Facilities (CARF).
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| Behavioral Health Emerges as a Key Concern Among Bariatric Surgery Healthcare Professionals
Behavioral health was the theme of many of the presentations at the 21st Annual Meeting of the American Society for Bariatric Surgery (ASBS) held June 12–18, 2004. This year’s meeting marks the first time so many behavioral health professionals supporting bariatric surgery met in a centralized location. At least ten presentations discussed the role of psychology and/or assessment in patient evaluations, including a workshop sponsored by Pearson Assessments.
In the presentations focusing on preoperative psychological/
psychosocial evaluations, three general premises presented a common thread.
First, published research to date provides neither predictors
of successful outcomes, nor a clear understanding of the
pre- and post-op psychosocial interventions that work for successful outcomes.
Second, there is general consensus that psychosocial evaluations provide value and are conducted for
several purposes:
- to determine psychological suitability for surgery,
- to better understand the patient in order to learn how the patient will likely react following surgery. This understanding is useful to prepare the patient for the post-operative challenges that person will likely
face, and
- to prepare the medical staff in order to anticipate and prepare for the patient’s likely reactions in the months following surgery.
Finally, testing is a valuable element of the psychological evaluation for the objective data it provides. Objective data
is essential for a number of reasons, including:
- to overcome the challenges presented in the clinical interview where patients are highly motivated to
present themselves in the best possible light
- to overcome the healthcare professionals’ tendencies to pass judgment based upon the patient’s appearance, odors, breathing, etc.
- to support the evaluation in court, if necessary.
Some surgeons question the value of a presurgical psychological/psychosocial evaluation, citing the present lack
of research literature to support it as a predictor of outcomes. However, it appears most bariatric surgery programs believe such evaluations provide value to the team. A group of psychologists and physicians from Virginia conducted a survey of bariatric surgery programs across the country to determine their present practices concerning psychosocial evaluation.
188 surveys were mailed out and 81 surveys were returned.
Of those 81 programs, 88% require psychosocial evaluation regardless of insurance requirements.
Research studies continue, new data will be forthcoming,
and a subgroup of behavioral health professionals within
ASBS has organized to develop guidelines for psychological/
psychosocial evaluations of bariatric surgical candidates. Meanwhile, psychologists who provide such evaluations for bariatric surgeons continue to provide valuable education and tools to help these patients meet the challenges they face as they work to integrate lifelong lifestyle changes into their daily routines.
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