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The new paradigm in occupational health
By Patricia Whelan
Executive Vice President and Publisher
Work Loss Data Institute, Encinitas, CA
(Editor's note: As a principal of Work Loss Data Institute and publisher of Official Disability Guidelines and ODG Treatment in Workers' Comp, Whelan was asked to comment on the current state of productivity as it relates to health, absence, and disability in the workplace. The Work Loss Data Institute focuses on workplace health and productivity.)
When founded in 1995, Work Loss Data Institute (WLDI) clearly outlined its mission: To create, maintain, and market information databases to implement standards for managing work force productivity based on strict principles of evidence-based methodology, with ongoing focus on health care cost containment. Yet there has been a major recent shift of emphasis. No longer is the spotlight on productivity per se, but on restoring functionality to the ill or injured worker and using the latest scientifically proven evidence-based treatment methodologies to do so. Ironically, that subtle shift in focus from an economic to a more human perspective creates the kind of positive environment from which workplace productivity, among other things, becomes a natural by-product.
Over the past year, leaders in the field of occupational health have delivered a clear message: The best interests of our society, economy, businesses, and families are served when the primary focus of our profession is on the restoration of functional capacity and in keeping life as normal as possible for the ill or injured worker.
This means doctors committed to identifying and applying the most efficacious interventions to maximize the quality and quantity of life for individual patients, that insurers are expediently approving and paying for the most appropriate course of treatment, and employers and case managers identifying and accommodating safe and responsible stay-at-work or early return-to-work opportunities. For all, this means "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."1
Why evidence-based treatment? Some background: Three U.S. Supreme Court cases, beginning with the 1993 Daubert Decision,2 which held that judges were obligated to evaluate the basis for expert testimony, and following with two additional expert testimony cases, GE v. Joiner 3 and Kumho Tire,4 have set a new standard identifying population-based data and statistical studies, as opposed to opinion, albeit expert, as the most credible evidence admissible in court.
As a result, for the first time in 79 years, the Federal Rules of Evidence were amended in December 2000 to reflect the admissibility of statistical studies as generally satisfying the more important aspects of the "scientific knowledge" requirement articulated in the Daubert Decision. When the Daubert Challenge is invoked in court, the expert opinion must be backed up by either scientific studies published in peer-reviewed journals or population-based survey data, without which the testimony is considered inadmissible.
Legalities aside, treatment based on evidence-based medicine, where efficacious treatment modalities are groomed and documented in randomized controlled settings to identify the likelihood of successful outcomes, also is the best approach to patient care. Unnecessary or unproven surgical and nonsurgical interventions focused on chasing the pain rather than restoring functionality often are debilitating and contribute to delayed recovery, prolonging a patient's dysfunction and resulting in excessive or even unwarranted utilization of medical services.
Little info available from clinical trials
There also is little information available from clinical trials to support the use of many physical medicine modalities often employed based on anecdotal or case reports alone. As a general rule, it is not advisable to use these modalities beyond two or three weeks if signs of objective progress toward functional restoration are not demonstrated. For example, in the case of lower back pain, "the strongest medical evidence regarding potential therapies for low back pain indicates that having the patient return to normal activities has the best long-term outcome."5
Or, when carpal tunnel syndrome (CPT) is correctly diagnosed, especially in patients with moderate or severe CPT, the prompt referral for carpal tunnel release surgery is well supported and the outcomes from surgery are better than splinting or other interventions. Simply stated, when functionality is safely restored, all else follows — productivity included.
The challenge, then, is how busy health care professionals can keep up with the findings from the latest meta-analysis, randomized controlled trials, and other important studies. The National Guideline Clearinghouse, created by the Agency for Healthcare Research and Quality (AHRQ) in partnership with the American Medical Association and the American Association of Health Plans, offers an Internet-based resource on clinical practice guidelines at www.guideline.gov.
As of March 1, 2000, this site provided access to 700 evidence-based practice guidelines from 125 different organizations.6 By December 2003, the number is expected to grow to 3,500. Clearly, this is a burgeoning area. Most publishers of these guidelines are primarily professional societies of various health care specialty providers, and the guidelines are oriented toward treatment by their own members, e.g., neurologists, orthopedic surgeons, radiologists, physiatrists, etc.
Consequently, the guidelines often have reputations for supporting the constituencies of their authors, and not always providing the best multidisciplinary treatment pathways for each condition. Work Loss Data Institute has endeavored to remedy some limitations of other guidelines with the introduction in May 2003 of ODG Treatment in Workers' Comp (ODG/TWC), setting new standards in the field for presenting and summarizing the highest-quality, most up-to-date scientific studies. ODG/TWC has been accepted for inclusion in the National Guideline Clearinghouse by AHRQ and has been linked to the common procedures used in workers' comp conditions with a summary of the results of these important medical studies and, further, the supporting documentation.
As a result of this new focus on restoring functionality through evidence-based medicine, outcomes are beginning to turn the corner; health care costs should soon follow, and productivity is increasing, but there's a long way to go. What is most rewarding is the purpose behind this effort — to help find and utilize the most verifiable ways to treat, manage, improve, and restore the health and well-being of ill and injured workers. I cannot think of a better or more satisfying course to pursue.
1. Sackett DL, Rosenberg WMC, Muir Gray JA, et al. Evidence-based medicine: What it is and what it isn't. BMJ 1996; 312:71-2.
2. Daubert, et al. v. Merrill Dow Pharmaceuticals Inc., No. 92-102, 509 U.S. 579 (June 28,1993).
3. General Electric Co. v. Joiner, No. 96-188, 522 U.S. 136 (Dec. 15, 1997).
4. Kumho Tire Inc. v. Carmichael, No. 97-1709, 526 U.S. 137 (March 23, 1999).
5. Work Loss Data Institute. Official Disability Guidelines Treatment in Workers' Comp. Encinitas, CA; 2003.
6. Agency for Healthcare Research and Quality. National Guidelines Clearinghouse Triples Number of Guidelines. Rockville, MD; 2000.
[For more information, contact Patricia Whelan, Executive Vice President and Publisher, Work Loss Data Institute, 169 Saxony Road, Suite 210, Encinitas, CA 92024. www.worklossdata.com.]