By Anthony Vecchione
Although formal assessment of medical interventions using controlled trials was established in the 1940s, it wasn’t until the late 1970’s early 1980s that evidence-based medicine (EBM) became part of the medical lexicon. Today, applying the scientific method to clinical decision-making is a common practice in healthcare. David Sackett, M.D., the Canadian epidemiologist who helped pioneer evidence-based medicine, defines it as“the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient.” But what is the role of EBM in occupational medicine? And is it having an impact?
Swedish researcher Jos Verbeek, Ph., said that evidence-based medicine goes beyond the development of guidelines to urge practitioners to find the best evidence for any clinical problem. “Little is known about the clinical problems occupational physicians encounter in their daily practices, and the information needs raised by these problems, in contrast to the situation in general [medical] practice,” said Dr. Verbeek.
Methods of evidence-based medicine, Dr. Verbeek surmised, could be difficult to apply in this field because occupational medicine differs from general clinical medicine. Some experts, including Dr. Verbeek, argue that the application of EBM in occupational medicine is hindered because the field is more dependent than other specialties on government regulations. Other experts say it faces an uphill battle because there is a dearth of research evidence on occupational maladies.
Steven Crawford, M.D., corporate medical director at MeridianOccupational
Health in West Long Branch, N.J., agrees that when it comes to EBM and occupational health, there are other influences and factors at play.“If you hurt your back and you go to the doctor, there may be some secondary gain, but not necessarily monetary. In the workers’ compensation world, there is potential monetary gain,” Dr. Crawford said. In his research, Dr. Verbeek and his colleagues attempted to determine if the methods used in evidence-based medicine could answer a few of occupational medicine’s most puzzling and common quandaries.
They concluded that EBM is a feasible and useful method for occupational medicine issues, but instruction and training will be needed for most occupational physicians to increase their searching and critical appraisal skills. More research will be needed to determine the information needs of these physicians, Dr.Verbeek said, and to develop tools that facilitate literature searches.
A 2009 study published online at BMC Health Services Research (www.biomedcentral.com) explored the knowledge infrastructures being used by occupational physicians (OPs) in different countries and how important they are for the successful practice of EBM. The study authors concluded that OPs use many knowledge infrastructure facilities and find them important for their EBM practice. However, in the article entitled: “Knowledge infrastructure facilities support evidence-based practice in occupational health? In an exploratory study across countries among occupational physicians enrolled in Evidence-BasedMedicine courses,” author Nathalie R Hugenholtz and colleagues conclude that OPs are not used to using evidence-based sources and face barriers that are comparable to the barriers physicians face in primary care. (Read the article at www.biomedcentral.com/1472-6963/9/18.)The study’s authors found that to
ensure high professional quality, practice by OPs is essential and an exceptional grasp of the knowledge infrastructure can support this. However, they said that simply enabling(local) access to knowledge might not be sufficient to improve EBM practice.
Industry experts agree that interest in evidence-based occupational medicine is growing. A glance at the National Institutes of Health (NIH) website reveals an abundance of peer-reviewed articles on topics as diverse as:
• Evidence-based guidelines for the prevention, identification, and management of occupational asthma
• Occupational medicine practice guidelines for interventional pain management
• Evidence-based practice-relevance to occupational health nurses
OCCUPATIONAL MEDICINE PRACTICE GUIDELINES GAIN A WIDER AUDIENCE
In October of 2013, the ReedGroup, Ltd., acquired the American College of Occupational and Environmental Medicine’s (ACOEM), Occupational Medicine Practice Guidelines.
While the Reed Group publishes and distributes ACOEM’s Practice Guidelines, ACOEM continues to provide the research, content development, and methodology for the guidelines.
Industry insiders applauded the acquisition. Many said it would broaden the distribution base for the Practice Guidelines, increasing their availability to new audiences while at the same time providing access to valuable resources that would ultimately benefit users.
The integration of Reed Group’s Extensive return to work (RTW) and absence-management strategies and resources for employers with ACOEM’s guidelines were viewed as another benefit of the partnership. The Practice Guidelines contain more than 2,500 evidence-based recommendations and 15,000 medical literature references and are considered by many to be the industry standard for the effective treatment of occupational injuries and illnesses.
“The acquisition has had a significant positive impact that we have broadened our offering from RTW to the area of treatment and practice. The Broadening of our content has resulted in a broadening of our customer base,” said Joe Guerriero, the Reed Group’s senior vice president of Disability Guidelines.
“The ACOEM guidelines acquisition [have] allowed us to have deeper relationships with physicians and other allied clinicians, as well as platform companies, looking to provide a more informed point of care experience.”The Guidelines, Mr. Guerriero asserted, help employers by offering practical safe RTW content and data that provides actionable and measurable information for benchmarking performance.
SUCCESSFUL MODELS
Washington is a single-payer state for workers’ compensation and as a result
has better control over outcomes than other states. In fact, its Department Of Labor and Industry is designing new occupational health best practices that span the full period of an injured worker’s recovery. Best practices currently used by the Centers for Occupational Health and Education (COHE)providers focus primarily on the first 12 weeks of treatment after an injury. The Centers for Occupational Health And Education is a Washington state agency that works with medical providers, employers, and injured workers in a community-based program to improve injured worker outcomes and reduce disability by training providers and coordinating cases. Also under development at Washington State’s Department of Labor and Industry:
A Surgical Best Practices Pilot: A pilot program that will test a new set of best practices on surgical patients. ASurgical Health Services Coordinator will be located in the orthopedics clinic to assist 10 orthopedic and hand surgeons. In addition, a Surgical HealthServices Coordinator will be located at the COHE in St. Luke’s Rehabilitation Institute in Spokane.
Activity Coaching:
A pilot program to help patients recover by increasing their activity. It includes a standardized intervention delivered by professional therapists trained by the ProgressiveGoal Attainment Program (PAYTM). Activity coaching can help patients by reducing psychosocial barriers to rehabilitation progress, promoting reintegration into life-role activities, and facilitating return to work.
Functional Recovery Interventions:
A pilot program to identify the risk of disability and recommend interventions. It began in March 2013 and ended in February 2014. Its goals included testing interventions in cases where a patient was at high risk for disability. (Without interventions, nearly 40% of high-risk patients will still be off work one year after injury.)Yet another example of the Department of Labor and Industry Making use of evidence-based decisions and guidelines is its Health Technology Assessment program. This program is guiding a number of the state’s agencies, ensuring treatments and services paid for with state dollars are safe and effective. It serves as a resource for any state agency purchasing healthcare.
The program commissions scientific reports on the safety and effectiveness of various medical devices, procedures, and tests. An independent clinical committee of healthcare practitioners then uses the reports to determine if programs should pay for the service or device. Participating state agencies include the Health Care Authority, the Department of Social and Health Services (Medicaid), Labor and Industries, Corrections, and Veterans Affairs.
State Agencies using the same evidence-based reports make more informed and consistent coverage decisions. In addition, this same department has developed Medical Treatment Guidelines (also referred to as Medical Practice Guidelines or Review Criteria). These guidelines are used in the utilization review program, in claim management, and in physician education. They reflect the best available scientific literature and outcome data for Washington’s injured workers.
WORKING WITHIN THE SYSTEM
The Ohio Bureau of Workers’ Compensation (www.bwc.ohio.gov) views EBM in occupational health as a boon, taking advantage of what research is available to discover what works and what doesn’t.
“We have legal aspects to our system that allow the injured worker to get almost anything – so if there are limitations on what we can do, we try to promote the things we know have been successful in the past,” said StephenWoods, M.D., the Bureau’s chief medical officer.
“We also recognize that there isn’t a double-blinded randomized trial that covers every aspect of care, so we take the best evidence we have. We do this mostly through official disability guidelines [ODG],” Dr. Woods said.
According to its mission statement, Joe Guerriero ODG is designed for clinical practice as well as utilization review/management. Among the overall objectives of users of the treatment guidelines in ODG:
- To improve outcomes and patient satisfaction by focusing on restoration of functional capacity through prompt, responsible delivery of healthcare based on the best medical evidence.
- To reduce excessive utilization of medical services (and corresponding medical costs).
- To identify and target ineffective and harmful procedures.
- To reduce delayed recovery rates and indemnity costs with the concurrent management of treatment and time away from work.
- To improve clinical practice/utilization management by indexing procedures adjacent to a summary of their effectiveness based on supporting evidence, provided by way of a link, in abstract form. Dr. Woods asserted the ODS are relied upon for utilization review and they expect their providers to look at these as they develop their treatment plan.
“It doesn’t mean that if there’s a special situation where a case may fall outside of ODG the provider could not make an exception. That Happens rather frequently.”The Work Loss Data Institute (www.worklossdata.com) has determined that when it comes to implementing EBM at the state level using ODG, the decision to adopt guidelines is not as critical to success as which guidelines the state chooses to adopt. The institute has noted that ODG can improve medical and RTW outcomes as well as reduce costs and improve efficiencies.
One example of how EBM works in Ohio’s system, asserted Dr. Woods, is in the area of lumbar fusion. “We understand what ODG says about the standard of care for fusion. We understand what [the] North American SpineSociety says. But we wanted to look at what happens when you apply those rules or guidelines to our system.”
Dr. Woods added that in the Ohio system, they found that those who had fusion just didn’t do well. They used more medication (their pain scores were higher). In the first two years, they may have done a little better, but after two years they went back to medication at higher doses with higher pain levels and nearly everyone ended up with psychiatric allowances in addition to their spine allowance.
“We shared that information with ODG and we’re looking at the necessity of potentially more (sic) strict guidelines. Not that we’re trying to limit care, but sometimes it just doesn’t make sense,” said Dr. Woods.
The Bureau is also addressing EBM in regard to drug utilization. Dr.Woods said it’s important to make sure workers are getting the medications they need and that those medications benefit their recovery and their return to work without causing side effects or other problems. (For example, if a worker is injured and requires an opioid, they don’t end up with an addiction problem.)
John Hanna, pharmacy program director at The Ohio Bureau of Workers’ Compensation, said the pharmacy and therapeutics (P&T) committee is charged with the development and maintenance of their formulary. The formulary is managed according to the belief that if you have appropriate drug utilization you’re going to positively impact the worker’s recovery and his return to work with a reduced side effect profile and at reduced cost. “But the cost follows everything else. And we’ve been able to demonstrate that across the board . . since the formulary went into effect in 2011,” said Mr. Hanna. Mr. Hanna said the bureau has consistently added limitations to the original formulary and applied best practices.
“For instance, we don’t cover Soma[carisoprodol] or any other drug in that class because there are better and safer alternatives on the market,” said Mr.Hanna.He added that they don’t cover any of the sustained-release opioids like oxycodone, and Exalgo (hydromorphone hydrochloride) until an injured worker has demonstrated that they cannot take basic morphine sulfate extended-release.
“We have restrictions on the Benzodiazepines, on our maximum daily amount of Xanax (alprazolam)-type drugs. That was done by looking at the psychological literature that was out there to [determine] what’s a reasonable dose,” said Hanna.
“We’ve seen a significant drop in our opioid utilization over the last four years,” he said.
The Bureau is in the process of reviewing the Ohio Pharmacy Board Database. The Pharmacy Board has a prescription medication-reporting program and Mr. Hanna intends to look at patients who had a substantial change in their opioid utilization. “We Are going to look at it [and ask] ‘did we actually reduce that patient opioid consumption or did they simply move to another payer?’ By mid-year, we’re hoping to report that data.”
LESSONS LEARNED
GOING FORWARD
Dr. Woods pointed out that the ability to review internal data is crucial to for future decision-making. “We have a huge data warehouse and we can look at how people did based on what the guidelines were. If people aren’t doing as well as we expect, we may need to adjust the treatment protocols or guidelines,” said Dr. Woods. In Addition to looking at spinal fusion, the bureau is currently looking at spinal cord stimulators and shoulder care. In a 2006 article, “Evidence-Based OccupationalHealth: From Theory To Practice,” published in the Italian Medical Journal of Work and Ergonomics, GiulianoFranco, M.D., tries to illustrate the opportunity presented. Dr. Franco stated that in spite of some barriers, such as time constraints, the evidence-based decision-making process should be founded on evidence provided by major resources. “Acquiring the skill for information managing facilitates searching appropriate solutions to[the] problems usually met in professional practice and the adoption of behaviors which will improve the practice,” Dr. Franco said.
In the BMC Health Services Research article, the authors say that among the strategies important for the support of an EBM practice are: 1) support from colleagues and management to practice EBM and 2) the motivation of OPs to take responsibility for delivering the best possible occupational healthcare. They also say that new initiatives for providing cost-free access to medical and occupational literature databases and full-text articles would contribute to knowledge dissemination. Occupational medicine experts contend that there is overwhelming evidence that scientifically based guidelines developed by occupational medicine physicians’ have had a major impact on addressing problems within workers’ compensation systems.
In an article published in a 2004 edition of Health Psychology and Rehabilitation, Kathryn Mueller, M.D., president of The American College of Occupational and Environmental Medicine (ACOEM), said that one of the key steps in the development of evidence-based practice guidelines is the creation of multidisciplinary teams.
“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.” Dr. Mueller, former medical director of the Colorado Division of Workers Compensation, added: “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.”
Creating scientifically based guidelines, asserted Dr.Mueller, “performs a useful service for practitioners in this information age while at the same time providing the scientific foundation that individual practitioners can’t develop for themselves.”Epidemiologist, Edward Whitney, M.D., said that among the many benefits of producing evidence-based guidelines is the issue of adherence. “Scientific support is one of the variables that gives guidelines credibility making it more likely that practitioners will implement them.” looking at a) the number and percentage of occupational medicine patients returning to your center for urgent care; and b) the number and percentage of your urgent care patients who were originally occupational medicine patients.
Because many mixed-model centers utilize different practice management systems for occupational medicine and urgent care, this may entail “dumping” patient records into an external database and creating custom reports. Patients who have top-of-mind awareness and fully intend to use a center for urgent care may not have an immediate medical need, so conversion is typically looked at in six, nine, and 12-month intervals. A “forward” look matches occupational medicine patients during a certain month to urgent care records with the same identifier (i.e., social security number or home address) over each of the subsequent six to 12 months. Using this approach, conversion rates for a particular month will increase over time as more patients return to the center. This approach generally requires a full year to attain an accurate conversion figure.
The alternative approach starts with urgent care records during a certain month and looks backward to see if those patients had previously come in for occupational medicine.
The advantage of the latter is a mature conversion figure at the outset. A shortcoming is that both methods imply causation; the assumption is that the patient came back for urgent care due to conversion tactics as opposed to other reasons such as long-term loyalty. Conversion may be reported at the individual patient or household level (realizing the value of word-of-mouth in families and that a parent may return with a child) as well as for a single center or for all centers in a multi-site operation.
Additional metrics include questions on patient satisfaction surveys such as: “Are you aware this center offers urgent care services,” or, “At any time during your visit, did our provider or staff explain our urgent care services to you?” These types of questions not only force accountability on the center’s team but also reinforce the message as the patient completes the survey.
CONCLUSION
As we witness the convergence of occupational medicine, urgent care, and clinic-based medical services, it should always be less expensive and easier to educate existing patients about additional services offered at your facility than to draw entirely new patients in from the street. Conversion tactics are somewhat simple to execute, starting with posters and flyers in your center and expanding to messages communicated by providers, staff, and employer clients.
Success entails understanding the levers that drive your patients’ healthcare decision-making, communicating your message in a way that sticks, and establishing reporting processes that will help you gauge your performance.
