“The Evidence Based Guideline Company”
www.worklossdata.com
ODG
Treatment
This edition of ODG Treatment incorporates the
latest findings
from Work Loss Data Institute’s rigorous, comprehensive and ongoing systematic literature search and review of
existing scientific evidence published in peer-reviewed journals.e Together with the annual release of Official
Disability Guidelines, and ODG Top 200 Conditions, the ODG
product line has emerged as the industry leader in disability duration and
medical treatment guidelines for workers’ compensation and non-occupational
disability cases.
Designed for use by providers, employers, insurance claims
professionals, and state workers’ comp authorities, ODG Treatment is the
only reference to unite evidence-based protocols for medical treatment with
normative expectations for disability duration for every illness and injury,
organized by ICD9 diagnosis. Without
any specific affiliation, WLDI is unique in being able to bridge the interests
of the many professional groups involved in diagnosing and treating a
particular condition in providing widely accepted, nationally recognized
guidelines for managing short term, long term or workers’ comp conditions. ODG has been accepted by the Federal Agency for
Healthcare Research & Quality (AHRQ) for inclusion in the National Guidelines Clearinghouse: www.guidelines.gov. This description of ODG Treatment contains the following
sections, along with page numbers below:
Features of ODG
Treatment
1. Treatment Planning 3
2. Codes for Automated Approval 4
3. Procedure Summary (additional features below)
5
- Summaries of Medical Studies 6
- Physical Therapy/Chiropractic Guidelines 8
- Activity Modifications for Restricted Work 10
Background On Development of ODG
Treatment
1. State of the Guideline Marketplace 11
2. The Evolution of Official Disability Guidelines 13
3. The Unique and Major Advantages of ODG 15
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FEATURES OF ODG TREATMENT
ODG Treatment is
organized into the following sections:
Treatment Planning
This is presented as an ideal case plan, indicating selected interventions recommended for each visit, along with timing for these visits. The Treatment Planning section is only a recommendation. It is NOT to be used as a rigid protocol applied in all cases. Healthcare providers may choose to follow the Treatment Planning section at their own discretion. They may also consider interventions outside of the Treatment Planning section. When doing this, they should verify these interventions are recommended as options in the Procedure Summary. An insurance carrier should not use the absence of a particular therapy from the Treatment Planning section as a basis to deny care. Below is a screen shot covering part of the Treatment Planning section for Low Back Problems:
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This next section applies ICD9 diagnosis codes and CPT® procedure codes to the Treatment Planning section, and it is presented as an optional tool to streamline the UR process (Web version only). Codes for Automated Approval maps procedure codes to diagnosis codes with a field indicator for maximum occurrences for auto-approval. This is does not constitute a recommendation. Insurance carriers and utilization review companies may choose to streamline their processes by automatically approving procedures in the Codes for Automated Approval section. However, this is at their discretion. The interventions here may have specific patient selection criteria – found in the Procedure Summary – that may also be applied. The “maximum occurrences” listed here are for the purpose of auto-approval only. Additional therapy may be recommended / allowed for in the Procedure Summary. Below is a screen shot covering part of the Codes for Automated Approval for Low Back Problems:
CPT © 2005 American Medical Association.
All Rights Reserved. CPT is a
registered trademark of the American Medical Association.
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This is the most important section of ODG. Listed here alphabetically are all possible therapies, including surgeries, physical medicine modalities, diagnostic and imaging tests, and virtually any other treatment or procedure that might be considered for each condition or body part. Beside each is a recommendation for appropriate use, if any, along with a summary of the supporting medical evidence. Links are also provided to abstracts of the cited references, which are ranked and weighted alphanumerically. This should be the basis for utilization review (UR) using ODG. The Procedure Summary is generally where an insurance carrier or a medical provider will look to determine if a given intervention is supported by adequate medical evidence and therefore recommended as an option. Each entry will begin with one of the following three terms: “Recommended…”, “Not Recommended…” or in some cases, “Under Study”. It will then specify patient selection criteria, clinical criteria, or other treatment plan that should be applied or considered. Below is a screenshot covering the beginning of the Procedure Summary for the Low Back chapter:
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Summaries
of Medical Studies
In supporting treatment decisions, or decisions to approve or deny medical
services, users of ODG Treatment can go beyond quoting a set of
guidelines, and copy and paste the results of the actual study, taking
"evidence based medicine" to its logical end point. Clicking on the hyperlinks (containing
author name and study year) in the Procedure Summary will take you directly to
the studies supporting that statement.
These reference summaries, including an abstract, plus the WLDI
evaluation and rating of the reference, are in alphabetical order for those who
want to browse them all, and important points in the study are
highlighted. WLDI uses a proprietary
rating system to evaluate the quality of the studies, ranging from 1a to
11c. See the chapter Explanation of Medical
Literature Ratings for a detailed explanation of this rating system. For key references, you can even click on
the summary to go to full copy if included as a separate document. Below is a screen shot covering part
of what would appear if you clicked on (Tulder-Cochrane, 2000), one of
the links for Acupuncture in the Procedure Summary for the Low Back chapter:
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Within the Procedure Summary
there are specialized guidelines for various topics that stand out because they
are highlighted in light blue, including specific utilization review (UR)
criteria often presented in an algorithmic format. These may be provided even if the procedure is not recommended,
because these are guidelines and not every case will meet the guidelines so the
reviewer and provider should be aware of these criteria if they decide to go
ahead with the procedure anyway. For
surgical procedures that are supported by high quality medical studies, ODG
Treatment presents a decision matrix called “ODG Indications for SurgeryÔ”
that itemizes the decision-making process and patient selection criteria for
successful outcomes from the surgery.
While ODG includes evidence-based recommendations for surgical
procedures used in workers' compensation cases, ODG does not attempt to provide
detailed guidance on surgical technique, operating tools required, necessary
anesthesia, or postoperative follow-up visits, because those decisions are best
made by the operating team (including the surgeons, OR nurses, and
anesthesiologists). Consequently, when a surgical procedure is approved based
on ODG, this approval should also cover the appropriate anesthesia and other
ancillary services, unless otherwise specified. Below is an example screen shot
for Anterior cruciate ligament (ACL) repair in the Procedure Summary for the
Knee chapter:
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Physical Therapy and
Chiropractic Guidelines
Also within the Procedure Summary
there are other specialized guidelines for various topics that stand out
because they are highlighted in light blue.
Contained in this section, where
appropriate under "Physical Therapy" and "Manipulation",
are the recommended frequency and duration of treatment by physical therapists
and chiropractors from Official Disability Guidelines. This section may also contain information on
patient selection criteria, to identify those patients most likely to benefit
from these treatments. Below is
a screen shot for Physical therapy in the Procedure Summary for the Knee
chapter:
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Also within the Procedure Summary
there is another specialized guideline for various topics that stands out in
light blue. Contained in this section, where appropriate under imaging procedures,
such as Radiography, Magnetic resonance imaging (MRI), or Ultrasound, are the
recommended criteria for those modalities.
Below is a screen shot for Radiography in the Procedure Summary
for the Low Back chapter:
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Capabilities &
Activity Modifications for Restricted Work
Also within the Procedure Summary is another specialized guideline that stands out because it is highlighted in light blue. Contained in this section, under Work, are the ODG Capabilities & Activity Modifications for Restricted Work from Official Disability Guidelines. Below is a screen shot for Work in the Procedure Summary for the Carpal Tunnel Syndrome chapter:
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BACKGROUND ON DEVELOPMENT OF ODG
TREATMENT
State of the
Guideline Marketplace
In conjunction with the quest for evidence-based medicine, the number of
treatment guidelines has been mushrooming over the last few years. The National Guideline Clearinghouse,
created by the U.S. Government Agency for Healthcare Research and Quality
(AHRQ), in partnership with the American Medical Association (AMA) and the
American Association of Health Plans (AAHP), 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 clinical practice guidelines from 125 different organizations[1]. By December 2003 this guideline database was
expected to contain a total of 3,500 clinical practice guidelines.[2] Publishers of these guidelines are primarily
the professional societies of various healthcare specialty providers, and the
guidelines are oriented toward treatment by their own members, e.g.,
neurologists, orthopedic surgeons, radiologists, physiatrists, chiropractors,
occupational therapists, etc.
Consequently, the guidelines often have reputations for supporting the
constituencies of their authors, and not always providing the best multi-disciplinary
treatment pathways for each condition.
Of the 125 different organizations, only five are commercial entities
and the rest are nonprofit. Some of the
commercial entities also represent particular constituencies, for example, if
their subscribers are primarily managed care providers and insurance companies.
Unlike treatment guidelines, which recommend treatment maps that include
initial evaluations and treatment options, lost time guidelines, which
recommend disability duration, are available from only a few publishers. There are only four published versions of
lost time guidelines, and three of these are published by commercial entities.[3] While it seems logical that there would be
significant integration of treatment guidelines with lost time guidelines, that
is not the case. In addition to ODG,
only two other guidelines, Milliman & Robertson Health Management
Guidelines (HMG), last published in 1998 and the Occupational
Medicine Practice Guidelines, second edition, authored by the American
College of Occupational and Environmental Medicine (ACOEM), released in January, 2004, have both
treatment guidelines and selective lost time guidelines integrated together.
Further, the HMG guidelines have the reputation of representing a managed care
constituency.[4]
Treatment guidelines and lost time guidelines should not exist in a
vacuum. With the selection of an
appropriate treatment path, there should be expectations about
return-to-work. Why hasn’t this
happened earlier? Part of the problem is
that treatment guidelines were designed for use by healthcare providers, and
lost time guidelines were originally used primarily by employers and their
representatives at insurers. Within the
last few years, this has been changing, with significant growth in interest
among healthcare providers in having access to lost time guidelines. After all, they are the primary
decision-makers controlling return-to-work decisions, and information on normal
disability durations was typically not something they learned in medical
school. One publisher has seen the
percent of sales of lost time guidelines to healthcare providers (primarily
physicians) grow from 7% of total sales in 1996 to 49% in 2000.[5] Providers are obviously taking an increasing
interest, along with their patients, in expectations for return to productivity
after an injury or illness.
Over the last decade there has been a substantial evolution in the
admissibility of medical testimony in court, and this evolution has mirrored
the growth in evidence-based medicine.
Three U.S. Supreme Court cases, beginning with the 1993 Daubert Decision[6],
which held that judges were obligated to evaluate the basis for expert
testimony, and following with two additional expert testimony cases, GE v.
Joiner[7]
and Kumho Tire[8] have set the
standards for the way federal courts approach expert testimony, and
increasingly, are profoundly affecting state court practice as well. According to the Claims Support Professionals
Association, experts with a long tradition of being readily admitted, such as
clinical medical doctors, are now being excluded from court when they testify
based on their opinions alone.[9] A recent roundtable workshop was held by
the federal guideline agency AHRQ and the Institute Of Medicine, which
concluded that “Evidence-based medicine in practice defines the likelihood of
something happening. It is never
100%. It is not absolute truth.” The workshop identified that
population-based evidence is most important in court.[10]
As a result of these Supreme Court decisions, the Federal Rules of
Evidence were amended in December 2000.
The new rules state that statistical studies will be admissible under the
Federal Rules of Evidence, and that such methods generally satisfy important
aspects of the “scientific knowledge” requirement articulated in the Daubert
Decision.[11] Furthermore, it states that “courts have
described surveys as the most direct form of evidence that can be offered, and
several courts have drawn negative inferences from the absence of a survey.”[12]
These developments have significant impact on the outcome of court cases
involving workers’ comp claims, and they may even lessen the weight of
Independent Medical Examination (IME) testimony that does not also reference
evidence-based medicine. Furthermore,
primary credence will be based on actual experience data, and not just expert
judgement in determining what should happen.
When this experience data is backed by a credible survey, such as the
CDC National Health Interview Survey, it will have even more weight.[13]
The Evolution of Official Disability Guidelines
The first edition of Official
Disability Guidelines (ODG)
in 1996 provided lost time guidelines using actual experience data from federal
government databases, including OSHA BLS (Occupational Safety and Health
Administration – Bureau of Labor Statistics) and CDC NCHS NHIS (Centers for
Disease Control and Prevention, National Center for Health Statistics, National
Health Interview Survey). The raw data
was presented graphically so users could compare it directly with their own
experience, and it was designed to enhance a timely and appropriate
return-to-work for workers suffering from illness or injury.
From the beginning, ODG was based on actual experience, not
“expert” opinion. This made ODG
fair to employees and defensible by employers.
With the changes to the Federal Rules of Evidence, the ODG
guidelines also became the most likely to stand up in court.
The next step in the evolution of ODG was the identification of
pathways for each condition, based primarily on the raw data in the NHIS. These pathways provided the different
treatment options with their resultant time out of work, including
considerations for severity and type of job.
These treatment pathways are titled “Return-To-Work Best Practice
Guidelines”, and, in effect, were the first steps in Official Disability Guidelines offering treatment guidelines. The treatment options were indicated in many
cases, but the decision-making logic on which pathway to choose was still
missing. The “Best Practice” guidelines
were first launched in the 1997 edition of ODG, but they have been
expanded in each subsequent annual edition.
Currently, Official Disability
Guidelines has “Best
Practice” guidelines for four times as many conditions as in 1997, and the
average number of treatment options per condition is more than double what it
was in 1997. With over 16,000 clients,
the “Best Practice” guidelines in ODG are nationally
recognized. Since they are based on
actual experience data from the federal government, they are scientifically
valid and outcome-based. New users of
lost time guidelines have gravitated toward ODG because the “Best
Practice” guidelines, the heart of ODG, identify what makes a difference
in return-to-work. Rather than looking
at an average or a median for all cases for a particular condition, ODG
allows comparison among like cases.
Within a diagnosis, some cases should return earlier than others because
they are on a different pathway. Trying
to make them all adhere to an overall median will not only let some cases be
out too long, but will also force some cases back to work too soon. As ODG became a focal point
facilitating communication among all parties in the return-to-work process,
including patients, it has been assisting all parties with regard to the
appropriate treatment and management of work related injuries and illnesses. The framework of the “Best Practice”
guidelines has established elements against which aspects of care can be
compared, and allowed identification of treatments and services that are
reasonable and medically necessary for treatment of a particular injury.
The next logical step in the evolution of ODG was the
incorporation of decision-making logic for each of these pathways, resulting in
integrated treatment and lost time guidelines.
This process was begun in 2000 as part of an effort to re-write the
State of Texas Treatment Guidelines for Workers’ Compensation. Development
was chaired by Medical Editor, Charles W. Kennedy Jr., MD, a founding
member of the Evidence Analysis Committee and member of the Guides
Development Committee for the American
Academy of Orthopaedic Surgeons (AAOS), chairman of the Texas
Orthopaedic Workers’ Compensation Committee, and member of the Board of
Directors of the American Academy of Disability Evaluating physicians. Publication
of a specialized provider edition of ODG covering major conditions seen in
workers’ compensation cases was anticipated for 2002. ODG’s approach was to integrate the major nationally
recognized, scientifically valid, and outcome-based treatment guidelines with
the ODG “Best Practice” guidelines, and validate these treatment guidelines
against ODG’s major database, the CDC National Health Interview Survey.
The Selection of Work Loss Data Institute by ACOEM and Others
The American College of
Occupational and Environmental Medicine (ACOEM) represents more than 5,000
physicians specializing in occupational and environmental medicine. In the spring of 1997 ACOEM published the
ACOEM Clinical Practice Guidelines.
Healthcare is rapidly changing and methods of diagnosis exist today that
were not present when the ACOEM Guidelines were first drafted and
published. With that in mind, ACOEM
embarked upon a process to update the 1997 Guidelines under the direction of
ACOEM’s Practice Guidelines Committee, and on July 31, 2001, a Request for
Proposals (RFP) was issued to seek a qualified contractor to participate in the
guideline update process. On April 15,
2002, ACOEM selected Work Loss Data
Institute as the contractor to provide research assistance to ACOEM as
it went through a one-year process to update its previously published text Occupational Medicine Practice Guidelines,
and to draft the text of the new guidelines.
According to the WLDI proposal to ACOEM, “The next step in the evolution of ODG is integrated treatment and
release to work guidelines. This
process is underway with anticipated publication of a specialized provider
edition of ODG in 2003 covering major conditions seen in workers’
compensation cases. As a result, Work
Loss Data Institute is in an ideal position to help ACOEM update their own
Clinical Practice Guidelines.”[14] Consequently, ACOEM contracted with WLDI,
and ACOEM’s Occupational Medicine
Practice Guidelines, second
edition, was released in January, 2004.
Work Loss Data Institute has furthered its role in the ACOEM Practice Guidelines
by becoming the electronic publisher of the first-ever Web version.
How are the Occupational
Medicine Practice Guidelines,
authored by ACOEM, and ODG Treatment different? They each serve a somewhat different purpose
and they may be used on a complementary basis.
The ACOEM Practice Guidelines are provided as a text that is an
evidenced-based, nationally recognized standard in clinical occupational
medicine. The guidelines provide physicians, other health care professionals
and insurance claims managers with valuable clinical information. They also provide high quality educational
information to physicians and other health care professionals, both on a
generalized practice basis as well as for selected conditions. In addition, the ACOEM Practice Guidelines
represent the official positions of a major professional society, the American
College of Occupational and Environmental Medicine. ODG Treatment is not meant to be a text, but a database
meant for use electronically, and it covers condition-specific guidelines for
diagnoses commonly seen in workers’ compensation, but it does not contain
generalized practice guidelines for any particular group of providers. Unlike the ACOEM Practice Guidelines, for
each condition ODG Treatment contains specific recommended protocols
along with expected percentage likelihood, benchmark costs, and resulting
disability duration. It also contains
procedure codes that can be used for automatic approval of medical charges for
cases that meet the requirements of the protocols. In addition, ODG Treatment is unique in having an
alphabetical list of all procedures along with a summary of the scientific
evidence, plus a copy of the findings from the high quality studies that
support these conclusions. In
supporting decisions to approve or deny medical services, users of ODG
Treatment can go beyond quoting a set of guidelines, and copy and paste the
results of the actual study, taking “evidence based medicine” to its logical
end point. The publisher of ODG
Treatment, Work Loss Data Institute, is an independent medical publisher
and is not affiliated with any group of medical providers. Finally, new medical evidence, incorporating
the latest scientific studies, is added to ODG Treatment on a regular
basis, so it is always up-to-date. ODG
Treatment serves as a filter -- identifying, evaluating, and linking the
appropriate medical evidence together.
In late 2002, the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) approached Work Loss Data Institute about researching and authoring treatment guidelines for the chiropractic profession. Chiropractic is playing an increasingly important role in helping injured workers recover and return to productivity, and the costs of chiropractic are growing as a total percentage of workers’ compensation costs. There has been significant variation in treatment patterns from one chiropractic provider to another, and there is lack of agreement among payers and other providers concerning the appropriate role of chiropractic. The only national guidelines for the chiropractic profession, the “Mercy Guidelines”, were published in 1992 and are no longer current, and they do not have full support from many chiropractors. Furthermore, these were developed as “consensus” guidelines, whereas current medical practice and recent court decisions are demanding that guidelines be based on scientific evidence – specifically high quality medical studies published in the peer reviewed medical literature. The new chiropractic guidelines are expected to be available later in 2006. Like ACOEM’s Occupational Medicine Practice Guidelines, the new chiropractic guidelines will be the official guidelines of another major medical specialty group, the chiropractic professionals.
The Unique and Major Advantages of ODG
Below are the
unique and major advantages of Official Disability Guidelines – Treatment in
Workers Comp (ODG). Work Loss Data
Institute is the copyright owner, trademark holder, author and publisher of
ODG, which is delivered online at www.odgtreatment.com.
- ODG is unique among
workers’ compensation guidelines in taking evidence-based guidelines to
their logical end point; the conclusions are linked directly to the evidence
in the studies and references.
ODG is clearly evidence-based, using an aggregate of over 10
million cases from CDC & OSHA, and a comprehensive and ongoing medical
literature review with preference given to high-quality systematic
reviews, meta-analyses and clinical trials, referred to as “most direct
form of evidence that can be offered” under the revised Federal Rules of
Evidence. Each recommendation is
linked to the supporting medical evidence, provided in abstract form,
which has been ranked, highlighted and indexed. No other workers’ comp guideline utilizes such a substantial
evidence-base, nor provides an explicit link from each recommendation to
the supporting evidence.
§
ODG provides
integrated medical treatment guidelines and disability duration guidelines (also known as lost work time guidelines or
return-to-work guidelines). Treatment
and duration guidelines must work together to be effective (timeframes for
duration correspond precisely to treatment pathways). Other guidelines typically contain ONLY disability duration OR
treatment guidelines.
§
ODG has met the
stringent criteria of the Federal Agency for Healthcare Research & Quality
(AHRQ), and has been accepted for
inclusion in the National Guidelines Clearinghouse (NGC), located at www.guidelines.gov. All of the criteria below
must be met for a clinical practice guideline to be included in NGC.[15]
1) The clinical practice guideline contains systematically developed statements that include recommendations, strategies, or information that assists physicians and/or other health care practitioners and patients make decisions about appropriate health care for specific clinical circumstances.
2) The clinical practice guideline was produced under the auspices of medical specialty associations; relevant professional societies, public or private organizations, government agencies at the Federal, State, or local level; or health care organizations or plans. A clinical practice guideline developed and issued by an individual not officially sponsored or supported by one of the above types of organizations does not meet the inclusion criteria for NGC.
3) Corroborating documentation can be produced and verified that a systematic literature search and review of existing scientific evidence published in peer reviewed journals was performed during the guideline development. A guideline is not excluded from NGC if corroborating documentation can be produced and verified detailing specific gaps in scientific evidence for some of the guideline's recommendations.
4) The full text guideline is available upon request in print or electronic format (for free or for a fee), in the English language. The guideline is current and the most recent version produced. Documented evidence can be produced or verified that the guideline was developed, reviewed, or revised within the last five years.
§
ODG is
continuously updated reflecting the findings of new studies as they are
conducted and released; subscribers are always up to date. ODG undergoes a comprehensive annual update process based on
scientific medical literature review, survey data analysis and expert panel
validation. In addition, as new studies
are released, the Web version is updated throughout the year to reflect these
new studies. Other guidelines are
typically updated every 3-5 years or more, historically, but new and groundbreaking
studies are published regularly in peer-reviewed medical journals evaluating
the efficacy of new or existing treatment modalities. They simply cannot be overlooked. ODG is proud to be the leader in this area. The 85-member Advisory Board for ODG is lead by Senior
Medical Editor Dr. Charles W. Kennedy, MD.
Dr. Kennedy is a founding member of the Evidence-Analysis Committee for
the American Academy of Orthopaedic Surgeons.
§
ODG
covers every reportable condition, all 10,000 ICD9 codes.
Competing guidelines are not
comprehensive – lacking in areas where ODG is not.
§
ODG is independent of
any medical specialty group and multidisciplinary in scope, and represents all medical specialties, and not just
occupational medicine doctors, orthopaedic surgeons, chiropractors, physical
therapists, etc. ODG has realized
considerable provider acceptance (including adoption by 16 states – more than any
other guideline) because ODG is evidence based, and recommendations are linked
directly to the most up to date studies; the results of that research are
reflected in the constant updating of the guidelines. These studies are focused
on one outcome: What is best for the injured worker. Unlike medical specialty society guidelines, ODG does not
represent the interests of any one provider-group over other providers.
§
ODG is
available in a Web-based version, which users can access from any location with an Internet
connection, while the raw experience data from ODG is also available to clients
in tabular format to compare with internal claims data.
§
ODG is designed to be
used for utilization review (UR),
unlike other guidelines, which may be designed as practice guidelines
(sometimes referred to as "cookbook" medicine), or as a nursing
textbook (lacking any basis for UR).
ODG seeks clarity in recommendations, and ODG allows the ability to copy
& paste, saving time and effort in documenting approvals or denials of
treatment.
For a detailed description of the methodology
and scope of ODG Treatment, using the AGREE Instrument, see the Appendix, Methodology Description using the AGREE
Instrument.
“The Evidence Based Guideline Company”
www.worklossdata.com
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