“The Evidence Based Guideline Company”
This edition of ODG Treatment incorporates the
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
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. . This description of ODG Treatment contains the following sections, along with page numbers below:
ODG Treatment is organized into the following sections:
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:
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.
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:
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:
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:
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:
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:
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:
BACKGROUND ON DEVELOPMENT OF ODG TREATMENT
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. By December 2003 this guideline database was expected to contain a total of 3,500 clinical practice guidelines. 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. 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.
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. 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, which held that judges were obligated to evaluate the basis for expert testimony, and following with two additional expert testimony cases, GE v. Joiner and Kumho Tire 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. 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.
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. 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.”
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.
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 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.” 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.
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 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.
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”
 National Guideline ClearinghouseÔ Triples Number of Guidelines. March 1, 2000. Agency for Healthcare Research and Quality.
 Washington Highlights. January 15, 1999. Association of American Medical Colleges.
 “The Use of Evidence-Based Duration Guidelines”, The Journal of Workers Compensation. Summer, 2001. Standard Publishing Corp., Boston, MA
 “Care Guidelines Used By Insurers Face Scrutiny,” The Wall Street Journal (September 14, 2000); “Two Pediatricians Hope Their Lawsuit Will Stop Milliman & Robertson From Publishing,” AMA News (March 27, 2000); “Challenge payers who use HMG Guidelines,” Montana Chiro-News (September 1, 2000); “National Class-Action Filed Against Prudential Health Care,” PR Newswire (April 14, 2000); “Aetna Weighs a Managed-Care Overhaul,” Wall Street Journal (January 17, 2001)
 Official Disability Guidelines customer file by type, 1996 versus 2000, Work Loss Data Institute.
 Daubert v. Merrill Dow Pharmaceuticals, Inc. United States Supreme Court, 1993
 General Electric Co. v. Joiner. United States Supreme Court, 1997
 Kumho Tire Inc. v. Carmichael. United States Supreme Court, 1999
 The Daubert Decision: Recent Trends and Their Implications for Testifying Experts. May 28, 2001. The Claims Support Professionals Association, Ft. Lauderdale, FL
 Will Evidence-Based Practice Help Span Gulf Between Medicine and Law? June 7, 2000. Journal of the American Medical Association.
 Reference Manual on Scientific Evidence, Second Edition, Federal Judicial Center 2000, page 86.
 Above, page 236
 The National Health Interview Survey (NHIS), produced annually by the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics (NCHS) is the primary data source used by Official Disability Guidelines, 1996 through 2005, published by Work Loss Data Institute.
 Work Loss Data Institute proposal, "ACOEM Clinical Practice Guidelines Update", September 14, 2001, page 5
 National Guideline Clearinghouse™ (NGC) Inclusion Criteria http://www.guidelines.gov/about/inclusion.aspx