medical outcomes are worse for workers’ compensation patients: why is this and what can be done...
TRANSCRIPT
Medical Outcomes are Worse for Workers’ Compensation Patients:
Why is This and What Can be Done About It?
Dr. James Talmage, John Peterson & Debbie Nelson, Panelists
Jay Blaisdell, Moderator
Tennessee Division of Workers’ Compensation 17th Annual Meeting
June 19, 2014
9 to 10 AMText 208599 and your Questions to 22333
Panelists• Debbie Nelson, RN
– Senior Account Manager, Comprehensive Health Services, at Nissan
• John Peterson– United Steel Workers Union– Employee at Bridgestone/Firestone, Lavergne
• James B. Talmage MD– Private Practice, Occupational Health Center,
Cookeville– Assistant Medical Director, Tennessee Division of
Workers’ Compensation
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Questions ?James B. Talmage MD,
Occupational Health Center,
315 N. Washington Ave, Suite 165
Cookeville, TN 38501
Phone 931-526-1604 (Fax 526-7378)
[email protected] Text 208599 and your Questions to 22333
James B. Talmage MDAdjunct Associate Professor
Division of Occupational Medicine– Department of Family and Community
Medicine
Meharry Medical College, Nashville, TN
AMA Publications
2005 & 2011• 2nd Edition
• I receive royalties
AMA Press: Royaltieswww.ama-assn.org
FINANCIAL CONFLICT OF INTEREST
No role
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Paid Consultant• Federal Motor Carrier Safety Administration
– Physician Work Group– National Registry Certified Medical Examiner
• Item Writing Group and Test Development Group
– Consultant on medical issues affecting commercial motor vehicle driver safety
Emergency Part/Full Time Job
• I was the TEMPORARY “Fill in” Medical Director, Tennessee Division of Workers’ Compensation: March to December 2013.
• Now part time Assistant Medical Director.
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UNPAID CHAIR: Spine Committee• Legally presumed correct
treatment for workers’ compensation utilization review in California and Nevada.
• Low Back Chapter 2007– 366 pages– 1310 articles reviewed and
referenced.• Neck chapter 2011
– 332 pages– 895 articles reviewed and
referenced2007 14Text 208599 and your Questions to 22333
The speaker is a Past President of
“The premiere society for the prevention and management of disability”
For more information, contact AADEP
@ 1-800-456-6095 or visit the website @ www.aadep.org
UNPAID Text 208599 and your Questions to 22333
Focus for the Next Hour
• Outcomes of treatment of common injuries– Same injury, same surgery, OUTCOMES are WORSE
when the surgery occurs in compensation settings compared to health insurance settings.
– Outcomes include objectively measurable factors like joint motion, infection after surgery, etc. These are NOT different.
– Outcomes include “other factors” like pain, narcotic use, return to work rates, etc. • These ARE DIFFERENT.
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I Harris, et al.,JAMA 2005;
293 (13): 1644-1652
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JAMA 2005; 293: 1644-1652
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Causation Decision Affects OutcomePublished since the Harris Meta-Analysis
Condition ReferenceTotal Knee Replacement J Arthroplasty 2004; 19 (3): 310-312
Total Knee Replacement J Can Chir 2005; 48 (2): 100-105
Cervical HNP The Spine J 2005; 5: 639-644
Lumbar HNP Spine 2006; 31 (26): 3061-3069
Multiple Trauma Med J Australia 2007; 187 (1): 14-17
Rotator Cuff Repair JBJS 2008; 90: 2105-2113
Carpal Tunnel Syndrome Occ Med 2008 doi:10.1093/occmed/kqn099
Lumbar HNP Spine 2009; 35 (1); 89-97
Lumbar HNP Spine 2009; 9: 193-203
Lumbar Fusion Spine 2010; 35 (19): 1812-1817
Lumbar Fusion Spine 2011; 36 (4): 320-331
JAAOS 2013; 21 (2): 67-77K. I. Gruson et al
• Workers’ Compensation and Outcomes of Upper Extremity Surgery
• Clinical outcomes following upper extremity surgery among workers’ compensation patients have traditionally been found to be worse than those of non–workers’ compensation patients. In addition, workers’ compensation patients take significantly longer to return to their jobs, and they return to their pre-injury levels of employment at a lower overall rate. Text 208599 and your
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JAAOS 2013; 21 (2): 67-77
REFERENCES• Misamore GW, JBJS 1995; 77(9):
1335-9• Namdari S, JBJS 2008; 90 (9): 1906-
13• Henn RF, JBJS 2008; 90 (10): 2105-
13• Balyk R, CORR 2008; 466 (12):
3025-33• Krishnan SG, Arthroscopy 2008; 24
(3): 324-8• Spangehl MJ, J Shoulder Elbow Surg
2002; 11 (2): 101-7• Connor PM, Orthopedics 2000; 23
(6): 549-54• Hawkins RJ, J Shoulder Elbow Surg
2001; 10 (3): 225-230• Nicholson GP, JBJS 2003; 85 (4):
682-9• Gartsman GM, JBJS 1990; 72 (2):
169-8023Text 208599 and your
Questions to 22333
JAAOS 2013; 21 (2): 67-77
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Am J Orthop 2005; 34 (3):122-6
J Hand Surg 2009; 34 (5): 849-57
J Plas Reconstr Aesthet Surg 2008; 61 (9): 1095-9
J Hand Surg 1999; 24 (3): 566-70
JAAOS 2013; 21 (2): 67-77
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JAAOS 2013; 21 (2): 67-7752. Duncan SF, A comparison of workers’ compensation patients and non-workers’ compensation patients undergoing endoscopic carpal tunnel release. Hand Surg 2010;15(2): 75-80.
53. Nagle DJ, Fischer TJ, Harris GD, et al: A multicenter prospective review of 640 endoscopic carpal tunnel releases using the transbursal and extrabursal chow techniques. Arthroscopy 1996;12(2): 139-143.
54. Higgs PE, Edwards D, Martin DS, Weeks PM: Carpal tunnel surgery outcomes in workers: Effect of workers’ compensation status. J Hand Surg Am 1995;20(3): 354-360.
55. al-Qattan MM, Factors associated with poor outcome following primary carpal tunnel release in non-diabetic patients. J Hand Surg Br 1994;19(5):622-625.
56. Atroshi I, Use of outcome instruments to compare workers’ compensation and non-workers’ compensation carpal tunnel syndrome. J Hand Surg Am 1997;22(5):882-888.
57. Shin AY, Disability outcomes in a worker’s compensation population: Surgical versus non-surgical treatment of carpal tunnel syndrome. Am J Orthop (Belle Mead NJ) 2000;29(3):179-184.
58. Bessette L, Prognostic value of a hand symptom diagram in surgery for carpal tunnel syndrome. J Rheumatol 1997;24(4):726-734.
59. Katz JN, Predictors of return to work following carpal tunnel release. Am J Ind Med 1997;31(1):85-91.
60. Olney JR, Contested claims in carpal tunnel surgery: Outcome study of worker’s compensation factors. Iowa Orthop J 1999;19:111-121.
61. Filan SL, The effect of workers’ or third-party compensation on return to work after hand surgery. Med J Aust 1996;165(2):80-82.
Are Workers’ Compensation Patients BAD People?
• Are they motivated only by money to exaggerate and get a FINANCIAL reward?
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Malingering and Fraud?
• Malingering and Fraud, desire for financial reward, exist, but are relatively UNCOMMON
• The MUCH BIGGER Problem in terms of number of injured workers and cost (human cost and financial cost) to the “system” are the workers who are not malingering, but who have sub-optimal outcomes based on pain, willingness to work, etc.
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Are Workers’ Compensation Patients BAD People?
1. Someone else puts a scratch on your car while it is parked in a shopping center.
2. YOU put a scratch on your own car backing up into a pole in a parking lot.
OR, Are WE just like them in many ways ???Text 208599 and your Questions to 22333
Questionnaire: PCSPain Catastrophizing Scale
• Sullivan MJ, Bishop LS. The pain catastrophizing scale: development and validation. – Psychol Assess. 1995;7:524-32.http://sullivan-painresearch.mcgill.ca/pdf/pcs/PCSManual_English.pdf
13 questions
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PCS
One of MANY Published Studies on Catastrophizing
• Kim, HJ et al. Influence of Educational Attainment on Pain Intensity and Disability in Patients with Lumbar Spinal Stenosis. Spine 2014; 39 (10): E637-44– Seoul National University College of Medicine, Korea– 155 patients with lumbar spinal stenosis, equal mix of elementary,
junior high, senior high, and college educated folks
– Older folks (most 52-77), with PCS 12-38. – Conclusion. This study demonstrated that lower
educational attainment was associated with increased pain intensity and disability in patients with LSS, which was mediated by the coping mechanism, catastrophizing. Text 208599 and your
Questions to 22333
AngerYet Another Factor in OUTCOMES
Perceived InjusticeThe IEQ (Injustice Experience Questionnaire)
• High IEQ score (> 20) correlates with:– Delayed recovery– Low Return to Work rate– Pain severity– Sullivan MJ, et al. The Role of Perceived Injustice in the
Experience of Chronic Pain and Disability: Scale Development and Validation. J Occ Rehab 2008; 18 (3): 249-61
• Anger mediates the relationship between Perceived Injustice and Poor Outcomes– Scott W, et al. Anger differentially mediates the
relationship between perceived injustice and chronic pain outcomes. Pain 2013; 154: 1691-98.
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IEQ• 12
QUESTIONS• Rated 0-4 by
the patient• > 20 is high
or “at risk”
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Gordon Waddell MD
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WADDELLPAIN 1992; 52:
157-168
•Physical Activity Scale score is sum of # 2,3, 4, & 5.
•Work Scale is sum of # 6, 7, 9, 10, 11, 12, & 15.
FEAR – Avoidance Belief Questionnaire
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Tampa Kinesiophobia
Scale• Measures the
concept, or Patient BELIEF that “Pain MEANS Harm/Injury IS Occurring as I do things”
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Flawed Causation AnalysisLeads to Sub-Optimal Outcomes
• DOCTOR: – “You INJURED your ___ (shoulder, back, etc.)
lifting a 3 pound box at work.”– “Now it is time to go back to work and lift a
lot of 3 pound boxes.”
• PATIENT:– “I BELIEVE IF I Have Pain doing activity,
I MUST be INJURING Myself.”
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Medical/Psychological Explanations for Sub-Optimal Treatment Outcomes1. Catastrophizing
• Making mountains of molehills?• Or unaddressed FEAR that this injury will
permanently end working in this career ??
2. Anger over circumstances of Injury3. Fear Avoidance Beliefs
• Fear that Pain with activity means Harm or Additional Injury
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Today’s Job for the Panel AND the AUDIENCE
• What factors contribute to sub-optimal outcomes in TENNESSEE workers’ compensation patients?
• What can we CHANGE to improve OUTCOMES?– Legislation, Rules– Employer Practices– Employee Education– Physician behavior Text 208599 and your
Questions to 22333
