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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,

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Presentation on theme: "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,"— Presentation transcript:

1 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

2 Tennessee Division of Workers’ Compensation 17 th Annual Meeting June 19, to 10 AM Text and your Questions to 22333

3 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 Text and your Questions to 22333

4 Questions ? James B. Talmage MD, Occupational Occupational Health Center, 315 N. Washington Ave, Suite 165 Cookeville, TN Phone (Fax ) Text and your Questions to 22333

5

6 James B. Talmage MD Adjunct Associate Professor Division of Occupational Medicine –Department of Family and Community Medicine Meharry Medical College, Nashville, TN

7 7 7 AMA Publications AMA Press: or

8 AMA Publications

9 2005 & nd Edition royaltiesI receive royalties

10 AMA Press: Royalties FINANCIAL CONFLICT OF INTEREST No role

11 11 Paid Consultant FederalFederal 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

12 Emergency Part/Full Time Job I was the TEMPORARY “Fill in” Medical Director, Tennessee Division of Workers’ Compensation: March to December Now part time Assistant Medical Director.

13 NO Longer I NO Longer Have a FINANCIAL CONFLICT OF INTEREST

14 14 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 referenced Text and your Questions to 22333

15 The speaker is a Past President of “ The premiere society for the prevention and management of disability” For more information, contact or visit the UNPAID Text and your Questions to 22333

16 Focus for the Next Hour Outcomes of treatment of common injuries OUTCOMES are WORSE in compensation settings –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. pain, narcotic use, return to work rates, –Outcomes include “other factors” like pain, narcotic use, return to work rates, etc. These ARE DIFFERENT. Text and your Questions to 22333

17 I Harris, et al., JAMA 2005; 293 (13): Text and your Questions to 22333

18 18 JAMA 2005; 293:

19 19

20 Causation Decision Affects Outcome Published since the Harris Meta-Analysis ConditionReference Total Knee ReplacementJ Arthroplasty 2004; 19 (3): Total Knee ReplacementJ Can Chir 2005; 48 (2): Cervical HNPThe Spine J 2005; 5: Lumbar HNPSpine 2006; 31 (26): Multiple TraumaMed J Australia 2007; 187 (1): Rotator Cuff RepairJBJS 2008; 90: Carpal Tunnel SyndromeOcc Med 2008 doi: /occmed/kqn099 Lumbar HNPSpine 2009; 35 (1); Lumbar HNPSpine 2009; 9: Lumbar FusionSpine 2010; 35 (19): Lumbar FusionSpine 2011; 36 (4):

21 JAAOS 2013; 21 (2): K. I. Gruson et al Workers’ Compensation and Outcomes of Upper Extremity Surgery outcomes worse nonClinical 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 and your Questions to 22333

22 JAAOS 2013; 21 (2): 67-77

23 REFERENCES Misamore GW, JBJS 1995; 77(9): Namdari S, JBJS 2008; 90 (9): Henn RF, JBJS 2008; 90 (10): Balyk R, CORR 2008; 466 (12): Krishnan SG, Arthroscopy 2008; 24 (3): Spangehl MJ, J Shoulder Elbow Surg 2002; 11 (2): Connor PM, Orthopedics 2000; 23 (6): Hawkins RJ, J Shoulder Elbow Surg 2001; 10 (3): Nicholson GP, JBJS 2003; 85 (4): Gartsman GM, JBJS 1990; 72 (2): Text and your Questions to 22333

24 JAAOS 2013; 21 (2): Am J Orthop 2005; 34 (3):122-6 J Hand Surg 2009; 34 (5): J Plas Reconstr Aesthet Surg 2008; 61 (9): J Hand Surg 1999; 24 (3):

25 JAAOS 2013; 21 (2):

26 JAAOS 2013; 21 (2): Duncan SF, A comparison of workers’ compensation patients and non-workers’ compensation patients undergoing endoscopic carpal tunnel release. Hand Surg 2010;15(2): 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): 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): al-Qattan MM, Factors associated with poor outcome following primary carpal tunnel release in non-diabetic patients. J Hand Surg Br 1994;19(5): Atroshi I, Use of outcome instruments to compare workers’ compensation and non-workers’ compensation carpal tunnel syndrome. J Hand Surg Am 1997;22(5): 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): Bessette L, Prognostic value of a hand symptom diagram in surgery for carpal tunnel syndrome. J Rheumatol 1997;24(4): Katz JN, Predictors of return to work following carpal tunnel release. Am J Ind Med 1997;31(1): Olney JR, Contested claims in carpal tunnel surgery: Outcome study of worker’s compensation factors. Iowa Orthop J 1999;19: 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.

27 Are Workers’ Compensation Patients BAD People? Are they motivated only by money to exaggerate and get a FINANCIAL reward? 27 Text and your Questions to 22333

28 Malingering and Fraud? but are relatively UNCOMMONMalingering and Fraud, desire for financial reward, exist, but are relatively UNCOMMON The MUCH BIGGER Problem notThe 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. Text and your Questions to 22333

29 Are Workers’ Compensation Patients BAD People? 1.Someone else 1.Someone else puts a scratch on your car while it is parked in a shopping center. 2.YOU 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 and your Questions to 22333

30 Questionnaire: PCS Pain Catastrophizing Scale p sSullivan MJ, Bishop LS. The pain catastrophizing scale: development and validation. –Psychol Assess. 1995;7: questions Text and your Questions to 22333

31 PCS

32 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): E –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 –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 and your Questions to 22333

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34 Anger Anger Yet Another Factor in OUTCOMES

35 IEQ Perceived Injustice The 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): Anger mediatesAnger 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: Text and your Questions to 22333

36 IEQ 12 QUESTIONS Rated 0-4 by the patient > 20> 20 is high or “at risk” Text and your Questions to 22333

37 Gordon Waddell MD 37

38 WADDELL PAIN 1992; 52: 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 Text and your Questions to 22333

39 Tampa Kinesiophobia Scale Measures the concept, or Patient BELIEF that “Pain MEANS Harm/Injury IS Occurring as I do things” Text and your Questions to 22333

40 Flawed Causation Analysis Leads to Sub-Optimal Outcomes DOCTOR: –“You INJURED your ___ (shoulder, back, etc.) lifting a 3 pound box at work.” Nowgo back to workand lift a lot –“Now it is time to go back to work and lift a lot of 3 pound boxes.” PATIENT: IF I Have Pain I MUST be INJURING Myself.” –“I BELIEVE IF I Have Pain doing activity, I MUST be INJURING Myself.” Text and your Questions to 22333

41 Medical/Psychological Explanations for Sub-Optimal Treatment Outcomes 1.Catastrophizing Making mountains of molehills? Or unaddressed FEAR that this injury will permanently end working in this career ?? 2.Anger over circumstances of Injury 3.Fear Avoidance Beliefs Fear that Pain with activity means Harm or Additional Injury Text and your Questions to 22333

42 AND the AUDIENCE Today’s Job for the Panel AND the AUDIENCE What factors contribute to sub-optimal outcomes in TENNESSEE workers’ compensation patients? What can we CHANGEWhat can we CHANGE to improve OUTCOMES? –Legislation, Rules –Employer Practices –Employee Education –Physician behavior Text and your Questions to 22333

43 Thank You for Your Attention


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