When it comes to workers’ compensation claims, low back injuries are the most costly musculoskeletal condition representing 20-25 percent of all loss, according to an analysis of Lockton claims. Further analysis of claims over $250,000, indicate they represent 25 percent of loss dollars.
Keith Rosenblum, senior strategist for Workers’ Compensation Risk Control in Lockton’s Kansas City operation, addressed the importance of using evidence-based medicine for accurate diagnoses and proper treatment in a February white paper, “Red Herrings and Medical Overdiagnosis Drive Large-Loss Workers’ Compensation Claims”.
Since 2004, the report noted the use of MRIs and CT scans to diagnose and dictate treatment for chronic low back pain has increased substantially. The author notes that while medical imaging and overdiagnosis increases the cost of claims, outcomes for injured workers have not improved.
Rosenblum said that in chronic pain cases, “medical imaging findings are often red herrings. In medicine, a red herring is a diagnosis made based on poor science or inaccurate criteria. False certainty is created, and the search for the actual problem ends.
The real source of pain and distress usually lies elsewhere, but treatments options, usually pain medication, are aimed at the abnormality showing in the spinal imaging.”
He said that medical imaging can also result in overdiagnosis, “when a physician labels a condition more serious than it truly is, attributing a usually benign condition to more serious causes than the scientific data and situation warrant. A clear example is diagnosing a condition that requires major surgery when the patient actually has a problem that needs a less hazardous and more helpful form of care.”
According to the white paper, The American College of Physicians identifies two indications for imaging: severe neurological conditions [bowel/bladder dysfunction, progressive weakness/sensory loss indicating possible significant spinal cord or nerve root compromise], and serious spinal instability [infection, tumor, fracture, or dislocation]. Otherwise, routine use of imaging is “strongly” discouraged and is considered in and of itself, invalid.
Though common treatment of chronic pain is through the use of painkillers, like opioids, there is new research that suggest the pain may be the result of changes in the way the brain processes information.
“Opioids remain the de facto treatment for most workers with chronic pain,” said Rosenblum. “Yet comprehensive reviews of medical literature show chronic pain is frequently caused by the brain itself, making traditional treatment ineffective. We are following and assessing new, innovative models in diagnostic technology that may ensure more accurate diagnosis and treatment.”
Rosenblum said that when brain processing goes wrong chronic pain can result.
“Unfortunately, physicians may not have been trained to recognize and properly manage the relevant factors which may exist in any of several life domains (now referred to as bio-psycho-socio-economic factors). Physicians often intuitively sense that something else is going on, but continue ordering more imaging tests and looking for a structural explanation,” said Roseblum. “New neuroscience technologies are now being applied to patients with chronic pain. These technologies show changes in brain regions involved in perception and emotional processing; and not in regions dealing with pain sensation.”
The Lockton senior strategist suggests adjusters intervene early in the claim – within two to four weeks – which allows an adjuster time “to engage with the treating physician and encourage them to comply with medical treatment guidelines.”
“We recommend that adjusters proactively seek objective evaluations prior to approving all aggressive treatment plans for spine and major joint chronic pain because of the risk of red herring MRI results and medical overdiagnosis,” said Rosenblum. “In order to head off claims destined for delayed recovery (and high cost), we also recommend that adjusters take steps to detect and identify potentially mitigatable bio-psycho-socio-economic factors, then employ simple and low cost methods to address them.”
According to the white paper, evidence-based medicine means to rely on the highest quality evidence available.
“Diagnosing patients’ complaints based more on evidence-based medicine and less on imaging studies, where not recommended, will make a substantial impact on the cost of claims,” said Rosenblum. “Most importantly, it will avoid many cases of unnecessary disability for working Americans.”