Published 9/1/2009
J. Mark Melhorn, MD

EBM, CPGs, and workers’ compensation

Building a foundation for better care, improved decision-making

Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Clinical practice guidelines (CPGs) aim to guide decisions and criteria regarding diagnosis, management, and treatment in specific areas of health care. And, if part of your orthopaedic practice involves workers’ compensation claims, you need to be aware of the impact of both EBM and CPGs on the care you provide.

EBM recognizes that many aspects of medical care depend on individual factors, such as quality- and value-of-life judgments, which are only partially subject to scientific methods. EBM, however, seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure the best prediction of outcomes in medical treatment, even as debate continues about which outcomes are desirable.

CPGs, also called medical guidelines, clinical guidelines, clinical protocols, or clinical treatment guidelines, are developed using strict criteria and established levels of evidence. The AAOS, through the Guideline and Technology Oversight Committee (GTOC) and the Evidence-Based Practice Committee (EBPC), has developed and published several clinical guidelines using the EBM approach. These documents represent the results of a systematic review of all published studies regarding a specific topic. They often include discussions of prevention, diagnosis, prognosis, therapy (including medication dosages), risk/benefit analyses, and cost-effectiveness.

EBM-based CPGs define the most important questions related to clinical practice and identify all possible decision options and their outcomes. They may include decision or computation algorithms. Thus, clinical guidelines integrate the identified decision points and respective courses of action with the clinical judgment and experience of practitioners. Many guidelines place the treatment alternatives into classes to help providers decide which treatment to use.

The United States and other countries maintain medical guideline clearinghouses. The U.S. National Guideline Clearinghouse maintains a catalog of high-quality guidelines published by various organizations.

Why is this important to you?
Many state workers’ compensation programs are now incorporating clinical guidelines. This move is part of efforts to standardize medical care, raise the quality of care, reduce risks (to the patient, the health care provider, medical insurers, and health plans), and achieve the best balance between cost and medical parameters such as effectiveness, specificity, sensitivity, and outcomes.

In California, for example, the American College of Occupational and Environmental Medicine’s (ACOEM) Occupational Medicine Practice Guidelines are presumed to correct and now control treatment options. Other states have elected to use part or all of other guidelines, such as the Official Disability Guidelines (ODG) or The Medical Disability Advisor: Workplace Guidelines for Disability Durations (MDA).The trend is to move this “model of guidelines” into general health care arenas (government supported plans, health maintenance organizations, private health insurers).

In handling work-related injuries your patient care role expands beyond clinical treatment to incorporate legal, administrative, ethical, and insurance issues. To increase your knowledge and understanding of EBM, clinical treatment guidelines, and workers’ compensation, plan to attend the 11th Annual AAOS Occupational Orthopaedics and Workers’ Compensation course, Nov. 6–8, 2009, in Boston. For more information on the course, visit www.aaos.org/courses

J. Mark Melhorn, MD, is chair of the AAOS Occupational Health Committee, a member of the GTOC, and a medical consultant for ACOEM, ODG, and MDA. He is also the course director for the Occupational Orthopaedics and Workers’ Compensation course.