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Tennessee Division of Workers’ Compensation 17 th Annual Meeting June 19, 2014 9 to 10 AM

Medical Outcomes are Worse for Workers’ Compensation Patients: Why is T his and What Can be Done About It? Dr. James Talmage, John Peterson & Debbie Nelson, Panelists Jay Blaisdell, Moderator. OUTCOMES ARE DIFFERENT. Tennessee Division of Workers’ Compensation 17 th Annual Meeting

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Tennessee Division of Workers’ Compensation 17 th Annual Meeting June 19, 2014 9 to 10 AM

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  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, PanelistsJay Blaisdell, Moderator

  2. OUTCOMES ARE DIFFERENT Tennessee Division of Workers’ Compensation 17th Annual Meeting June 19, 2014 9 to 10 AM Text 208599 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 208599 and your Questions to 22333

  4. Questions ? James B. Talmage MD, Occupational Health Center, 315 N. Washington Ave, Suite 165 Cookeville, TN 38501 Phone 931-526-1604 (Fax 526-7378) olddrt@frontiernet.net olddrt@occhealth.md Text 208599 and your Questions to 22333

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

  6. AMA Publications • AMA Press: 1-800-621-8355 or • www.amapress.com 7

  7. AMA Publications

  8. 2005 & 2011 • 2nd Edition • I receive royalties

  9. AMA Press: Royaltieswww.ama-assn.org FINANCIAL CONFLICT OF INTEREST No role

  10. 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 11

  11. 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.

  12. www.mdguidelines.comI NO Longer Have aFINANCIAL CONFLICT OF INTEREST

  13. 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 208599 and your Questions to 22333 2007 14 14

  14. 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

  15. 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. Text 208599 and your Questions to 22333

  16. I Harris, et al.,JAMA 2005; 293 (13): 1644-1652 Text 208599 and your Questions to 22333

  17. JAMA 2005; 293: 1644-1652 18

  18. 19

  19. Causation Decision Affects OutcomePublished since the Harris Meta-Analysis

  20. 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 patientshave traditionally been found to be worsethan 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 Questions to 22333

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

  22. 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): 169-80 Text 208599 and your Questions to 22333

  23. JAAOS 2013; 21 (2): 67-77 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

  24. JAAOS 2013; 21 (2): 67-77

  25. JAAOS 2013; 21 (2): 67-77 52. Duncan SF, A comparison of workers’ compensation patients and non-workers’ compensation patients undergoing endoscopic carpal tunnel release. Hand Surg2010;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 Rheumatol1997;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 Aust1996;165(2):80-82.

  26. Are Workers’ Compensation Patients BAD People? • Are they motivated only by money to exaggerate and get a FINANCIAL reward? Text 208599 and your Questions to 22333

  27. 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. Text 208599 and your Questions to 22333

  28. Are Workers’ Compensation Patients BAD People? • Someone else puts a scratch on your car while it is parked in a shopping center. • 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

  29. 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 Text 208599 and your Questions to 22333

  30. PCS

  31. 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

  32. AngerYet Another Factor in OUTCOMES

  33. Perceived InjusticeThe IEQ(Injustice Experience Questionnaire) Text 208599 and your Questions to 22333 • 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 betweenPerceived 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.

  34. IEQ Text 208599 and your Questions to 22333 12 QUESTIONS Rated 0-4 by the patient > 20 is high or “at risk”

  35. Gordon Waddell MD 37

  36. 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 Text 208599 and your Questions to 22333

  37. Tampa Kinesiophobia Scale • Measures the concept, or Patient BELIEF that “Pain MEANS Harm/Injury IS Occurring as I do things” Text 208599 and your Questions to 22333

  38. 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 workand lift a lot of 3 pound boxes.” • PATIENT: • “I BELIEVEIF I Have Pain doing activity, I MUST be INJURING Myself.” Text 208599 and your Questions to 22333

  39. Medical/Psychological Explanations for Sub-Optimal Treatment Outcomes • Catastrophizing • Making mountains of molehills? • Or unaddressed FEAR that this injury will permanently end working in this career ?? • Anger over circumstances of Injury • Fear Avoidance Beliefs • Fear that Pain with activity means Harm or Additional Injury Text 208599 and your Questions to 22333

  40. Today’s Job for the PanelAND 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

  41. Thank You for Your Attention

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