IAIABC Perspectives : Perspectives on Evidence-Based Medicine (November 2019).
by Alana Letourneau, M.D., MBA, Senior Vice President, Clinical Strategy
Over half of Americans report that they rely on their “gut intuition” to make decisions. In workers’ compensation, where these decisions directly impact patient recovery paths, data needs to be in the driver’s seat.
Evidence-based medicine (EBM) improves the medical decision-making process by integrating scientific analysis and medical consensus. EBM has been widely accepted in most medical professions; however, these practices have been a challenge to implement consistently in the workers’ compensation industry. Fragmentation, including differences in state-by-state policies, and workers’ compensation specific guidelines add to this challenge. Studies examining workers’ compensation data from over 1200 claims leaders have found that less than 40% of insurers, third party administrators, and employers report usage of evidence-based guidelines and/or predictive models. Of significance, there is a direct correlation between incorporation of evidence-based practices and claims closure rates.
At the core of EBM is the usage of quality, peer-reviewed research. Both basic science and clinical research literature have established the linkage between mental and physical health. Relevant to injured workers, data on the interaction of physical injury, mental health and interdisciplinary care exists; it’s time that the worker’s compensation industry started using it.
Injury Pain and Mental Health
Through neuroimaging studies examining neuroplasticity, it is possible to better quantify the bidirectional relationship between physical injury pain and mental health.
A network of brain areas responds to pain, including the insula and anterior cingulate cortex. Other brain areas respond to emotion, including the amygdala. In individuals with chronic pain, the brain’s response changes over time; if these individuals experience pain, brain regions responsible for emotion will activate. Conversely, in patients with a diagnosed mood disorder, the brain’s response also changes.
If these individuals experience symptoms of depression or anxiety, brain regions responsible for physical pain will activate.
This interchange between physical and mental health directly impacts our injured worker populations.
We can look to the research evidence to better understand and mitigate this impact on recovery.
Delayed Recovery:
The Workers Compensation Benchmarking Study demonstrated that the number one barrier to successful recovery is due to unaddressed psychosocial factors. Similarly, a five-year prospective study showed that psychosocial factors predict an injured worker’s return to function; in this study, 30% of injured workers had poor mental health five years post injury, which was directly correlated with community re-integration.
Back Pain:
According to the Centers for Disease Control (CDC), chronic conditions, such as back pain, cost employers an average of $1,685 per employee, per year. Research has shown that those with chronic back pain are six times more likely to develop depression, with the rate of depression increasing with pain severity. Reversing this relationship, those with depression are three times more likely to develop chronic back pain. Predictive models forecasting return to work in work-related low back injury have demonstrated physical and mental-health related quality of life as key predictive factors. Depression in back pain patients is a direct predictor of poor outcomes, including delayed return to work.
Spinal Cord Injury:
While catastrophic injuries may only represent 1% of overall claims, these injuries represent up to 20% of claims costs. Studies have established that up to 50% of patients are depressed following spinal cord injury (SCI). The Model of Disability has demonstrated that psychosocial factors directly impact pain experience in paralyzed patients, including factors such as depression, anxiety, and lack of social support. Related, suicide is a leading cause of mortality in SCI, with a five times increased risk of suicide compared to the general population; pain and lack of social support are thought to influence rates of suicide in SCI patients.
Opioid Use:
Early prescription of opioids in workers’ compensation claims predicts increased claim duration, higher medical costs and increased utilization rates of disability services.
Almost 60% of patients with any use of prescription opioids report major depressive episode, including suicidal ideation. Injured workers with diagnosed depression have a higher prevalence of prescription opioid misuse compared to those without depression, with aberrant use occurring in up to 24% of cases.
On the topic of opioid use disorders, chronic pain patients are three times more likely to develop substance use. Reversing this relationship, those engaging in substance use are one and a half times more likely to develop chronic pain. Research has demonstrated a link between long-term opioid use and increased pain sensitivity, known as hyperalgesia. Of interest, studies of patients weaned from opioids to non-steroidal anti-inflammatory drugs (such as ibuprofen) have reported significant pain reduction.
Post-Traumatic Stress Disorder (PTSD): In research studies, PTSD predicts long term disability. Injured workers with PTSD have more missed days of work, more medical visits, and increased rates of unemployment. In looking specifically at individuals with traumatic brain injury and co-occurring PTSD, it has been shown that untreated PTSD drives physical symptomology in this injury population. This is to say that the post-concussive symptoms may improve from PTSD treatment.
Mental Health and Workers’ Compensation Coverage
Despite the research evidence of mental health and physical injury connection, equal coverage is not reflected in policy. Using Post Traumatic Stress Disorder as an example, mental health coverage in workers’ compensation can vary largely by state, with specific requirements.
In numerous states, PTSD coverage is only available for the first responder population. PTSD has been estimated to occur in 32% of first responders, including 19% of police officers. In Connecticut, PTSD claims are permitted only for police officers who experienced deadly force in the line of duty or firefighters who witnessed a co-worker die on the job. In New Hampshire, PTSD and acute stress disorder may be added to the definition of “injury” if the employee meets the criteria of “emergency response/public safety worker.”
In certain states, PTSD coverage depends upon causality and whether the state recognizes that event as a work injury. For example, in Texas, PTSD symptoms must be a direct response to events from the scope of work. In California, workers must have been employed for at least six months and work conditions must be at least 51% responsible for the PTSD symptoms.
Some states do not require physical injury for PTSD compensability. In Florida, based on an effective law from 2018, indemnity benefits for first responders suffering from PTSD do not require a physical injury to have occurred. In other states, such as South Dakota, a physical injury to the body is required.
Other aspects of compensability may require comparison of working conditions. In New York, employees must demonstrate they were under a greater level of stress than other employees. In Iowa, work condition and circumstances leading to the mental condition must exceed that which is typically experienced by peers in that same profession.
With differing state requirements, access to mental health care is compromised in workers’ compensation injuries, along with case outcomes.
The Biopsychosocial Model and Implementation
Given the impact of mental health on physical health recovery, an evidenced-based, biopsychosocial approach is needed.
The concept of a biopsychosocial model is not new; the model was first developed by Dr. George Engel in 1977. The International Classification of Functioning, Disability and Health officially recommends a biopsychosocial perspective in trauma rehabilitation.
Use of the biopsychosocial model in injured patients has research support, demonstrating that social and psychological factors mediate the relationship between pain and life satisfaction. Systematic review of multi-domain interventions in injured workers shows that incorporating a multi-component, biopsychosocial approach (i.e. psychotherapy, care coordination, medical care provision, work place modification, etc.) significantly reduces mental health symptom severity, musculoskeletal pain, delay in return to work and healthcare cost. Thus, a biopsychosocial model may help both identify and prevent delayed recovery.
The patient-centered, humanized approach to care in the biopsychosocial model is favored by the medical community. However, in the past, it has not been well-defined, operationalized, and repeatedly tested in the research literature. Through creating a specific, replicable model, we can move toward evidence-based evaluation with the ability to measure outcomes in workers’ compensation cases.
Best practices in an evidenced-based biopsychosocial tool include:
• A set of interview questions that is replicable, with specific, well-defined components;
• A patient centered approach through open ended, non-directive questions. In 2001, the Institute of Medicine declared a patient centered approach to be one of the six domains of quality, effective care.
• An empathetic, partnering approach, preferably using a face-to-face interview or via telehealth to identify body cues and build rapport;
• Psychological testing and mental status examination;
• Prior life stressors or traumas, including prior history of abuse or mental health conditions must be assessed, as this can represent predisposing factors;
• Family and environmental life stressors, including financial and social consequences of the workplace injury must be identified;
• Sufficient time with the claimant in review: time is necessary to sort out causation, impairment and treatment needs; and
• Sufficient record review: all medical and mental health records should be reviewed for a complete health evaluation.
Post identification of clinical needs, the treatment plan is guided by evidence-based practices and interdisciplinary coordination. When the behavioral intervention is instituted early, outcomes can be most impacted. Evidence suggests that multi-modal therapies are more effective than monotherapy, and patients with multi-modal therapies in a collaborative care model are more likely to be prescribed nonopioid alternative treatments. Examples of integrated pain treatment may include: physiatry, psychiatry, psychotherapy, relaxation techniques, massage, exercise, physical therapy, occupational therapy, neuromodulators, interventional techniques and vocational rehabilitation.
Future Directions: Data and Technology
In tandem with standardization of evidence-based medicine tools in workers’ compensation, there needs to be end-to-end data tracking of clinical progress from time of injury through return to work. For many injured workers, validated clinical assessments may be administered in the acute hospitalization or during inpatient rehabilitation, but what happens when these individuals return home?
For case managers tracking clinical progress, technology may be the answer. Smartphones allow for passive data collection around physical activity and geolocation. New mobile apps readily connect patients with their care team, tracking appointments, medications and clinical assessment results. Use of standardized tools with longitudinal data collection allows for both outcomes’ analytics and the creation of predictive recovery models.
Ultimately, following the data is what will allow us to achieve better outcomes and, eventually, to prevent injuries from occurring in the first place.
If you would like to read the full issue or other issues of the magazine, please visit : https://www.iaiabc.org/iaiabc/Perspectives.asp
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