John Kuhnlein ,DO, MPH, CIME, FACPM, FACOEM Medix Occupational Health Ankeny Iowa
“Energy in the executive is a leading character in the definition of good government. A feeble executive implies a feeble execution of government. A feeble execution is but another phrase for a bad execution: and a government ill executed, whatever it may be in theory, must be, in practice, a bad government.” Alexander Hamilton, Federalist Papers, No. 70
“Energy in editorial control is a leading character in the definition of a good Guides. A feeble or misguided editorial control implies a feeble execution of the Guides. A feeble execution is but another phrase for a bad Guides: and a Guides ill executed, whatever it may be in theory, must be, in practice, a bad Guides.”
So what do you need to know about the 6th Edition? • The Iowa Task Force regarding the use of the 6th Edition voted against it’s use in Iowa, and I’ll try to explain my thoughts about this. You can view the report at the Iowa Workforce Development website. • One can look at this position in a number of ways; • Wait and Watch what happens in other states prior to considering implementation • Not never, just not now • Never in it’s current iteration and format
The 6th Edition uses 5 new axioms for impairment rating (2) • The Guides adopts the terminology and conceptual framework of the International Classification of Functioning, Disability and Health (ICF) Fig 1-1 (3) Old model 5th Fig 1-1 (8) • The Guides becomes more diagnosis based
The 6th Edition uses 5 new axioms for impairment rating (2) • “Simplicity, ease-of-application, and following precedent, where applicable, are given high priority, with the goal of optimizing interrater and intrarater reliability” (italics added) • Rating percentages “functionally based” • “Conceptual and methodological congruity within and between organ system ratings”
Some of the basics - • The Guides originally came from a series of articles in JAMA from 1958-1970 The First Edition of The Guides • Subsequent Editions have been evolutionary in approach; the 6th is revolutionary, using a very different model, not only conceptually, but in how ratings are practically derived.
So what’s different? • In the other Editions, we took the injury apart into range of motion, motor, sensory, ligamentous structure, sometimes DRE and then combined them back into the impairment-it was mostly based on the physical examination regardless of diagnosis, most of the time
So what’s different? Remember this is simple and easy. • Radically different methodology based on a Clinical Diagnostic Class (CDX), which assigns impairment to the median value in a grid of impairments, with several exceptions. • The CDX is then modified using the Net Adjustment Formula (NAF) using modifiers for functional history, physical examination, and diagnostic studies (GMFH-CDX)+(GMPE-CDX)+(GMCS- CDX)
So what’s different? Remember ease-of-application! • This model is used most of the time, except for: • mental health, • carpal tunnel syndrome, Table 15-23, (449) • sometimes upper extremity, (amputation, some CDX 3 and 4 injuries) (461) and • sometimes lower extremity (amputation, some CDX 3 and 4 injuries) (543)
The 5th is far from perfect • No real scientific support for impairment rating values – always has been a consensus process. • If the doctor doesn’t read the book, significant errors may ensue. • Open the book, look at a few tables and use one of the numbers to assign a rating. Some docs don’t even do this much. • The doctors don’t mention the tables and pages so the reader can follow where the numbers are coming from.
The 5th is far from perfect • Lack of internal consistency-visual system ratings aren’t consistent with the MSK chapter ratings. • Sometimes there are significant gaps between DRE impairments-what’s wrong with 3%? It jumps from 0 (DRE I) to 5% (DRE II) Fig 15-3, page 384 • Sometimes major nerves are missing, e.g. in the lower extremity, Table 17-31, Page 544
The 5th is far from perfect • In the case of multiple spine surgeries- you use the ROM method (379-380), but the numbers come out LOWER than if you only have one surgery. With one surgery only cervical fusion is minimum 25% BAW Fig 15-5 392 • Mental health issues have no ordinal values
The 6th has some advantages • The spine gaps are filled in • Nerves are addressed that weren’t before • There is a methodology for rating mental health issues-although in error originally. Recently corrected in the first 52 page errata. • Tendinitis/epicondylitis handled now • May be a bit more straightforward if the strict methodology is followed, although the exceptions are significant and confusing.
The 6th Edition has issues • So many issues, so little time • THE PARADIGM SHIFT • What is a paradigm shift • Who voted to say we needed a paradigm shift in the first place? • “By physicians for physicians” but: • AMA was threatened by lawsuit by ACA if the wording didn’t change • No one asked the end users (e.g. the worker’s compensation users) if needed or wanted at all. It doesn’t appear that the true impact on the end users was considered • Methodology includes disability issues so mixing impairment with disability measures
The 6th Edition has issues • THE PARADIGM SHIFT • Despite the editors assertions that this edition of the Guides will “move the process forward” there are still practical issues of implementation that, if considered, don’t seem to have been considered important.
The 6th Edition has issues • THE PARADIGM SHIFT • May produce untoward and unexpected outcomes or harm to either party – the 2006 injury vs. the 2008 and outcomes. 25 v. 6, MH issues • There doesn’t seem to be a mechanism in place to assess +/- impact for adaptation. Rondinelli comment 2/1/08 re AMA actuarials
The 6th Edition has issues • THE PARADIGM SHIFT • “Do No Harm” principle - issues of harm to employee, multistate employer, physicians • Physicians who write Guides forget common sense. They get bound up in methodology, testify as to science, and studies, but forget to step back and look at this as a social process. We hear about studies and evidence based medicine, but no comment upon real implementation problems and issues
The 6th Edition has issues • THE PARADIGM SHIFT • My view – intriguing concept, but • Iowa should wait and watch. Let sister states who mandate use find out if this paradigm is usable and then reevaluate. • Not never, just not now.
The 6th Edition has issues • Changes in Ordinal Values- Untoward and Unexpected Outcomes • Cervical Fusion ratings may be dramatically different. 5th = 25-28% DRE. 6th may be 6% or 0% BAW. Table 17-2 page 564. • Mental health now present so ratings here may go up. You have numbers where you didn’t before. • Tendinitis • Uncertain whether certain conditions change dramatically, if overall ratings go up/down
The 6th Edition has issues • Cultural and Racial Issues • Reported to Task Force that QuickDASH, AAOS, PDQ not culturally sensitive. • People of culture are often also people of different race. • Because of the way the questionnaires are used, there may be either an advantage or disadvantage to people of culture and color. See pp. 446-447 6th Edition re QuickDASH scoring.
The 6th Edition has issues • Physician Issues • Carpal Tunnel syndrome can be diagnosed using one set of EMG/NCV criteria but is rated using another set of EMG/NCV criteria. This creates a double standard. (446) • Physicians may see complaints to state Boards of Medicine for “unnecessary surgery”. Maybe not. • Task Force was told that the EMG/NCV standards outlined in Appendix 15-B were determined by consensus. They are not the criteria from AMA component societies. But AMA says it wants Guides to be more objective. Seems this is not.
The 6th Edition has issues • Physician Issues • The learning curve • 8 hour course work at several hundred dollars expense if not more because of travel expenses. • Dr. Melhorn indicated about 25-30 hours necessary to learn on your own. • If physicians simply pick up the book and look at tables and figures, the errors will increase, with increased case cost. • Will fewer physicians do ratings?
The 6th Edition has issues • Physician Issues • 52 page errata took 3.5 hours for one Task Force member to correct with the 6th Edition, i.e., the 11 cm PDQ line, the MH BPRS • More errata may be coming, uncertain now. • If physicians who rarely use the book don’t review and correct with the errata, error rates will go up • If the reader doesn’t know if the physician was aware of the latest errata, confusion will ensue as to whether the rating is incorrect. Was the reader aware of the most recent errata?
The 6th Edition has issues • Consensus • Editorial Issues • Dr. Rondinelli 85/15 issues • Dr. Mueller listing issues • Dr. Colledge issues • Dr. Douglas Martin issues brought to Task Force • “hidden agendas and biased allegiances which many physicians (involved in the development of the Sixth Edition) cannot say” • Dr. Brigham issues
The 6th Edition has issues • Bias? Unattributed statements in the text, unrelated to impairment issues per se • Mental health impairment limited to one diagnosis(349) Malingering T. 14-3, (350) • UE three nerve issue (448) • MMI at two stable OV’s one month apart after CTR (447)
The 6th Edition has issues • Bias? Unattributed statements in the text, unrelated to impairment issues per se • Unreferenced LE CRPS comments re “incorrect” (539) Table 16-15 (541), also see bibliography “preliminary”, “proposed” • Issues related to excluding GMFH (LE 516), GMPE (LE 517), and GMCS values (UE 448 re postop EMG/NCV)
The 6th Edition has issues • Consensus and bias • Who wrote the chapters? We couldn’t find out. • Who were the authorswho • Might have “hidden agendas and biased allegiances” who • Made up the consensus that • Created the paradigm shift with the • Potential cultural/racial issues that • Might create problems for physicians? • And why did this book get hurried in the rush to publish, and who made the corrections • Published in the 52 page errata that had to be • Rushed to publishbecause of the original • Rush to publish a version we’ve been told is • A beta version?
The 6th Edition has issues • Interrater Reliability • Editors mentioned this several times in discussions with the Task Force • So what? The deck is stacked anyway. • There will be greater interrater reliability because there are essentially only five choices anyway based on the CDX
The 6th Edition has issues • Interrater Reliability • Problem is accuracy in ratings not interrater reliability which comes back to the consensus. • If the consensus is biased, the data in the grids is bad. • If the data in the grids is bad then the ratings are bad. Physicians can all come up with the same number but if the data is bad, then the rating is bad, it will still be an incorrect number
The 6th Edition has issues • Simplicity and ease of use • Remember that there are occasions when the GMFH, the GMPE, and the GMCS can be disregarded, based on the particular scenario. • Remember that you can have objective physical findings that can DECREASE the rating.
Summary • Wait and Watch the 6th implementation in other states. Basically let other states find out if these are all valid concerns. • There is no harm in waiting. • Not never, just not now.