North Carolina is considering adopting evidence-based guidelines for medical care of injured workers. According to a WorkCompCentral news article on Oct. 13 by Joey Berlin, the state admires how Texas appears to have successfully used guidelines. The guidelines and pre-authorization there, per a North Carolina official, “reduced the number of medical disputes, increased and expedited injured workers’ access to medical providers and increased satisfaction with the system ... North Carolina may benefit from a similar system.”

In the face of that kind of endorsement, it sounds curmudgeonly to offer only two cheers for evidence-based guidelines. But guidelines, while valuable in distilling the most reliable evidence about treatment, are easy to overrate for their effectiveness.

To be sure, is it impossible to argue against the principle of quality medical care. 

Some of the leading medical experts in the workers’ compensation field are exacting in their critique of what they view as deficient care. One of the more articulate and prolific experts is Gary Franklin, medical director of Washington’s Department of Labor and Industries. Franklin has been relentless in his advocacy of more prudent use of opioids for pain. He has repeatedly critiqued some surgical procedures.

In a recent article (he’s authored over 100), he and colleagues blamed deficient medical practice with longer durations of disability and higher rates of enrollment by injured workers in Social Security Disability Insurance.

The authors call out three treatments where physician practice sorely needs improving, despite a great deal of published research and guideline development (at the first two, at least). One is chronic opioid therapy, “which until recently most physicians did not know was contributing to long-term disability.” Another is lumbar fusion surgery, “which most spine surgeons still do not recognize as potentially harmful.” A third is thoracic outlet surgery for disputed neurogenic thoracic outlet syndrome, “a procedure infrequently conducted by a very small percentage of surgeons in each state.”

American College of Occupational and Environmental Medicine endorsed the use of guidelines and has promoted the guidelines concept among its members. “Evidence-based guidelines,” a position statement says, “have changed the nature of medical decision support in recent years. As treatment options have increased in recent years, variation in care has resulted, with availability sometimes driving demand rather than intended outcomes. Evidence-based guidelines ... become a mechanism for minimizing variations in care when properly applied to a given clinical situation.”

So what could be wrong about treatment guidelines?

ACOEM’s reference to “minimizing variance” is a clue as to how guidelines may not perform as workers’ compensation professionals expect. 

The Journal of the American Medical Association ran an article earlier this year in which it describes how there may not be a best care bright path. It cited the American Board of Internal Medicine as identifying 135 health interventions in which evidence suggests equivalence among options in terms of benefits, harms, and costs.

“Rather than justifying a drive for uniformity of care,” the authors wrote, guidelines should “highlight the desirability of (in most clinical situations) tailoring care to patients’ particular circumstances and their individual values and preferences.”

The same article noted that the evidence itself may be weak, and the research flawed. It said, “Studies directly addressing the relevant questions may not have been undertaken, or if they have, they may be small, poorly designed or implemented, show inconsistent results, be limited by publication bias, or have enrolled idiosyncratic populations of questionable applicability.”

Michael Shor, managing director of Best Doctors Occupational Health Institute, notes scenarios where treatment guidelines are not helpful.

He says that they “are written for patients who are in the middle of the bell curve. Treatment runs off the rails when complicating risk factors are not considered in a treatment plan. Unfortunately these become the ‘creeping catastrophic’ cases, which cause much mischief in injury recovery.”

Shor also notes that doctors frequently misdiagnose their patients, which treatment guidelines cannot correct. In the words of one study, “Diagnosis errors are frequent and important, but represent an underemphasized and understudied area of patient safety. Diagnosis errors are challenging to detect and dissect. It is often difficult to agree whether an error has occurred, and even harder to determine with certainty its causes and consequence.”

And, psychological risks are often overlooked, according to Shor. A recent review of surgeons’ use of psychological assessment of surgical candidates included that surgeons “have a long way to go in recognizing and appreciating how much psychological factors and mental health can impact the success of their back surgeries.”

There appears to be no published study of the rate of compliance with treatment guidelines with actual treatment. Nor has anyone shown that adherence to treatment guidelines leads to better end outcomes, meaning return to productive work. It be would be a good idea to get these studies done.

Articles cited:

Djulbegovic D et al, Evidence-based practice is not synonymous with delivery of uniform health care. JAMA. 2014 312(13).

Franklin G et al, Workers' compensation: Poor quality health care and the growing disability problem in the United States. Am J Ind Medicine. Oct 2014.

McLellan R et al, The role of ACOEM’s practice guidelines in treatment decisions. ACOEM.

Schiff D et al, Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. 2005.

Young A et al, Assessment of presurgical psychological screening in patients undergoing spine surgery: use and clinical impact. Journal of Spinal Disorders & Techniques. 2014 27(2).