Development and evaluation of a categorization methodology for occupational back and shoulder injuries using claims data

Exploration of the Usual Care Pathway for Rotator Cuff Related Shoulder Pain in the Western Australian Workers' Compensation System

PURPOSE

Investigate components of care for rotator cuff related shoulder pain in workers' compensation in relation to claim outcomes (claim duration, total medical spend, total claim cost, return to work outcome).

METHODS

Engagement with (had care, time to care) four components of care (prescribed exercise, imaging, injections, surgery) were obtained from auditing 189 closed workers' compensation files. Associations were analysed between components of care and claim outcomes.

RESULTS

80% received prescribed exercise, 81% imaging, 42% injection and 35% surgery. Median time to imaging (11 days) was shorter than the prescribed exercise (27 days), with injection at 38 days and surgery 118.5 days. With univariable regression analysis higher age, the involvement of legal representation and the presence of rotator cuff pathology from diagnostic imaging (partial thickness tear or full thickness tear) were all associated with increased claim duration, total medical spend, total claim cost and less successful return to work outcomes. After adjusting for these three associations, having an injection or surgery were both positively associated with longer claim duration and greater medical spend, and surgery with greater total claim costs. In general, longer time to receiving components of care was associated with increased claim duration and reduced odds of returning to full duties at work.

CONCLUSION

Early management was not consistent with clinical guidelines for managing workers' compensation rotator cuff related shoulder pain. This may negatively affect claims outcomes.

The Impact of Adherence to Clinical Practice Guidelines on Medical Costs

OBJECTIVE

To examine the association between non-adherence to clinical practice guidelines (CPGs) and medical and indemnity spending among back and shoulder injury patients.

METHODS

Workers compensation claims data was used from a large, US insurer (1999 to 2010). Least square regression models were created to examine the association between spending and guideline-discordant care.

RESULTS

Non-adherence to CPGs was associated with higher medical and indemnity spending for 11 of the 28 CPG indicators. Failure to adhere to the other CPGs did not increase medical or total spending. After covariate adjustment, non-adherence to these 11 CPGs was associated with spending increases that ranged from $16,000 for physical therapy (PT) to $114,000 for surgery.

CONCLUSIONS

Our results demonstrate that failure to adhere to a subset of CPG indicators significantly predicts increased medical and indemnity spending for two important occupational injuries.

Geographic variability of adherence to occupational injury treatment guidelines

OBJECTIVES

To determine the geographic variability and relationship between six occupational injury practice guidelines.

METHODS

Guidelines were developed by an expert panel and evaluated using workers' compensation claims data from a large, national insurance company (1999 to 2010). Percentage compliance for each guideline was adjusted for age and sex using linear regression and mapped by hospital referral region. Regions with the lowest compliance were identified, and correlations between guidelines were calculated.

RESULTS

Compliance to the unnecessary home care guideline showed the lowest geographic variation (interquartile range: 97.3 to 99.0), and inappropriate shoulder bracing showed the highest variation (interquartile range: 77.7 to 90.8). Correlation between the guidelines was weak and not always positive.

CONCLUSIONS

Different guidelines showed different degrees of geographic variation. Lack of correlation between guidelines suggests that these indicators were not associated with a single underlying health care quality or patient severity construct.