The ACOEM treatment guidelines for orthopedic patients - How are they working out

Work-injured patients and their physicians encounter some obstacles when they seek coverage for musculoskeletal treatment.

Issue: April 2006

Peter J. Mandell, MD (moderator): In 2004, the State of California conferred upon the American College of Occupational and Environmental Medicine’s Occupational Medicine Practice Guidelines, 2nd Ed., the presumption of correctness when treating work-injured patients. As would be expected from a document written largely by and for physicians doing primary and preventive care in occupational medicine, the focus of the guidelines is on treating acute and subacute industrial injuries and diseases. The guidelines acknowledge such a time frame in the “master algorithm” that prefaces each treatment chapter.

The guidelines also recommend the prompt referral of “red flag” conditions for consultation and/or specialized treatment. This recommendation is certainly reasonable given that musculoskeletal injuries comprise the lion’s share of industrial accidents, and yet the guidelines had little input from orthopedic surgeons. Neither the American Academy of Orthopaedic Surgeons nor any of the multiple orthopedic subspecialty societies are listed in this book as participating specialty societies. Indeed, despite the multiple musculoskeletal body regions discussed in the guidelines, it appears that only a single orthopedic surgeon was clearly acknowledged as a contributor.

Against such a background, is it any wonder that many orthopedic patients in California are having considerable difficulty getting treatment for conditions lingering beyond the subacute phase, as well as for specialized diagnostic tests, office care and surgery?

Peter J. Mandell, MD [photo]
Peter J. Mandell

Let’s talk about how the American College of Occupational and Environmental Medicine (ACOEM) guidelines have impacted the treatment of your patients.

Jan Henstorf, MD: You mentioned that the ACOEM guidelines were not written to recommend treatment for patients with “red flag” conditions, or for those who had failed conservative measures and were subsequently referred to a higher care level. In fact, a California workers’ compensation judge rendered the opinion that, “The ACOEM Guidelines themselves, in the opinion of this ‘WCJ,’ clearly provide for applicability only during the first 90 days following the industrial injury.”

Let me give you an example: A firefighter suffered a work-related injury to both knees and his low back. He was initially treated with conservative measures. Those failed. As a result, over seven years, he underwent six surgeries on his right knee and three on his left knee. Due to the continued progressive pain and disability imparted by his knees, he was referred to my practice in August 2003.

Jan Henstorf, MD [photo]
Jan Henstorf

The patient ultimately requested bilateral total knee arthroplasty. We sought treatment authorization. The reviewing physician said knee replacement was not recommended, based on the clinical rationale, “Services are inconsistent with ACOEM guidelines for the treatment of the accepted industrial injury, based on the information available at the time with insufficient severity of disability documented, insufficient recent diagnostic evaluation documented and inadequate trial of recent nonsurgical treatment documented with no apparent medical contraindication to such treatment.”

That response came despite the fact that we had sent numerous reports to the insurance carrier for review documenting his complete disability since 2000, his continued conservative care, the results of diagnostic evaluations including plain radiographs, MRI scans of the knees, operative reports and intraoperative photographs of the patient’s left knee arthroscopy. Perhaps the reviewer was having trouble because total knee arthroplasty is not discussed anywhere within the ACOEM guidelines.

With appeal, the patient’s surgery was eventually authorized, but not without a painful and frustratingly significant delay for him and significant additional effort on the part of my office in providing a summary and additional copies of all of the previously supplied documentation to support the diagnosis and treatment alternatives. A second review by a different physician reviewer was also required, adding additional time and expense.

Mandell: What is your take on the ACOEM guidelines with regard to upper extremity injuries?

Norman P. Zemel, MD [photo]
Norman P. Zemel

Norman P. Zemel, MD: The ACOEM guidelines for the upper extremity are reasonable for the initial eight weeks of the patient’s complaints. The caveat to this statement is obtaining an accurate diagnosis of the patient’s condition. A complete tear of a ligament in the hand or wrist may require a special imaging study shortly after injury to determine early on whether surgical treatment is necessary. Simply treating a complete ligament tear of the scapholunate joint as a sprain is poor medicine. It prolongs the patient’s time off work and can create permanent disability and loss of wrist function.

The guidelines for early compression neuropathy symptoms are valid as long as there is no muscle atrophy. However, if the patient has symptoms that have been present for several years, the guidelines do not apply.

Exceptions to the guidelines are ever present in musculoskeletal systems. Patients can have a compressive neuropathy in spite of normal electrodiagnostic tests. Dynamic carpal tunnel syndrome is a recognized entity. In my opinion the guidelines are not applicable in recurrent compressive neuropathies following unsuccessful previous surgical treatment. This is a difficult condition and does not respond to the conservative modalities used in the primary (not previously treated) condition.

In my opinion, the ACOEM guidelines have no place in determining the orthopedic postoperative care of a patient — probably because they were largely not written by orthopedic surgeons. Utilization reviewers frequently cite the guidelines as a reason for denial of post-operative physical therapy. I have multiple patients whose necessary postoperative therapy has been denied for this reason. This simply extends their care and in all probability affects the surgical outcome.

Mandell: How do you analyze the impact of the ACOEM guidelines on your practice?

Leslie Kim, MD: The potential for inappropriate use of the guidelines is real, especially when rigid compliance replaces sound judgment. I recently had a phone conversation with a seemingly well-qualified reviewer concerning a patient with clinically diagnosed subacromial impingement syndrome. The discussion devolved into a debate over what constitutes “imaging evidence of a lesion that has been shown to benefit … from surgical repair,” as quoted from the Guidelines. This board-certified orthopedic surgeon acknowledged that the generally accepted indications for arthroscopic decompression were present and, in fact, surgery would probably be offered to the patient in his practice. But he was required to follow the guidelines and therefore denied authorization.

Leslie Kim, MD [photo]
Leslie Kim

More disturbing is another experience cited in a California Medical Association survey, in which a physician reviewer told a respondent that, “the insurance company is looking at his number of denials and if he falls below an undisclosed amount he may lose his job!”

Slavish adherence to guidelines sometimes leads to illogical, if not absurd utilization review decisions. One of my patients had a somewhat protracted recovery due to excess pain, but he agreed to an explicit treatment plan and fixed timetable for his return to work. This plan involved the time-limited use of a single effective analgesic for pain management and supervised exercises in physical therapy, which had already yielded some objective improvement. The therapy would be continued if measurable functional recovery and progress toward his return to work could be demonstrated.

While this plan would seem to satisfy the spirit of the ACOEM pain and functional restoration chapter, it apparently does not satisfy the letter of the guidelines. Treatment was denied, and I was instructed to refer the patient (at far greater time and dollar cost) to a “multidisciplinary care” program at a formal pain management center.

Mandell: Is it the guidelines or those who use them that are to blame for our current problems?

Glenn B. Pfeffer, MD: Overall, the ACOEM guidelines are an admirable attempt to apply treatment parameters to acute orthopedic care. As you mentioned, the guidelines clearly state their purpose and limitations. Unfortunately, many carriers use them not as a guideline but as an edict. This inappropriate use leads to the denial of needed care for the injured worker, often at a time when receiving that care is critical.

I recently operated on an obese woman for an unstable trimalleolar ankle fracture. She tried crutches postoperatively, but fell down. When I requested a wheelchair, I was told that it did not meet ACOEM guidelines. She did poorly.

Glenn B. Pfeffer, MD [photo]
Glenn B. Pfeffer

Another patient developed Complex Regional Pain Syndrome (CRPS) several weeks after surgery and did not have physical therapy approved for two months. Her symptoms never resolved.

Were these denials the fault of the guidelines, or those who misused them? A large percentage of orthopedics, especially chronic care, will never be amenable to guidelines, algorithms or evidence-based medicine. We will have to rely on expert opinion and, more importantly, common sense.

Prior to guideline enforcement, an injured worker had a team of an adjuster, an orthopedic surgeon, and perhaps a nurse case manager to coordinate treatment. They worked together on previous cases and knew how to deliver appropriate and cost-effective care. The team approach was always helpful and often essential.

Several self-insured companies wisely continue with this approach and rely on the doctors in their select medical provider networks to make appropriate medical decisions. Most third-party carriers do not. Anonymous and often biased utilization reviewers call the shots while hiding behind the shield of the ACOEM guidelines.

This distortion of treatment will continue until the State of California enacts stringent regulation of utilization review organizations and the misled carriers who hire them. Until then, frustrated orthopedic surgeons will increasingly drop out of the workers’ compensation system, and injured workers will pay a price that far exceeds anything the guidelines or utilization review may save.

Mandell: Thank you to all of the participants. It looks like we’re in agreement that for many simple orthopedic problems in the acute and subacute phases, the ACOEM guidelines work reasonably well. But there are at least a couple of problems. The guidelines are being used to evaluate care for chronic conditions and “red flag” conditions – areas that the guidelines freely admit they are not equipped to handle. Also, some utilization reviewers are very strictly applying the letter of the guidelines instead of their spirit and intent.

It appears that both utilization reviewers and providers will need to gain a better understanding of the guidelines’ value and limitations so that our patients will get high-quality care delivered expeditiously.