Risk-stratification and provider peer-review as injury management strategies

Dr Andrew Leaver

Discipline of Physiotherapy

Faculty of Health Sciences

The University of Sydney Page 2

Acknowledgements

– National Health and Medical Research Council

– Motor Accidents Authority of NSW

– Motor Accidents Insurance Commission

Research team

Trudy Rebbeck

Andrew Leaver

Aila Bandong

Justin Kenardy

Kathryn Refshauge

Ian Cameron

Geoff Mitchell

Martin Mackey

Simon Willcock

Carrie Ritchie

Jagnoor Jagnoor,

M Sterling

The University of Sydney Page 3

Outline

– T Rebbeck, A Leaver, A Bandong, J Kenardy, K Refshauge, L Connelly, I Cameron ,G Mitchell, S Willcock, C Ritchie, J Jagnoor, M Sterling.

Implementation of a guideline-based clinical pathway of care to improve health outcomes following whiplash injury: Protocol of a randomised controlled trial. Journal of Physiotherapy (In press)

– A Bandong , A Leaver, M Mackey, J Kelly, M Sterling, C Ritchie, T Rebbeck,

– Use of interdisciplinary specialist referral in physiotherapists, chiropractors and osteopaths

– Use of clinical practice guidelines for the management of Whiplash

– Applications of pathway of care for management of non-specific back pain (and other STI) in a workers compensation setting

The University of Sydney Page 4

– Comprises 70% of CTP claims from survivable crashes

– Total costs $950million p.a.

– Around 50% do not fully recover

– Many treatments are ineffective

– Best practice physical therapy not more effective than minimal treatment

Whiplash in a CTP Setting

Low back pain in a workers compensation setting

The University of Sydney Page 5

guideline-based clinical pathway of care

Rebbeck et al (JOP in press)

The University of Sydney Page 6

guideline-based clinical pathway of care

Rebbeck et al (JOP in press)

The University of Sydney Page 7

guideline-based clinical pathway of care

Rebbeck et al (JOP in press)

The University of Sydney Page 8

guideline-based clinical pathway of care

Rebbeck et al (JOP in press)

The University of Sydney Page 9

What determines the level of risk?

– Clinical prediction rule (Ritchie et.al. 2013 Pain)

– Older age

– High initial score on Neck Disability Index

– Hyper arousal

– Positive predictive value 71%

The University of Sydney Page 10

guideline-based clinical pathway of care

Rebbeck et al (JOP in press)

The University of Sydney Page 11

What is a whiplash specialist?

– Practitioner with expertise and experience in managing complex / chronic whiplash and musculoskeletal pain.

– Physiotherapist, chiropractor, osteopath

– Medical practitioner or medical specialist (Rehab/ Occ Health)

– Modelled on WorkCover NSW Independent Consultants

– Recommended by MAA Whiplash Guidelines since 1999.

– Within-discipline referral in allied health is rare

The University of Sydney Page 12

guideline-based clinical pathway of care

Rebbeck et al (JOP in press)

The University of Sydney Page 13

Focus group interviews

– Determine if physical treatments are indicated, referral as indicated

Or

– Advise the local provider about treatment approaches

– Type, amount, duration, goals, outcome measures and review points

Or

– Take over care

The University of Sydney Page 14

Focus groups- within discipline referral

– Current patterns of referral- back to GP

– More physio

– Different physio

– Different physical provider

– Radiology

– Surgical opinion

– Positive attitudes to within-discipline referral

– Shared care model

– Expectation of feedback, guidance

– Expectation of advocacy

– Concern about being sidelined.

The University of Sydney Page 15

Application to workers compensation

– Problem of long term costly claims, chronic MS pain and disability

– Patterns of over-servicing

– Low risk claims

– Referral cycles.

– Validated stratification tools. (Orebro Musculoskeletal Pain Questionnaire, START Back)

– Evidence of stratified care for back pain in other settings

– Existing network of Independent Consultants (WorkCover NSW)

– Clinical pathway – address current inadequacies in management practices

– EARLY use of independent consultants (IC)

– Routine review of IC recommendations and claimant progress

The University of Sydney Page 16

Application to workers compensation- Research

program

– Research team

– Industry partners – professions and insurers

– Expertise and seeding funding

– Program funding

– Development of a pathway for workers compensation

– Pilot testing. Cohort studies

– Demonstrating efficacy. Randomised controlled trial.