REPORT
Health care professionals’ attitudes towards Evidence Based Medicine
Principal investigators:
Nieke Elbers, Ian Cameron
Steering Committee:
Robin Chase, Ashley Craig, Lyn Guy, Ian Harris, James
Middleton, Michael Nicholas, Trudy Rebbeck, John Walsh and
Simon Willcock
Co-investigator
Keri Lockwood
Institutional affiliation:
John Walsh Centre for Rehabilitation Research, Kolling
Institute, Sydney Medical School Northern, University of
Sydney; Northern Sydney Local Health District, St Leonards
NSW 2065 Australia.
Executive Summary
The aims of the current study are twofold: to explore health care professionals’ attitudes to
evidence based medicine (EBM), also called evidence based healthcare in general, and their
attitudes to an EBM tool [name censored] to be applied specifically in a workers’
compensation setting.
The study had two components. First, a validated questionnaire was used to obtain specific
information about practitioners’ knowledge, attitudes and behaviour regarding EBM. Second,
detailed interviews were conducted that were transcribed and coded, to identify themes about
EBM in general and with reference to its application in workers’ compensation.
Two hundred and thirty one health care practitioners (medical and non-medical) completed
the on-line questionnaire and fifteen practitioners completed the detailed interview.
Questionnaire findings
Practitioners (n=231) from a wide range of relevant professional backgrounds participated in
the study. Generally they were very experienced and most provided services to injured
workers. They work in a variety of geographic regions and were split between public and
private practice.
Participants reported that 76% of their clinical practice was evidence based. They indicated to
be well aware of the evidence-base in their field, they also felt confident and motivated to
perform and adopt evidence-based practices. Health care practitioners perceived more
difficulties around applying EBM. General practitioners were the professional group that
reported greatest obstacles to applying EBM, although it should be noted that the number of
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participants was small (n=15) so the results need to be interpreted with caution. Chiropractors
and clinical psychologists reported greatest adherence to EBM.
Participants were well aware of the existing guidelines, considered them useful, and were
using at least one guideline. A quarter of respondents already use a guideline tool. All use
other sources of evidence such as relevant articles or reviews addressing specific clinical
issues. A very wide range of guideline tools are currently being used.
Keywords associated with EBM clustered into positive and negative descriptors. Positive
descriptors were more common and those used repeatedly were: effectiveness, efficacy, best
practice, quality, good/better/improved outcomes. Negative descriptors were: not patient
centred, time consuming, tedious and rigid.
Interview findings
In the qualitative study, participants identified several advantages of evidence based guideline
tools. Such tool would provide guidance for clinicians, potentially reducing inappropriate
treatment or over-servicing and managing patient expectations.
Additionally, there are substantial concerns about how evidence based guidelines will be
applied. Views were expressed that the EBM tool does not adequately reflect the current
evidence based paradigm that environmental and contextual factors (termed by some “social”
factors), and particularly employer behaviour, are important determinants of outcome after
work injury.
There were also views that the approach of the EBM tool would not necessarily work well in
Australia. This related both to treatment and assessment. Views were expressed that the EBM
tool guidelines reflected an American approach that differed to that in Australia.
Another theme identified was timeliness and appropriateness of treatment provision. A
number of participants said that this is currently a practical issue and they wondered whether
use of the EBM tool would assist with this.
Strengths and limitations
The strengths of the study are that a moderately large sample of practitioners was surveyed.
The interviewees had substantial clinical experience, including opinion leaders in the field.
Two potential limitations of the study are: (1) The questionnaire was self-reported, and selfreport of EBM practise or knowledge thereof does not necessarily reflect actually practise of
EBM. (2) Although effort has been made to recruit the general HCP population with opinions
across the spectrum, maybe participants with a certain point of view were more likely to
respond.
Recommendations
A general recommendation includes education about the potential benefits of the EBM tool,
while recognising that their implementation can be challenging in some circumstances. In
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particular, there should be a specific strategy for engagement with general practitioners, the
Australian Medical Association (NSW branch) and the Royal Australasian College of
Physicians. Also, development of an independent advisory committee to provide input on
implementation, use and monitoring of the EBM tool is recommended.
The study furthermore suggests that implementation of EBM tool in NSW may require
additional work on the specific parts of the tool to adapt it to Australian conditions and to
address some content areas, for example pain management. The EBM tool is considered
mainly an approval tool for claims managers. Continuous training of claims managers in
using the tool is considered a necessary element of successful implementation. Promoting use
of the tool by health care practitioners may not be successful because health care
professionals readily access high quality evidence from other sources. The EBM tool can be
seen as a tool for timely treatment approval. It may be best to emphasise this in its
implementation.
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Introduction
This paper is a report of a study investigating the attitudes of health care professionals in New
South Wales to evidence based medicine in the workers’ compensation setting. It was
commissioned by Insurance and Care New South Wales (icare), a statutory corporation
governed by an independent Board of Directors that delivers insurance and care services to
the people of New South Wales.
The problem being addressed in the study concerns the approval process of treatment after a
compensable work injury, which can be cumbersome and take a significant amount of time. It
is burdensome for health care professionals, due to the amount of paperwork required in
order to get treatment approved. It takes time, because claims managers need to make a
decision about the adequacy, appropriateness, and effectiveness of the treatment. This time
delay can mean that the injured person has delayed access to treatment. Disputes arise when a
claims manager denies certain treatments. Other treatments may be provided at a frequency
greater than is clinically justified and this may be seen as over-servicing. There is also
approval of non-evidence based treatments (Duckett & Breadon, 2015). These delays in
treatment approval, disputes, unjust denial of treatment, overtreatment and approval of nonevidence based treatment are undesirable, can be harmful for injured people, and are costly to
the health care system, compensation system, workplaces, and society.
In response to the challenges in the treatment approval process, icare has commissioned a
review of health service provision within the Workers’ Compensation Scheme . A key
recommendation of the review was to introduce an electronic Evidence Based Medicine
(EBM) guideline tool. An EBM guideline tool provides an extensive overview of evidence
based treatments and guidelines for a condition as well as recommendations based on the
quality of evidence. Such a tool could reduce the uncertainty about the adequacy,
appropriateness, and effectiveness of a treatment. Reducing the uncertainty could speed up
the decision-making process and reduce the need to seek second opinions from medical
examiners. Health care practitioners would no longer have to complete additional paperwork
for those evidence based treatments. In general, it could facilitate a common understanding
across those requesting treatment/services (i.e. allied health service providers) and those
approving/ reviewing the services requested (i.e. case managers). This aim of this study was
to investigate attitudes of medical practitioners and allied health professionals to the potential
implementation of an EBM tool in the workers’ compensation setting.
Evidence based medicine is a widely known concept, which has been defined as an approach
to medical practice intended to optimize decision-making by emphasizing the use of evidence
from well designed and conducted research (Sackett, Rosenberg, Gray, Haynes, &
Richardson, 1996). In this seminal paper Sackett and colleagues state “Evidence based
medicine is the conscientious, explicit, and judicious use of current best evidence in making
decisions about the care of individual patients. The practice of evidence based medicine
means integrating individual clinical expertise with the best available external clinical
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evidence from systematic research”. These authors emphasise that clinical judgement is
required in applying the evidence to individual patients.
EBM concepts have been widely applied in the provision of healthcare over the last two
decades and it is now an accepted part of clinical practice for all health professionals. There
have, however, also been some detractors who have criticised EBM (Greenhalgh, Howick, &
Maskrey, 2014; Timmermans & Mauck, 2005). While the title of Greenhalgh and colleagues
paper included “a movement in crisis” they advocate returning to the fundamental principles
of EBM which are “to individualise evidence and share decisions through meaningful
conversations in the context of a humanistic and professional clinician-patient relationship”.
In summary, these critiques declare that while there are potential positives - including
changes in health professional behaviour, improvements in treatments, and less variability
and potential cost containment; there are also negatives such as the idea that EBM is
“cookbook medicine”, the inability to account for individual patient factors, and reductions in
professional freedom.
The EBM tool that icare is considering is [name censored], an American tool developed by
the Work Loss Data Institute (www.worklossdata.com). The EBM tool has two main
functionalities. The first main functionality is that it provides a recommendation whether to
approve certain health care services (treatment, imaging and medications) for a particular
injury. For each injury, EBM tool lists all possible health care services. For each health care
service, EBM tool has summarised the international literature. Based on the level of evidence
in the literature, a multidisciplinary advisory board draws a conclusion about whether a
treatment is recommended or not. Claims managers can use the summary and conclusion to
make a decision about whether or not to (automatically) approve the treatment. If treatment is
not automatically approved “more information” will be requested.
The other main functionality of the tool is that it provides the number of calendar days of
return to work (RTW) by tenth percentiles per injury type. The average is based on local,
national or international claims data. The number of days to RTW can be adjusted based on
demographic characteristics (e.g. age), comorbidities (e.g. psychosocial factors or pre-injury
illnesses), type of job (e.g. light versus heavy duties), and legal representation. Claims
managers can use the information about whether an injured person has surpassed the median
days of return to work for that particular injury as an indication that closer monitoring or a
different approach is needed.
The tool will be used primarily by claims managers. However, for the most optimal flow of
the treatment approval process, it would be desirable that health care professionals support
and use it too. The level of support and uptake of an EBM tool by health care professionals
will be partly dependent on the level of acceptance of EBM principles and their opinion about
the approval process in the Workers Compensation Scheme. There are likely to be other
factors operating, including their past experiences in working with injured workers and usual
practice in the specialty of healthcare in which the person is working.
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The aims of the current study are twofold: to explore the health care professionals’ attitudes
to (1) EBM, in general, and (2) an EBM tool applied in a workers’ compensation setting
specifically. For the attitudes to EBM in general, it was investigated whether there are
differences between clinical specialties in perceived barriers to EBM principles. The barriers
to using clinical guidelines have been argued to be: lack of awareness, lack of familiarity,
lack of agreement, lack of self-efficacy, lack of outcome expectancy, lack of motivation,
inability to reconcile EBM with patient preferences, lack of time, lack of resources, lack of
organisational support, and/or lack of financial reimbursement (Cabana et al., 1999). Based
on a UK study and on clinical experience, it is hypothesised that surgeons will be more
confident in their knowledge of EBM, and may also experience external (financial) barriers to
applying EBM compared to non-surgical specialties (Hadley, Wall, & Khan, 2007). Female
medical practitioners may be more likely to consider patient preferences above evidence.
Further, more work experience will be reflected in greater confidence in knowledge about
EBM (Hadley et al., 2007).
Additionally, how health care professionals feel about an EBM tool being applied in the
workers’ compensation domain is investigated. Their experiences in treating injured workers
in the workers’ compensation setting are also examined. It is investigated whether an EBM
tool would be able to solve some of the problems that health care practitioners may
experience in the workers compensation setting, and whether they would be interested in
using the tool in their clinical practice. It is hypothesised that health care practitioners will be
concerned that implementing such a tool could impinge upon their clinical judgement and
their ability to accommodate patient preferences or cultural beliefs. Furthermore, icare
hypothesised that some health care professionals might feel concerned that an EBM tool
would reduce their financial remuneration or the range and scope of available treatments.
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Methods
The method used is a concurrent mixed methods design. A quantitative study was conducted
to examine whether there were differences in attitudes to EBM between clinical specialties,
demographic and job characteristics. A qualitative study was also conducted to explore how
health care professionals feel about an EBM tool being applied in the workers’ compensation
domain. The quantitative and qualitative studies were conducted simultaneously. The
Northern Sydney Local Health District Human Research Ethics Committee approved the
study protocol.
A)
QUANTITATIVE STUDY
Participant recruitment
The participants were health care professionals with a background in chiropractic, clinical
psychology, general practice, injury management, musculoskeletal medicine, occupational
medicine, pain medicine, physiotherapy, rehabilitation medicine, rheumatology and
orthopaedic surgery. Participants were recruited by nine highly experienced health care
practitioners, who are well recognised in the health care professions under investigation. The
health care practitioners approached other health care practitioners in their network. The aim
was to recruit about 30 participants per clinical specialty. This estimate was based on an
estimate of sufficient numbers to detect major differences between groups combined with
feasibility of recruiting sufficient practitioners from some smaller groups. In case the required
number per group was not achieved, additional participants were recruited through lists of
allied health care professionals on the workers compensation regulator’s website.
Recruitment was achieved by sending invitations by email. If there was no email address
provided, recruitment was via fax. The email or fax contained an invitation to complete the
online questionnaire and the participant information sheet. Recruitment and data collection
occurred between December 2015 and March 2016.
Questionnaire
The questionnaire (see Appendix 1) began with background information about the gap
between evidence and practice and examples of potential barriers from the literature.
First, participants were asked for the percentage of their clinical practice they felt was
evidence based (McColl, Smith, White, & Field, 1998), followed by questions about potential
barriers towards EBM. The EBM questions were clustered in three themes: knowledge,
attitude, and behaviour (Cabana et al., 1999). Knowledge barriers were about awareness of
the evidence. Attitude barriers were about confidence and motivation to perform evidencebased practice. Behaviour barriers were about applying evidence-based treatment. To ease the
interpretation, the barriers were formulated as positive statements. All questions were
presented in a 5-point Likert scale form (1 = strongly disagree, 5 = strongly agree).
Additionally, participants were asked whether they perceived any barriers to using evidencebased guidelines. Then participants were asked whether they used an electronic guideline
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tool. Two open text boxes invited participants to name positive and negative keywords
associated with EBM.
Finally, the participants were asked to indicate their age, sex, clinical specialty, work
experience, work hours, clinical setting, and whether they provided services to the workers’
compensation setting. The questionnaire was programmed in Survey Monkey, which is
online software for creating questionnaires (www.surveymonkey.com).
Data analysis
Descriptive statistics (means and standard deviations (SD), numbers and frequencies) are
presented. One-way ANOVA-tests are used to explore the differences in responses between
clinical specialties, demographic and job characteristics. For significant ANOVA tests,
Fisher's Least Significant Difference (LSD) post hoc analyses were conducted. Statistical
analyses were conducted using SPSS software version 22.
B)
QUALITATIVE STUDY
Participant recruitment
The participants were health care professionals with backgrounds in general practice,
orthopaedic surgery, occupational medicine, rehabilitation medicine, pain medicine,
physiotherapy, chiropractic, or clinical psychology. The inclusion criterion was that the
participant should have had experience with treating patients in the workers’ compensation
system. Interviews were conducted until data saturation was reached. Data saturation is
reached when no new themes emerge. The steering committee members purposefully
recruited participants who were likely to have opinions across the spectrum with reference to
EBM principles (purposeful sampling). Some members of the steering committee were also
interviewed to capture their view of the issues influencing treatment of injured workers. The
potential participants received an email with the participant information sheet. Participants
were asked to sign a confidentiality agreement. Recruitment and data collection occurred in
January to March 2016. Participants were offered a $50 shopping voucher as reimbursement
for their time.
Interviews
The interviews consisted of three parts. Firstly, the participants were asked about their
experience with treating patients in the workers compensation setting. It was specifically
explored whether they perceived differences between workers compensation patients and
non-workers compensation patients regarding delays in treatment, the number of treatment
sessions, treatment content, or the amount of paperwork.
Secondly, it was asked how health care professionals (HCP) would feel about claims
managers adopting an EBM tool. The participants were informed about the two main
functionalities of electronic evidence based medicine tool: i.e. treatment recommendations
and the average number of days to return to work per injury type. Participants were
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interviewed as to their thoughts about the treatment recommendation functionality and the
RTW information, and whether it would have advantages or disadvantages.
Thirdly, it was explored whether health care professionals would use the EBM tool
themselves. They were asked to indicate the current sources they use to look for evidence,
whether the tool would be an addition, what the potential advantages and disadvantages
would be, and whether the subscription costs would influence a decision to subscribe.
Finally, participants were asked for some demographic and job characteristics. As an
example, the interview format for physiotherapists can be found in Appendix 2.
The interview scheme was discussed with the steering committee and pilot tested twice to
measure the duration and to evaluate the content. Based on the test interviews, some minor
changes were made. These involved some information being changed into questions and the
examples in the interview were adapted for each clinical specialty.
The interviews were conducted by the principal investigator [NE] by telephone. The average
duration of the interviews was 45 minutes. Participants signed a confidentiality agreement
before the interview. With consent of the participants, the interviews were audio recorded and
transcribed.
Data analysis
Data was analysed using a grounded theory approach, which involves three sequential phases
of coding: open, axial and selective coding (Strauss & Corbin, 1998). In the open coding
phase, the investigators identified preliminary concepts based on the themes in the interview
scheme. The following label structure was applied, consistent with a framework approach
(Gale, Heath, Cameron, Rashid, & Redwood, 2013):
(1) Experiences with providing treatment in the workers’ compensation setting. Sub
labels were e.g. delays, denial of treatment, disputes and over-servicing.
(2) Opinions about applying the EBM tool in the workers’ compensation setting. The
following sub classification was made: (i) opinions around evidence based medicine
in general, such as a lack of time to apply it, lack of sufficient evidence,
incompatibility with patient preferences, (ii) opinions around the tool, such as it being
an (North) American tool, and around the compensation process, such as the ability of
claims managers to judge the evidence.
(3) Opinions about using the EBM tool in clinical practice, such as whether it would be a
helpful addition to the evidence they already use.
In the axial coding process, the labels were restructured, sub-labels were applied, and new
labels emerged. During the selective coding, all the transcripts were re-analysed based on the
refinement that occurred during axial coding.
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The interviews were analysed in duplicate by three researchers [NE, IC and KL]. During the
cyclic analysis process, the two analysts discussed their findings and, through discussion,
they agreed upon the final set of labels. The interviews were analysed by using the computer
software program Atlas.ti (version 5.2).
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Results
The findings are presented separately for the quantitative and the qualitative study.
A)
QUANTITATIVE STUDY
Participants
In total, 231 participants filled out the survey. In total, approximately 950 email invitations
were sent, so the response rate was approximately 25%. It was noted that the response rate
varied substantially between different professional groups. The most prevalent age group of
participants was between 51-60 year old, two thirds were male, three quarters work in an
urban community setting, half had more than 20 years of work experience and more that 80%
were currently providing services to the workers compensation setting. The characteristics are
shown in Table 1.
Table 1 – Participant characteristics (n=231*)
Main category
Sub category
Age
Sex
Clinical specialty
Clinical setting (1)
Clinical setting (2)
N (%)
18-30 years
31-40 years
41-50 years
51-60 years
> 60 years
Female
Male
Chiropractic
Clinical psychology
General practice
Injury management
Musculoskeletal medicine
Occupational medicine
Pain medicine
Physiotherapy
Rehabilitation medicine
Rheumatology
Surgery, hand
Surgery, orthopaedic
Other
Urban
Rural
Both
Public hospital
Private hospital
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17 (7%)
43 (19%)
54 (23%)
79 (34%)
37 (16%)
83 (36%)
147 (64%)
31 (13%)
34 (15%)
15 (7%)
9 (4%)
6 (3%)
17 (7%)
6 (3%)
37 (16%)
25 (11%)
3 (1%)
3 (1%)
36 (16%)
8 (4%)
169 (73%)
36 (16%)
25 (11%)
27 (12%)
20 (9%)
Work experience
Providing WC services
Community
Multiple settings
<10 years
10-20 years
>20 years
No
Yes
96 (42%)
87 (38%)
41 (18%)
73 (32%)
116 (50%)
39 (17%)
191 (83%)
* 231 participants were included, of which one participant did not complete the demographic
characteristics.
EBM perceptions
On average, participants indicated that 76% of their practice was evidence based. They
indicated that they were well aware of the evidence-base in their field (mean knowledge score
= 4.2 on a scale from 1-5), they also felt confident and motivated to perform and adopt
evidence-based practices (mean attitudes score = 4.2). The participants scored lowest on
behaviour, meaning they perceive some barriers in applying evidence in their clinical practice
in this domain (mean score 3.6). Regarding guideline use, they were well aware of the
existing guidelines, considered them useful, and were using at least one guideline (mean
behaviour score = 4.2).
Table 2 –Evidence Based Medicine perceptions
Mean
(SD)
1. EBM practice
What percentage of the treatments you recommend and/or procedures
you undertake is evidence based?
2. Knowledge
a. I am aware of the evidence based practices in my field
b. I am familiar with the evidence based practices in my field
c. I have enough access to information about evidence based practices
d. I have/make time to keep myself up to date with evidence base
practices
e. I am able to interpret the evidence base from the literature
Mean knowledge score:
3. Attitudes
a. I feel confident that I can perform evidence based practice
b. I believe that evidence based practice leads to improved patient
outcomes
c. I am motivated to adopt evidence based practice
Mean attitudes score:
4. Behaviour
a. It is easy to apply evidence based treatment in my day to day practice
b. I am able to reconcile patient preferences with evidence based
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75.8 (20.0)
4.4 (0.7)
4.3 (0.6)
4.0 (0.9)
3.9 (0.9)
4.1 (0.8)
4.2 (0.6)
4.2 (0.7)
4.1 (0.9)
4.2 (0.8)
4.2 (0.7)
3.5 (1.0)
3.7 (0.8)
practice
c. There are enough resources/facilities (e.g. staff, educational material)
to adhere to evidence based practice
d. I have enough time to apply evidence based treatment
e. My colleagues are supportive of the evidence base in my field
f. In general, in my clinical field, payment systems can influence the
decisions about treatment
Mean behaviour score:
5. Guidelines
a. I am aware of evidence based guidelines available for my speciality
b. I believe evidence based medicine guidelines are useful in my field
c. I usually use at least one evidence based guideline in my practice
Mean guideline score:
Note: The scales ranged from 1-5
3.4 (1.0)
3.7 (1.0)
3.7 (1.0)
3.3 (1.2)
3.6 (0.6)
4.1 (0.8)
4.2 (0.8)
4.2 (0.8)
4.2 (0.6)
In general, health care practitioners perceived significantly more barriers around applying
EBM (Behaviour) than around awareness (Knowledge) and motivation (Attitudes) (Figure 1).
EBM barriers
5
Mean score (scale 1-5)
4.5
4.2
4.2
4
3.7
3.5
3
2.5
2
1.5
1
Knowledge
Attitudes
Behaviour
Figure 1 – Mean score EBM perceptions around knowledge, attitudes and behaviour.
Paired t-test results: knowledge and behaviour (t (230) = 16.4, p < .001), attitudes and
behaviour (t (230) = 17.7, p < .001), knowledge and attitudes (t (230) = -.1.1, p = 271)
Guideline tool
In total, 56 (24%) participants indicated they were using a guideline tool. The guideline tools
that were reported most frequently (i.e. about 3 to 4 times) were CIAP (Clinical Information
Access Portal), The Cochrane Collaboration, Medline, MDguidelines, Therapeutic
guidelines, and UpToDate. The [name censored] was not mentioned. The complete list can be
found in the Table 3. The answers to the question related to which guideline tool they use
(Table 3) involved mentioning agencies/centre, guidelines, a questionnaire, a guideline
evaluation tool, databases, fact sheets, search engines, risk assessment tools and online
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learning sources rather than a guideline tool being defined as an electronic evidence based
guideline tool that provides an extensive overview of evidence based treatments and
guidelines for a condition and provides recommendations based on the quality of evidence..
Table 3 – List of guideline tools being used
Guideline name
ACI (Agency for Clinical Innovation)
Acute pain guidelines (Australia)
ANZCA (Australian and New Zealand College of Anaesthetists) guidelines
AGREE (http://www.agreetrust.org/practice-guidelines/)
APS (Australian Psychological Society) guidelines
ATSDR (Agency for Toxic Substances and Disease Registry)
BMJ best practice
CDC (Centres for Disease Control and Prevention) from The National Institute for
Occupational Safety and Health (NIOSH) - USA
CIAP (Clinical Information Access Portal) http://www.ciap.health.nsw.gov.au/*
Cochrane Collaboration
Decision tool for mandatory reporting with child at risk issues
Dynamed
Evidence based assessment questionnaires eg Oswestry Disability Index
IASP (International Association for the Study of Pain) fact sheets
MAA whiplash guidelines
McMaster
MDguidelines (or ReedGuidelines)
Medline
Medical Disability Advisor
NHMRC (https://www.nhmrc.gov.au/guidelines/search)
NICE (National Institute for Health and Care Excellence)
National Drug and Alcohol Research Centre (https://ndarc.med.unsw.edu.au/)
NPS MedicineWise
OrthoEvidence
OrthoGuidelines (AAOS - American Academy of Orthopaedic Surgeons)
PEDro (Physiotherapy Evidence Database)
PsycBite (Psychological Database for Brain Impairment Treatment Efficacy)
PTSD Guidelines
Pubmed
RACGP (The Royal Australian College of General Practitioners) Red book
Scat 3 concussion tool
SCIRE (Spinal Cord Injury Research Evidence)
Stroke Guidelines
Therapeutic Guidelines
UpToDate (Clinical practice guidelines for specific conditions)
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Various online learning/ Continuing Professional Development activities
VuMedi (video education platform for doctors to improve patient care)
VTE (Venous Thromboembolism Prevention) risk assessment tool
Wikipedia
* CIAP is available only via individual log in for employees of public hospitals
Keywords
The positive keywords associated with EBM could be clustered in five themes (bold themes
are mentioned the most):
(i)
Research terms, e.g. demonstrated, double blind, effectiveness, efficacy,
hypothesis testing, level 1 study, meta-analysis, peer-review, proof, randomised
controlled trials, reduced bias, science, strong correlation, structured, systematic,
thorough, transparency, valid.
(ii)
Clinical terms, e.g. best practice, easy, efficient, empowering, faster recovery,
gold standard, high quality care, hope, minimise harm, overcoming restrictions of
personal experience, good/better/improved outcomes, patient-centred, safe,
justification, supported.
(iii)
Adjectives, e.g. correct, decisive, defensible, essential, important, relevant,
reliable, superior, progressive, rigorous, reassuring.
(iv)
Tools, e.g. Cochrane, UpToDate.
(v)
Costs, e.g. cost effective, fiscally efficient, utility.
The negative keywords associated with EBM were clustered in a similar structure, resulting
in the following overview (bolded keywords were mentioned more frequently):
(i)
Research/quality terms: unclear evidence, exclusion criteria, biased, assessing
quality of evidence is difficult, lack of evidence, hard to find, data, statistics,
disagreement in literature, publication bias, absence of evidence is not evidence of
absence, depends on who is interpreting the results, unsure, generalisation,
insufficient proof, level 4 study, hard to prove, inconclusive
(ii)
Clinical terms: lack of flexibility, gap between individual patient and research,
can’t cover newer treatment, does not address the issues that present in private
practice, narrow minded, unavailable, not easy to follow, patient preferences,
colleague resistance, case study, time consuming, individual differences,
disconnected to helping patients, clinical experience ignored, not patient centred,
not confident in delivery, loss of alternatives, not applicable to all clinical groups,
hard to apply, rarely adhered to in public health, clinically impractical, over
directive, training required, unnecessary for the experienced practitioner
(iii)
Adjectives: limited, ubiquitous, irritating, dumbed-down, naïve, bad, bureaucratic,
anecdotal, constraining, dictatorial, opaque, inflexible, unrealistic, weak, vague,
poorly attuned, unreasonably, restrictive, unsuitable, unknown, difficult, tedious
(iv)
Nouns: buzzword, cookbook, cookie cutter, dogma, failures, recipe based,
scepticism, white coats, laboratories, big Pharma + corruption, zealot behaviour,
slow, rigid
(v)
Costs: finance-dependent, costly, expensive
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Some words were mentioned both as a positive- and a negative keyword, e.g. average, double
blind, proven, meta-analysis, nil, pie in the sky. Some of the negative EBM keywords
potentially referred to usage in the workers compensation setting specifically, such as:
funding, surveillance activities dangerous if required by law, not understood by insurers.
Differences between clinical specialties
To analyse whether there are differences between clinical specialties and their perceived
perceptions to EBM, some clinical specialties were clustered to create larger groups.
Musculoskeletal medicine, occupational medicine and rheumatology formed one cluster; pain
and rehabilitation medicine formed a second cluster. The clinical specialties in the ‘other’
category were put in the designated category. This led to the following 8 categories and
participant numbers (Table 4):
Table 4 - Reclustering clinical specialties
Clinical specialties
N
Chiropractic
Clinical psychology
General practice
Injury management
Musculoskeletal & Occupational medicine & Rheumatology
Pain & Rehabilitation medicine
Physiotherapy
Surgery
31
36
15
14
26
31
37
39
There were differences between clinical specialties and all EBM themes (adherence,
knowledge, attitudes, behaviour and guidelines). Statistics of the overall differences between
the clinical specialties are shown in Table 5. The largest difference was in the EBM
behaviour category, which is the extent to which EBM principles and guidelines can be
applied in routine clinical practice.
Table 5 – Differences between clinical specialties
EBM Themes
F
Df
p-value
EBM adherence in clinical practice (%)
EBM knowledge (mean score)
EBM attitudes (mean score)
EBM behaviour (mean score)
EBM guidelines (mean score)
2.2
3.0
2.7
4.7
3.3
7, 221
7, 221
7, 221
7, 221
7, 221
.034
.005
.010
< .001
.002
Post hoc analyses revealed that general practitioners scored lowest on EBM adherence and on
the other EBM themes, i.e. knowledge, attitudes, behaviour and guidelines (Figure 2 and 3).
Note that this should be interpreted with caution because the number of GP respondents is
16
only 15. Chiropractors and clinical psychologists reported the highest percentage of EBM
undertaken in clinical practice (Figure 2).
EBM adherence
Percentage of clinical practice EBM
100
90
83
82
80
70
78
74
72
67
70
74
60
50
40
30
20
10
0
Figure 2 – Percentage of clinical practice adherence to EBM, divided by clinical specialism.
Horizontal line displays the average percentage across all clinical specialties.
17
5.0
Mean score (scale 1-5)
4.5
4.0
4.24.3
3.6
EBM perceptions
4.4
4.2
3.8
4.0
3.9
3.73.7
4.14.2
Attitudes
4.34.4
Behaviour
4.3
4.0
3.8
3.4
3.5
3.0
4.14.2
Knowledge
3.5
3.5
3.5
2.9
2.5
2.0
1.5
1.0
Figure 3 – Mean score on EBM perceptions (knowledge, attitudes, and behaviour),
differentiated by clinical specialty
Because health care practitioners in general scored lower on behaviour items compared to
knowledge and attitude items, the responses to the individual behavioural items were
investigated specifically. There were significant differences between clinical specialties to
most behaviour items (Table 6).
Table 6 – Differences between clinical specialties on behavioural items
F
Df
p-value Mean
1) EBM is easy to apply
Chiropractic
Clinical psychology
General practise
Injury management
Musculoskeletal/Occupational
medicine/Rheumatology
Pain & Rehabilitation medicine
Physiotherapy
Surgery
4.4
2) EBM can be reconciled with
2.3
7, 221
7, 221
18
Standard
deviation
< .001
.030
3.7
3.7
2.7
3.4
3.6
0.8
0.9
1.0
0.9
1.0
3.1
3.9
3.4
0.9
0.9
1.0
patient preferences
Chiropractic
Clinical psychology
General practise
Injury management
Musculoskeletal/Occupational
medicine/Rheumatology
Pain & Rehabilitation medicine
Physiotherapy
Surgery
3) Enough resources to adhere to
EBM
Chiropractic
Clinical psychology
General practise
Injury management
Musculoskeletal/Occupational
medicine/Rheumatology
Pain & Rehabilitation medicine
Physiotherapy
Surgery
4.2
4) Enough time to apply EBM
Chiropractic
Clinical psychology
General practise
Injury management
Musculoskeletal/Occupational
medicine/Rheumatology
Pain & Rehabilitation medicine
Physiotherapy
Surgery
2.1
5) Colleagues are supportive of
EBM
Chiropractic
Clinical psychology
General practise
Injury management
Musculoskeletal/Occupational
medicine/Rheumatology
Pain & Rehabilitation medicine
6.0
7, 221
7, 221
7, 221
19
3.9
3.9
3.2
3.2
3.8
0.6
0.8
0.9
1.0
0.7
3.6
3.7
3.6
0.8
0.8
1.0
3.5
3.8
2.5
3.1
3.2
1.0
1.0
1.0
0.9
1.1
3.1
3.8
3.5
1.0
0.9
1.0
3.9
3.7
3.0
3.3
3.6
0.7
1.0
1.1
1.1
0.9
3.6
4.0
3.7
0.9
1.0
1.0
3.5
4.2
2.9
3.4
3.7
0.9
0.8
1.2
1.1
1.0
4.0
0.6
< .001
.031
< .001
Physiotherapy
Surgery
6) In general in my field payment
systems can influence decisions
about treatment
Chiropractic
Clinical psychology
General practise
Injury management
Musculoskeletal/Occupational
medicine/Rheumatology
Pain & Rehabilitation medicine
Physiotherapy
Surgery
1.4
7, 221
4.1
3.4
0.9
1.0
3.1
3.4
3.4
3.9
3.0
1.1
1.2
1.4
1.0
1.3
3.7
3.4
3.2
0.9
1.4
1.2
.192
Difference in demographic and job characteristics
There were no differences in most of the demographic and job characteristics regarding EBM
themes. Only those working in rural areas perceived more EBM barriers around attitudes than
in urban areas. Statistics are reported in Table 7.
Table 7 – Differences in urban/rural/both
EBM Themes
F
Df
p-value
EBM adherence in clinical practice (%)
EBM knowledge (sum score)
EBM attitudes (sum score)
EBM behaviour (sum score)
EBM guidelines (sum score)
0.3
1.1
3.6
3.0
2.8
4, 227
4, 227
4, 227
4, 227
4, 227
.751
324
.029
.052
.061
Post hoc analyses showed that health care practitioners in rural areas scored lower on whether
they believed EBM leads to better patient outcomes (F(2,227) = 3.3, p = .040) and whether
they were motivated to adopt EBM (F(2,227) = 3.8, p = .024) compared to health care
practitioners who worked in urban settings (Figure 4).
20
EBM attitudes
5.0
Mean score (scale 1-5)
4.5
4.3 4.2 4.3
4.0
4.1
3.8 3.9
4.2 4.1 4.2
3.5
Urban
3.0
Rural
2.5
Both
2.0
1.5
1.0
Confidence
Belief
Motivation
Figure 4 – Mean score on EBM attitude items, categorised by whether the heath care
practitioners worked in an urban or rural setting, or in both (urban and rural setting).
B)
QUALITATIVE STUDY
Participants
In total, 15 participants were interviewed; 9 men and 6 women. All of them provided services
to the workers compensation system, ranging from 1 patient per week to 40 per week,
although for some it was in the past (one reported 5 years ago). Participant characteristics are
displayed in Table 8.
Table 8 - Characteristics of interviewees (n=15)
Characteristic
Sex
Age group
Work hours (clinical work)
Work experience in clinical practice
Professional background
Female
Male
30 to 39
40 to 49
50 to 59
60 plus
Part-time
Full-time
<10 y
10-20 y
>20 y
Physiotherapy
Psychology
General practice
Injury management
Occupational medicine
21
Number
6
9
3
3
6
3
6
9
3
4
8
5
2
1
1
1
Clinical setting (1)
Clinical setting (2)
Pain & Rehab
Surgery
Urban
Rural
Both
Public
Private
Public & Private
Community
3
2
11
1
3
3
6
4
2
Findings
The findings are clustered in three themes: (1) experience of treating patients in the workers’
compensation setting, (2) the EBM tool in the workers compensation setting, and (3) the
EBM tool in clinical practice. These themes are based on a predetermined framework that
was designed to capture issues that are important to the use of the EBM in the New South
Wales workers’ compensation system. Table 9 provides a summary of the issues detected
within the three themes. This is shown after the narrative explanation of the themes.
1) Experience of treating patients in the workers compensation system
Approval of treatment: delays, denials and disputes
Participants were asked whether the approval of treatment was an issue in treating patients in
the workers compensation setting. They stated that most of the time it was not an issue. Acute
treatment approvals are appropriate. Denial of treatment occurred in 10-20% of the cases.
These 10-20% are usually the patients with comorbidities and pre-existing conditions, or
people with secondary issues, such as a marriage conflict, or an alcohol problem associated
with the injury. Comorbidities, pre-existing conditions and secondary conditions are the
claims most likely to cause disputes and discussion.
Pain management was raised as a particular area of difficulty by a number of participants.
One rehabilitation physician said “In the last five to 10 years there’s [been] almost no
approval for treatment. (…) I’m really limited to using medication for pain relief rather than
actual treatment.” An occupational physician thinks the interdisciplinary pain management
programs are the ones that insurance companies seem to baulk at the most. It also may be
difficult to get patients into pain clinics, as a general practitioner noted: “Pain clinics are
citadels.”
Denial of treatment seems to be dependent on the claims manager or the insurance company.
The insurance companies look at things differently or the case managers had a different
assessment tool or approach, which some interviewees found difficult to explain to patients.
A number of interviewees were concerned that the case manager often had limited experience
and did not adequately appreciate all relevant issues for the injured worker. Another issue
with reference to the claims manager was that there can be multiple changes to the claims
22
manager over the course of the claim and that can cause difficulties for the worker and the
health professionals.
Whether the treatment approval process involved delays for the patient was dependent on
whether there is a dispute about whether the treatment was going to be approved. “If it is
clear cut then they will get the approval pretty quickly within a couple of weeks,” said an
orthopaedic surgeon, The delay lies in the fact that health care practitioners have to wait for
the approval. In general, the health care practitioners have a system in place to facilitate the
process, such as secretarial staff sorting things out prior to seeing the patient. Delays were a
big problem in pain management. A rehabilitation physician said that some have to wait one
or two years without even physiotherapy.
Paperwork
Interviewees were asked how they experienced the paperwork involved with treatment
approval in the workers compensation setting. All interviewees agreed it involves extra
paperwork in terms of the assessment report, the treatment planning and the frequency of
progress reports versus somebody who was not in a scheme. Although, some of the health
care practitioners just dictate their normal letter that they write to every patient, and that letter
is usually sufficient for WorkCover as well. “Sometimes they do come back with extra
questions which I have to answer, which I’m happy to do. (…) but in most cases that [letter]
is usually enough” (surgeon). “It’s really just a question of filling in forms and if practitioners
have a well-constructed management plan those forms are not difficult to fill out”
(physiotherapist).
The forms may not be as useable for and applicable to all clinical specialties. A general
practitioner: “GPs are not in the position to determine how much a patient can lift at work,
whether it should be five kilos or two kilos and how many hours they can stand or sit for. A
lot of those things are not particularly relevant and we are not occupational physicians. So
GPs leave it blank”. The paperwork was also considered inefficient. A lot comes in via faxed
or written letter. The GP interviewee suggested it would be much more efficient if claims
managers would organise an appropriate time to call rather than correspondence going back
and forth. Or preferably early case conferencing, in which everybody is sitting in the room,
including the patient, to discuss realistic goals and concerns. “There’s nothing more
frustrating than spending time making a recommendation and then you just get a letter back
from the insurer saying respond immediately but we want to know this, this, this and this. It’s
delaying tactic. (…) It’s quite common to get three pages of questions about a patient, when
really the issue is something that’s a specific issue.”
Payment system: over-servicing and financial aspects
There were a range of views about the financial aspects of treating workers compensation
patients. An injury management physician estimated that only 1 in 15 to 20 cases is over
serviced – “the claims managers know what to look out for”. Other interviewees identified, in
some cases, that over-servicing might be occurring because it is financially beneficial. A
physiotherapist said: “I don’t think anyone would admit it to being financial, I think people
23
would say it was in the patients’ best interest, but certainly some physiotherapists would see
some people more frequently than others. That might be their professional belief; obviously
they are going to gain financially from that, if it is a private practice.” Another
physiotherapist said their practice provides more treatment to workers compensation because
they get the complicated cases. “So our WorkCover patients tend to be long-lasting.”
“Over-servicing”, or inappropriate servicing, might also occur because involvement in the
system leads to different expectations: “A WorkCover patient is more likely to use all they’re
entitled to”. A psychologist highlighted that the way the system is set up is that you need to
prove injury, which is in conflict with getting better: “They [i.e. the patients] are wanting
people to believe that they have been bullied. (…) If they have overcome their depression,
and they will, does that mean that it wasn’t such a big deal, that it wasn’t that bad?” A
physiotherapist emphasised that health care practitioners are not (generally) deliberately overservicing. It comes from a mechanism in which the physiotherapist does not get the desired
outcome, so sends the patient back to the GP and the GP sends them back to the
physiotherapist telling them to ‘keep going’.
Regarding the “over-servicing” of MRIs, a physiotherapist said that 90% of MRIs are
inappropriate. The GP interviewee said that doctors often deny an investigation that the
patient may have asked about, but there is a fear of being sued if they do this and the patient
receives the wrong treatment. He acknowledged that doctors should not use an MRI as a
fishing trip and argues for better guidelines: “If you give somebody a good guideline as to
justifying their decision, and [after] explaining that to the patient, the patient insists that they
still want an MRI anyway, the doctor should be able to say that and say ‘Well you’re going to
have to take it up with the insurer because I’m following the guidelines’.”
Several interviewees said it was not financially beneficial to treat workers compensation
patients, because the consultation fee is much lower than the regular fee, and also the extra
time spent on it is not remunerated. “You don’t make money on WorkCover” (GP). In
contrast, the surgeons said WorkCover cases pay well, i.e. about the same as private patients,
and that some surgeries such as knee arthroscopy and chondroplasty are more lucrative.
Overall interviewees showed some lack of trust in the workers compensation process, and
some interviewees were critical of the system. “There is a fatigue factor in being
micromanaged by claims managers who are children in the industry” (injury management
specialist).
2) EBM tool in the workers compensation setting
This theme was subdivided into (i) opinions about the EBM principles, which the tool is
based on, (ii) opinions about the EBM tool being used in the workers compensation setting.
(i)
Opinions about EBM principles
24
Interviewees were very familiar and informed on the topic of evidence based medicine. They
could see both positive and negative aspects in using it and all subscribed to applying it as
much as was feasibly possible in their clinical practice.
Critical appraisal and guideline development
There were some concerns about how the “evidence” was interpreted, meaning how the
evidence was identified, synthesised and converted into recommendations. The process of
synthesis and development of recommendations is potentially contentious. “If you look at the
[Cochrane Collaboration] reviews for neck pain and the reviews for back pain (…) they are
more explained by the differences between Cochrane back group and the neck group and the
personalities in them than the differences between neck pain and back pain as a disease”
(physiotherapist). “You actually have to look at the quality of the evidence, how it was done,
whether it is applicable to your population” (general practitioner).
Patient variability
Another concern with EBM mentioned by the participants is whether it is applicable to the
individual patient. Evidence is usually based on averages and selective populations, whereas
“most people I see are not a ‘one size fits all’. Very frequently, some other extraneous thing
is going on, like they [have] got a particularly awkward job, [or] they [have] got one of these
other things, comorbid conditions” (general practitioner).
Clinical judgement
All interviewees agree with importance of EBM but some of them also point out the
importance of clinical judgement, which is generally considered part of the appropriate use of
EBM. “There is value in clinical opinions as well, based on experience, years of experience,
so we do tend to discuss what treatments we might use outside of the world of RCT’s and
meta-analyses and discuss those techniques and how they might work” (physiotherapist).
Another physiotherapist said: “Until it is proven otherwise it doesn’t mean that what you are
doing is incorrect.” The general practitioner noted: “You need clinical experience to interpret
the psycho-social tools. They need to be assessed by somebody who actually knows the
patient well.”
Patient preferences
Some interviewees confirmed that patients sometimes have different preferences than EBM.
For example, in physiotherapy some patients want to be massaged, or in psychology some
patients may not like the style of Cognitive Behavioural Therapy. However, the interviewees
felt confident in explaining that a non-evidence based treatment is not going to be effective.
The surgeons said patients usually follow the surgeon’s advice, although some patients waive
a surgery, even if the surgeon advised it. A rehabilitation physician reported that some Asian
patients have a preference to use medication and hands-on therapy rather than active
exercising. He therefore preferred best practice rather than just evidence based medicine. “It
needs to be treatment that is acceptable to the patient.”
Quality of the evidence: outcomes, not enough evidence, biased
25
Some participants were concerned with the quality of the current evidence base. The evidence
may not include meaningful outcomes. “Most research evidence is around outcomes related
to reducing pain, reducing disability, but not necessarily curing it” (physiotherapist), and a lot
of patients expect to fully recover (occupational physician). What is a good outcome, and for
who? A good outcome for the patient may not be a good outcome for the insurance company
or the treatment provider.
Not enough evidence is seen as a problem. For example, chronic pain and rehabilitation
programs were considered to be poorly studied. Some types of treatments are more likely to
be investigated than others. For example, a psychologist said there is a strong interest for
therapies that are manualised and that can be delivered quickest, such as CBT, but that
implies that other potentially good therapies are less likely to be investigated. A general
practitioner commented that, with reference to low back pain, many of the cited studies are
flawed in their methodology and conclusions, which means that they have relevance in
community based primary care. An occupational physician emphasised that “absence of
evidence does not mean evidence of absence.”
Private versus public setting
One orthopaedic surgeon spoke about a potential difference between the private and the
public setting. He said that he and most of his colleagues are trying to provide clinical
services in keeping with the best evidence, especially in the public settings. According to
him, this is because there is a much stronger peer review and peer pressure than in the private
hospital. There was support from others for these statements.
(ii)
Opinions about the EBM tool in the workers compensation setting
First, the advantages of the tool are described, and then the concerns will be discussed. ‘The
tool’ refers to [name censored], although the specific brand name was not used in the
interview.
Advantages
Trust and guidance for clinicians
With reference to positive aspects, interviewees recognised that the tool would generate trust:
“You’re automatically approving sessions so that’s really making a clear statement to the
physiotherapy profession that ‘we trust your judgement and we trust that you’re going to do
the right thing and we don’t have to micro-manage your practice’ ” (physiotherapist). It can
guide the clinician, but only if it is used flexibly. If it is presented as a computer making
decisions, it would raise resistance. If something is more out of range, it should still be
discussed openly.
The advantage of the tool is that it creates a framework. “It places a mark in the sand. It’s sort
of saying this is a reasonable ballpark to be operating in.” But it is important to keep
reviewing the information. It was noted that a unique characteristic of the tool is that it is the
26
first tool that indicates how many treatment sessions are actually supported by evidence. The
tool will improve the performance of doctors who don’t currently follow any sort of EBM.
By indicating how many treatment sessions on average are effective for a typical patient, the
tool provides an opportunity to monitor, detect and prevent chronic disability.
Limiting over-servicing
Several participants said that the tool might limit over-servicing or inappropriate servicing.
One of the physiotherapists said that it would be good if the tool would provide
recommendations around how to order MRIs and who they should be ordered for, (and
when). Another physiotherapist said that, for cases with high numbers of treatments, the tool
could assist in dissecting the modalities of the treatment and provide explanations as to why
that number of treatment sessions is not reasonable. One of the surgeons said the tool would
help to get rid of advising knee arthroscopy for degenerative meniscal tears, for example.
Patient expectations and claimant monitoring
The tool could assist with managing patient expectations. “You can set the timeframes in the
patient’s minds whether they are ahead or behind of schedule” (surgeon). This mirrors the
current interest in health literacy and its impact on patient behaviour. Another participant
suggested the tool can also alter the claims manager’s attitude. Claims managers are often
under a great deal of pressure to close a case. “If they have actually got that data in front of
them, they might understand ‘Well okay, you are tracking well’ or ‘there are barriers to this
patient returning to work, so what can we do about that?’ ”
Concerns
Individual differences and psychosocial factors
Interviewees raised questions whether the tool would take into account individual differences
and psychosocial factors. Those psychosocial factors, such as whether the patient enjoys
work, and whether they feel that they’re being supported by their boss are often much better
predictors of the outcome than the nature of the injury itself. Some patients do not fit any
specifically pre-arranged EBM program. Several interviewees were worried that the tool
would only approve the minimal number of sessions, and that it would not take into account
the workplace issues, or perhaps the personality disorder of the patient. The tool must take
into account the type of work and the duties performed, to be helpful as well as psycho-social
factors. Most patients are not ‘average’, and the reported average days of RTW in the tool
will not work for individuals: some of them will be back at work a lot sooner than others. It
was considered important to have room for discussion, not a rigid system. These issues are
significant and emerged strongly from the qualitative data.
Quality of evidence in EBM tool
Some interviewees made comments about the quality of evidence in the tool. One of the
psychologists noted that the evidence was quite broad. For example, the treatment
recommendations for depression do not make a distinction between whether somebody has
had a head injury versus a different injury. An injury management specialist said it is not
27
possible to cover all the evidence. Participants were also concerned whether the right
assessment scales were used. The tool should not only use physical measurements, but tools
should take into account the patients’ perception related to the severity of their pain and its
effects. Another critique was that a lot of the pain studies quoted were very old, from 1998,
2003, 2005.
A rehabilitation physician was concerned about the treatments for which there is a lack of
evidence, because then insurance companies can say that there is no evidence. However, the
fact that it is not published does not mean that it does not work. Also, some treatments might
have good evidence, but if only 1 out of 100 go back to work, the insurer may not approve
the program. Finally, some interviewees were worried that the insurance companies will be
selective with choosing the evidence.
Threat to autonomy
There was concern that the tool would be a threat to the autonomy of the clinician. “This is
taking away the ability of the practitioner to kind of consider those things themselves by just
putting them into boxes and saying, right, if you are not back at work by this time, we are
going to stop paying.” (GP). A physiotherapist expressed the concern that the profession is
going to be dictated to by other people, and that the tool is recipe driven and too prescriptive:
“Where is it going to end, technicians doing our job.” Other interviewees used words like “a
cookbook approach” and “encyclopaedia of injury”. Some interviewees stated that clinical
reasoning is required to adequately apply guidelines.
Timeliness and risk assessment
Several comments were made that the number of days given as to the expected time to return
to work were not particularly useful. An example of this is pain management. For lower back
pain the tool says 90% of patients would be back at work after 39 days and yet a pain
management specialist usually sees patients for the first time long after that. For pain
management programs, the tool recommends intervention as early as 3 to 6 months postinjury, but this is considered “a time waster and kind of missing the boat as there are
psychological and social factors that you can pick up on very early on” (rehabilitation
physician).
A number of participants mentioned the lack of (up to date) risk assessment in the EBM tool.
Risk assessment tools, such as the Orebro Musculoskeletal Pain Questionnaire (OMPSQ;
(Linton, Nicholas, & MacDonald, 2011), identify workers at risk of limited or delayed
recovery. Their view is that these tools should be applied soon after injury and not later when
problems were evident. It was suggested that the appropriate health professionals should be
getting referrals earlier, not just referrals after everything else has been tried. Claims
managers are not referring early because they try to avoid costs, but early referral could
actually save costs in some situations.
This theme for appropriate assessment and timing of treatment for injured workers was a
strong one, particularly in relation to pain management. A number of interviewees put the
28
view that workers at risk of prolonged recovery are readily identified soon after injury and
early intervention with reference to psychosocial approaches to pain management should be
provided much earlier than is implied by the tool.
American tool
Some interviewees expressed their concerns about the tool being developed in the USA. It
was acknowledged that the recommendations are based on international evidence, but one of
the surgeons thought the American advisory board would favour American research: “Those
studies will probably get a higher weighting than European studies.” One of the psychologists
said that Europeans are a lot more tolerant of psychodynamic treatments and sensory based
treatments. Participants also commented that America has a different health care system and a
more litigious society compared to Australia. They also raised the issue of differences
between state legislation and practices in Australia.
Claims managers using the EBM tool
There were concerns about how claims managers would apply the tool. A number of
interviewees felt that claims managers would require thorough training. Claims officers are
often “fairly junior, non-clinically trained, looking for a tick box sort of modality. They get
only half a day training, which is not enough to make sensible decisions” (general
practitioner). Several interviewees noted the stressful work environment of claims managers,
the high case load and a high turnover, which was considered part of the problem in workers’
compensation in general. One rehabilitation physician was worried claims managers would
abuse medical evidence. “They can always word it to suit themselves as a rationale for not
approving treatment.” The danger could be that a non-medical person might not understand
what is going on, and just put the claimant into a box saying, if you are not back at work by
this time, we are going to stop paying for treatment. They should not blindly follow the tool.
An injury management specialist was worried the insurers will use the tool as a “big stick”.
Other comments
Other comments about the tool were that it might streamline the initial process but not the
continuing process. This tool seems to automatically approve treatments for those cases that
were non-problematic already, and the 10-20% difficult cases will still have ‘red flag’
treatments that will be disputed. The tool may cover people that fit the plan, but these patients
are not the problem.
It was often noted that there needs to be continuous updates of the evidence to make things
better. “It’s not just a set, assess and forget, it’s actually it’s an ongoing process of review and
reassessment.” (rehabilitation physician)
One physiotherapist asked whether the tool’s number of days to RTW takes into account
whether the RTW was sustainable or not, or whether the patient was back but with reduced
hours. A psychologist wondered if the RTW days were with or without intervention.
29
A physiotherapist doubted whether the tool would be able to prevent over-servicing. “It
would prohibit approval of MRI’s but then solicitors can still say just go ahead and get it
anyway, we’ll claim the cost back.” The tool may also not necessarily prevent nonrecommended treatment, because health care practitioners do not tend to go into detail about
the management plan.
An injury management specialist said WorkCover have tried these tools before and keep
trying other things as well, but they are not necessarily making the system any better.
Several participants mentioned the important role of the employer in the recovery process of
the injured worker. “If the workplace is not helpful or facilitating in RTW, if they are too
rigid or obstructive, then it doesn’t matter how good the treatment is, the worker is unlikely to
go back to work” (pain management). It was stated that the EBM tool does not allow this
important factor to be addressed.
Some participants raised particular issues with reference to specific recommendations. In
particular, a number of participants had the opinion that the recommendations around the
treatment of back pain were not adequately evidence based and, on occasions, recommended
approval of non-evidence based treatments or investigations.
One rehab physician suggested that the tool could be used to collect information about
treatment outcomes, which over time could provide low level evidence.
3) EBM tool in current clinical practice
Current evidence sources
Evidence based medicine resources the participants currently use are guidelines which were
health discipline specific (e.g. PsycBITE, Equip) or broader, such as the Cochrane Library or
the United Kingdom National Institute of Clinical and Care Excellence (NICE) guidelines.
Other EBM resources were conferences, journals, Medline, colleagues, textbooks, and
teaching. One physiotherapist found it easy to keep up to date with the literature, because she
is actively involved in the profession, is going to conferences, and did research herself.
Another physiotherapist found it really helpful that his current practice has a structured
educational program and an open format in which current treatments are discussed. Only one
participant had used the specific EBM tool under investigation.
EBM tool in clinical practice
Several participants felt that an advantage of the tool for clinical practice is that it has the
potential to guide the therapist, to track the recovery progress, and the return to work journey.
It can help the therapist to communicate with the patient, in giving the patient a valid
prognosis and expectation of recovery. The therapist can set a timeline, a target, short-term
and long-term goals, and if the patient is not progressing, they can work out why.
30
A physiotherapist argued that the tool will mostly be useful in the communication with
insurers, because of the need to convince a third party. In his opinion the general population
of healthcare practitioners are not accountable. Also the number of days to RTW is not
transferable to the general population because workers compensation patients generally take
longer to recover. This has been observed in multiple situations and it is generally accepted
that compensation schemes often act to slow recovery.
Other interviewees thought it may not be specific enough for their particular specialty. “It is
not giving me information that I can’t already obtain elsewhere” (psychologist). She
suggested it may be good for specialists who do not necessarily have access to a lot of
databases themselves. One surgeon was of the opinion that it is only useful for case managers
who don’t have a scientific background. “It won’t be useful for me because I’m the first line
clinician and the patient’s in front of me and if I decide that this patient needs surgery then
I’ll ask for it.”
Subscription cost
Participants expressed varying opinions as to whether they would be prepared to subscribe to
the tool, which would cost $350 AU per year, per clinician. One physiotherapist said the cost
is more than reasonable for a private clinic. Another interviewee thinks that clinicians will
see it as a tool that benefits only the insurer, and will therefore be reluctant to pay for it.
Other interviewees would be reluctant because there are other tools available that are free and
because it doesn’t add to the information that is already available. Again another
physiotherapist thinks WorkCover will make practitioners pay for it: “if you don’t pay, you
can’t treat WorkCover patients”.
Table 9 - Summary of Qualitative Interviews by Theme
Theme
Experience of
treating patients in
the workers
compensation
system
Issue
Approval of treatment: delays,
denials and disputes
Paperwork
Payment system:
- over-servicing
31
Comment
Generally treatment approval is
not a major problem for the
80% of patients that recover as
expected, but it is a problem in
pain management and for the
20% of patients that do not
recover as expected
Treatment approval in the
workers compensation setting
leads to additional, or
inappropriate paperwork,
which is seen as a problem
Acknowledgement that over-
servicing occurs
-
financial aspects
Level of remuneration for nonprocedural work is inadequate
EBM tool in the
Opinions about EBM
workers
Critical appraisal and guideline
The interpretation of evidence
compensation setting development
is dependent on who does the
interpretation. It is also
important to critically look at
the population on which the
evidence is based
Patient variability
Patient variability is hard to
incorporate into guidelines
Clinical judgement
Patient preference
Quality of the evidence
Public and private sectors
Clinical judgement is
important and will be needed
Some patients prefer to have
non evidence based treatments
but in general those patients
can be convinced to value
EBM
For many topics there is
insufficient evidence available
or the evidence is not
replicated, or very specific to
certain populations
Use of EBM may be more
widespread in the public
healthcare sector
Opinions about the EBM tool in the workers compensation setting
Advantages tool
Trust and guidance for clinicians
Tool can have a positive effect
for clinicians
Preventing over-servicing
Tool could prevent overservicing
Tool may assist with managing
patient expectations
Patient expectations and claimant
monitoring
Concerns tool
Individual differences and
psychosocial factors
32
Tool may inadequately
consider individual differences
and psychosocial factors
Quality of evidence in EBM tool
Tool may not consider latest
evidence
Threat to autonomy
Some practitioners will
perceive the tool as being a
threat to autonomy, expressing
the concern that the tool may
overpass clinical judgement
Tool may inadequately
prioritise timely treatment, and
may not adequately assessed
risk of prolonged recovery
American cultural and health
system background of the team
evaluating the evidence could
lead to problems in the
Australian context
Inexperience or limited
training for claims managers
could lead to rigid usage and
unfair denials
 Tool won’t assist with the
20% most problematic
cases
 Concerns about how the
tool defines return to work:
sustained/full time
 Tool does not recognise
employer factors that
prolong return to work
Evidence is sourced from
profession specific guidelines
and conferences, journals,
colleagues, textbooks, and
teaching
Tool can be advantageous in
terms of guiding the therapist,
but it will mostly be beneficial
in communication with
insurers. In general, clinicians
already have/use more specific
guidelines
Some think the subscription
cost is ok, but most would not
Timeliness and risk assessment
American tool
Claims managers using the EBM
tool
Other issues
EBM tool in clinical
practice
Current evidence sources
EBM tool in clinical practice
Subscription cost
33
pay as they can access
guidelines free of charge
Discussion
This mixed methods study provides important insights into health practitioners’ knowledge,
attitudes and behaviours with reference to evidence based health care concepts and materials.
The questionnaire showed substantial experience and use of evidence based materials in the
context of injured workers. The interviews provide detailed insights into the assessment and
treatment of injured workers and also the Workers Compensation scheme broadly.
Quantitative findings
The quantitative study showed a high level of acceptance of evidence based healthcare and
reported that 76% of their clinical practice was evidence based. Previous research suggests
that 60-70% of health care practitioners adheres to EBM (Grol & Wensing, 2004). The high
level of knowledge suggests that there is no need for further education around EBM.
The study also showed that there were differences between clinical specialties and EBM
behaviour. These differences may stem from different treatment contexts and how issues are
presented by patients to these health professionals. For example, practitioners that are more
aware of the injured worker in their wider context, meaning their family, past health and
coping styles might perceive more barriers around applying EBM due to the concerns raised
in the qualitative part, that is, that an EBM guideline might not take into account individual
patient differences and psychosocial factors.
The finding that there were major differences between clinical specialties and between
practitioners working in rural versus urban settings in about EBM behaviour suggests that
specific professional groups and rural practitioners may require more support to apply
evidence based guideline tools. Ideally, end users of guidelines should be involved in their
development and application, which will assist in identifying the most relevant issues which
can aid in acceptance of the guidelines.
Qualitative findings
The themes that emerged were in keeping with a range of views that have been publicised
about evidence based healthcare (Greenhalgh, Howick, & Maskrey, 2014). Many
interviewees very aware of both the positives and negatives of evidence based medicine. All
accepted its general principles, but many provided critiques in relation to specific issues.
Interviewees particularly emphasised the importance of clinical judgement when applying the
evidence to individual patients, reflecting Sackett’s original and accepted definition of
evidence based medicine (Sackett et al., 1996). Another important theme in relation to EBM
was that lack of evidence of treatment effectiveness is not the same as evidence of lack of
treatment effectiveness. (For example, there are no randomised controlled trials for parachute
effectiveness (Smith & Pell, 2003)). For many areas of healthcare and particularly treatment
34
of injuries and pain there is limited research. Based on these concerns, an important
recommendation would be that the EBM tool should not be applied rigidly, that clinical
judgement is considered, and that lack of evidence does not imply that the treatment is going
to be denied.
Participants expressed three main concerns about the EBM tool1 being applied in the
workers’ compensation setting. Firstly, views were expressed that the EBM tool does not
adequately reflect the current evidence based paradigm that environmental and contextual
factors (termed by some “social” factors) and particularly employer behaviour are the most
important determinants of outcome after work injury. Recognition of work dissatisfaction,
family problems at home, and existing illness in older workers is considered vital to enable a
pro-active, comprehensive biopsychosocial approach.
Secondly, there was serious concern that the approach of the EBM tool does not necessarily
relate well to an Australian context, with reference to both assessment and treatment
concepts. It is recommended that commonly used assessment concepts, such as evaluation of
pain and disability, or assessment tools in Australia, such as the Orebro Musculoskeletal Pain
Questionnaire and the Depression, Anxiety and Stress Scale (DASS), be considered for
inclusion in the EBM tool. In Australia, there is a growing practice of using tools such as
these to identify injured workers at risk of limited recovery soon after injury. Also, the
Australian (and international) concepts for the management of acute and chronic pain, which
differ markedly, could be better reflected in the tool.
Thirdly, a strong theme was timeliness of treatment provision. A number of participants said
that timely treatment is inadequately prioritised. This was raised particularly with reference to
pain management. The tool can be optimised with reference to adapting it to recent
Australian pain studies and to addressing the importance of early referral, especially in pain
management.
The responses in this project suggest two meta themes that could explain some of the
responses, both general and specific, to the EBM tool. Firstly, past negative experiences with
the workers compensation system seem to have an impact on how implementation of the
EBM tool is viewed. Some interviewees were sceptical as they stated that similar initiatives
to improve the scheme had been undertaken in the past, and these did not succeed (either).
Strategies will need to be developed to address the issues that were raised and to remove
scepticism.
Secondly, EBM is a very familiar concept to health practitioners and they correctly are not
certain how the EBM tool will improve their individual practice. It may be preferable to view
the EBM tool as a mechanism to support quick and correct approvals for treatment for injured
1
In the interview, participants were informed about the modalities of the EBM tool without mentioning the
name.
35
workers, rather than a clinical guideline. Promoting the tool as a treatment approval tool
might aid its acceptance.
Strength and limitations
The strengths of the study are that a moderately large sample of practitioners was surveyed.
They had substantial clinical experience and are likely to be opinion leaders with reference to
clinical issues.
Potential limitations are the limited number of responses from some professional groups. In
some cases this is related to the relatively small number of practitioners in a particular area,
for example, musculoskeletal medicine and overlap with other clinical specialties. In
particular, it is difficult to be sure that the opinions expressed in both parts of this study are
representative of the opinions of general practitioners overall.
Furthermore, self-report of EBM practise (or knowledge thereof) does not necessarily mean
clinicians actually practise EBM. Also, the possibility of selection bias of the participating
practitioners is also acknowledged. This may have resulted in respondents having a greater
knowledge and use of EBM than practitioners generally.
Recommendations
In addition to more specific recommendations already stated above, the following general
recommendations could be made.
Considering the complexity and sensitivity of treatment approval process in the workers’
compensation setting, it would be worthwhile to consult and engage with specific
professional groups to further understand the issues. A relevant group is the Australian
Medical Association (NSW Branch), which is known to have interests in this area. Other
potential groups for consultation are the Royal Australasian College of Physicians, the Royal
Australian College of General Practitioners (the NSW Faculty), the Australian Orthopaedic
Association, and the Australian Physiotherapy Association. General practice opinion leaders
will be able to identify and address specific issues such as the application of evidence based
healthcare in general practice.
It is very likely that issues will arise in the implementation and use of EBM tool that will
require further discussion. An independent advisory committee can assist in addressing issues
as they arise, in monitor use of the tool and to provide a mechanism of feedback from
practitioners that are using the tool. There will need to be implementation and educational
strategies for roll out to the evidence based clinical guideline tool. Specific strategies for
general practitioners and for practitioners working in rural and regional areas may be needed.
The EBM tool is more likely to be used as an approval tool for claims managers rather than
being useful for health care professionals. Careful training of claims managers will be a
necessary element of successful implementation. Communication between claims managers
and health care practitioners is crucial. Health professionals can find decisions from a third
36
party difficult to understand in the context of individual patient factors. Promoting use of the
tool by health care practitioners might not be successful because health care professionals can
easily access high quality evidence from other sources and they are used to using these
sources.
There should be a program developed to involve stakeholders in the implementation of the
evidence based clinical guideline tool. This should include examples of how the tool could be
used to benefit the injured worker through timely and evidence based examples with
clinically credible scenarios. Further strategies could involve developing an initiative that
promotes the potential benefits of the EBM tool, i.e. approval of treatments with reasonable
evidence of effectiveness, and of low risk low cost treatments for which evidence of
effectiveness is minimal.
37
References
Cabana, M. D., Rand, C. S., Powe, N. R., Wu, A. W., Wilson, M. H., Abboud, P.-A. C., &
Rubin, H. R. (1999). Why don't physicians follow clinical practice guidelines?: A
framework for improvement. JAMA, 282(15), 1458-1465.
Duckett, S. P., & Breadon, D. R. (2015). Questionable care: Avoiding ineffective treatment.
Retrieved from
Gale, N. K., Heath, G., Cameron, E., Rashid, S., & Redwood, S. (2013). Using the
framework method for the analysis of qualitative data in multi-disciplinary health
research. BMC Medical Research Methodology, 13(1), 117.
Greenhalgh, T., Howick, J., & Maskrey, N. (2014). Evidence based medicine: a movement in
crisis?
Grol, R., & Wensing, M. (2004). What drives change? Barriers to and incentives for
achieving evidence-based practice. Medical Journal of Australia, 180(6 Suppl), S57.
Hadley, J. A., Wall, D., & Khan, K. S. (2007). Learning needs analysis to guide teaching
evidence-based medicine: knowledge and beliefs amongst trainees from various
specialities. BMC Medical Education, 7(1), 11.
Linton, S. J., Nicholas, M., & MacDonald, S. (2011). Development of a short form of the
Örebro Musculoskeletal Pain Screening Questionnaire. Spine, 36(22), 1891-1895.
McColl, A., Smith, H., White, P., & Field, J. (1998). General practitioners' perceptions of the
route to evidence based medicine: a questionnaire survey. BMJ, 316(7128), 361-365.
Sackett, D. L., Rosenberg, W. M., Gray, J., Haynes, R. B., & Richardson, W. S. (1996).
Evidence based medicine: what it is and what it isn't. BMJ: British Medical Journal,
312(7023), 71.
Smith, G. C., & Pell, J. P. (2003). Parachute use to prevent death and major trauma related to
gravitational challenge: systematic review of randomised controlled trials. BMJ:
British Medical Journal, 327(7429), 1459.
Strauss, A. L., & Corbin, J. M. (1998). Basics of qualitative research: techniques and
procedures for developing grounded theory. Thousand Oaks, CA: Sage.
Timmermans, S., & Mauck, A. (2005). The promises and pitfalls of evidence-based
medicine. Health Affairs, 24(1), 18-28.
38
Appendix 1 – Internet Survey
Questionnaire EBM
Thank you for participating in a short questionnaire investigating your attitudes towards
evidence based medicine.
The questionnaire will consist of statements about evidence based medicine, followed by
some questions about demographic and job characteristics.
The questionnaire is anonymous.
-------------------------------------------------< page break >--------------------------------------------
Evidence Based Medicine (page 1 out of 2)
In health care, there is often a gap between evidence and practice. A Lancet publication in
2003 reported that about 30–40% of patients do not receive care according to present
scientific evidence (Grol & Grimshaw, 2003). In 2015, a report by the Grattan institute stated
that far too many people get a treatment they should not get, even when the evidence is clear
that it is unnecessary or doesn’t work (Duckett & Breadon, 2015).
A simple example of the gap between evidence and practice is hand hygiene in hospitals. The
evidence says that hand hygiene among personnel could prevent about 15% to 30% of the
hospital acquired infections. Nevertheless, in practice, hand hygiene compliance is generally
less than 50% (Huis et al, 2012).
Health care professionals report various barriers to applying evidence based medicine in their
practice. Some say they are not fully aware of the current evidence, others feel it is difficult
to reconcile evidence based medicine with patient preferences, others say they don’t have
enough time to apply evidence based medicine, or that it is financially advantageous to apply
non-evidence based practices.
In this questionnaire, we would like to investigate whether you perceive any barriers to
applying evidence based practices and evidence based guidelines. We also want to
investigate whether you use an evidence based guideline tool to get better access to evidence
based medicine.
39
Practices
The first questions are about adopting evidence based practices. Applying evidence based
practices means that you use peer reviewed publications, or other peer reviewed materials,
that provide evidence for the effectiveness for specific treatments.
1. On estimation, what percentage of the treatments you recommend and/or
procedures you undertake is evidence based? (0-100%)
…..
strongly disagree
disagree
neutral
agree
strongly agree
2. Knowledge
To what extent do you agree with the following statements about your knowledge
of evidence based practices?
1.
2.
3.
4.
I am aware of the evidence based practices in my field
I am familiar with the evidence based practices in my field
I have enough access to information about evidence based practices
I have/make time to keep myself up to date with evidence base
practices
5. I am able to interpret the evidence base from the literature
strongly disagree
disagree
neutral
agree
strongly agree
3. Attitudes
To what extent do you agree with the following statements about your attitudes
towards evidence based practices?
1. I feel confident that I can perform evidence based practice
2. I believe that evidence based practice leads to improved patient
outcomes
3. I am motivated to adopt evidence based practice
4. Behaviour
To what extent do you agree with the following statements about your behaviour
towards evidence based practices?
40
strongly disagree
disagree
neutral
agree
strongly agree
1. It is easy to apply evidence based treatment in my day to day practice
2. I am able to reconcile patient preferences with evidence based
practice
3. There are enough resources/facilities (e.g. staff, educational material)
to adhere to evidence based practice
4. I have enough time to apply evidence based treatment
5. My colleagues are supportive of the evidence base in my field
6. In general, in my clinical field, payment systems can influence the
decisions about treatment
Guidelines
The next questions are about adopting evidence based guidelines. Using evidence based
guidelines means you use publications that summarise the evidence related to multiple
aspects of a health condition and suggest treatments that make up multiple components of a
management plan. Examples of evidence based guideline are the NSW Whiplash Guideline
and the Australia and New Zealand Guideline for Hip Fracture Care.
strongly disagree
disagree
neutral
agree
strongly agree
5. To what extent are you adhering to evidence based guidelines?
1. I am aware of evidence based guidelines available for my speciality
2. I believe evidence based medicine guidelines are useful in my field
3. I usually use at least one evidence based guideline in my practice
Tool
The next question is about whether you use an electronic evidence based guideline tool. An
electronic evidence based guideline tool gives you an extensive overview of evidence based
treatments and guidelines for a condition and provides recommendations based on the quality
of evidence. Examples of evidence based guideline tools are the ODG (Official Disability
Guidelines), or MD Guidelines.
41
6. Do you use an electronic evidence based guideline tool?
o No
o Yes, I use the following tool: ……
Keywords
7. What positive keywords do you associate with Evidence Based Medicine?
…………..
8. What negative keywords do you associate with Evidence Based Medicine?
………….
-------------------------------------------< page break >--------------------------------------------------Demographic and Job characteristics (page 2 out of 2)
The final questions are about your age, gender and clinical experience.
9. What
o
o
o
o
o
is your age?
18-30
31-40
41-50
51-60
> 60
10. What is your gender?
o Female
o Male
11. What
o
o
o
o
o
o
o
o
o
is your clinical specialty?
chiropractic
clinical psychology
general practice
injury management
musculoskeletal medicine
occupational medicine
pain medicine
physiotherapy
rehabilitation medicine
42
o
o
o
o
o
12. What
o
o
o
rheumatology
surgery, hand
surgery, orthopaedic
surgery, other
other …….
is the number of years of work experience in your current field of practice?
< 10 years
10 - 20 years
> 20 years
13. Do you work part time or full time?
o Part time
o Full time
14. Do you work in an urban or rural clinic?
o Urban
o Rural
o Both
15. In what clinical setting do you work?
o Public hospital
o Private hospital
o Community
o Multiple settings
16. In the last 12 months, did you provide services to the workers’ compensation scheme?
o Yes
o No
This is the end of the questionnaire.
Thank you very much for participating!
43
Appendix 2 – Interview scheme
EBM interview scheme (physiotherapists)
Confidentiality agreement has to be signed by participant upon agreeing to participate
Introduction (5 minutes)
Thank you for participating in an interview about evidence based medicine in a workers’
compensation setting. The interview will take about 30-45 minutes. We are offering a 50
dollar Coles voucher for your time.
Before we start, we would like to ask:
Q: Is it okay if I record this interview for transcription purposes? The transcripts will be
stored anonymously, meaning without your name being recorded. Your identity will not be
revealed in any report
Background
The background of the study is that Insurance and Care NSW (icare), which is the former
WorkCover in NSW and also the funding agency of this study, has recognised that the
approval process of treatment after injury is cumbersome and takes a lot of paperwork and
time. To reduce delays and paperwork, icare wants to introduce an electronic evidence based
medicine (EBM) tool, which will allow auto-approval of treatment based on evidence. The
tool will be used by icare scheme agents and preferably also by health care professionals. I
would like to explore how you feel about this initiative.
This interview will consist of three parts: (1) I would like to ask you about your experiences
with treating patients in the workers’ compensation, in general, and the approval of treatment,
in specific (2) I would like to ask you how you would feel about an EBM tool being applied
in the workers’ compensation setting, and (3) I would like to discuss whether you would be
interested in using an EBM tool yourself. I end the interview by asking you some
demographic and job characteristics.
Q: Before we start the interview, do you have any questions?
1. Providing treatment in workers’ compensation setting (5 minutes)
First, I would like to hear your experiences with providing treatment in a workers’
compensation setting.
Q: How many workers’ compensation patients do you see?
Q: Are there any differences between treating an injured person in a workers’
compensation setting compared to the public setting? What are the advantages or
disadvantages?
 Delays in treatment approval? over-servicing treatment? Paperwork? Disputes?
Treatment outcomes? Financially more interesting?
44
2. EBM in a workers’ compensation setting (10 minutes)
Insurance and Care NSW (icare) is considering the use of an electronic EBM tool to
automatically approve treatment to speed up the current treatment approval process. Before I
ask your opinion about that, I will briefly explain what the EBM tool involves.
The most important functionality of an EBM tool is that it provides a recommendation
about whether or not to approve a certain treatment for a particular injury. The
recommendations are made based on a summary of all published studies about this treatment.
The evidence is evaluated, and an overall conclusion is drawn.
For example, recommended treatment for low back pain would be:
Physical therapy
(PT)
Recommended. There is strong evidence that physical methods, including
exercise and return to normal activities, have the best long-term outcome in
employees with low back pain. See also Exercise. Direction from physical and
occupational therapy providers can play a role in this, with the evidence
supporting active therapy and not extensive use of passive modalities. The
most effective strategy may be delivering individually designed exercise
programs in a supervised format (for example, home exercises with regular
therapist follow-up), encouraging adherence to achieve high dosage, and
stretching and muscle-strengthening exercises seem to be the most effective
types of exercises for treating chronic low back pain. (Hayden, 2005) Studies
also suggest benefit from early use of aggressive physical therapy (“sports
medicine model”), training in exercises for home use, and a functional
restoration program, including intensive physical training, occupational
therapy, and psychological support. (Zigenfus, 2000) (Linz, 2002) (CherkinNEJM, 1998) (Rainville, 2002) Successful outcomes depend on a functional
restoration program, including intensive physical training, versus extensive
use of passive modalities. (Mannion, 2001) (Jousset, 2004) (Rainville, 2004)
(Airaksinen, 2006) One clinical trial found both effective, but chiropractic was
slightly more favorable for acute back pain and physical therapy for chronic
cases. (Skargren, 1998) A spinal stabilization program is more effective than
standard physical therapy sessions, in which no exercises are prescribed. With
regard to manual therapy, this approach may be the most common physical
therapy modality for chronic low back disorder, and it may be appropriate as a
pain reducing modality, but it should not be used as an isolated modality
because it does not concomitantly reduce disability, handicap, or improve
quality of life. (Goldby-Spine, 2006) Better symptom relief is achieved with
directional preference exercise. (Long, 2004) As compared with no therapy,
physical therapy (up to 20 sessions over 12 weeks) following disc herniation
surgery was effective. Because of the limited benefits of physical therapy
relative to "sham" therapy (massage), it is open to question whether this
treatment acts primarily physiologically, but psychological factors may
contribute substantially to the benefits observed. (Erdogmus, 2007) In this
RCT, exercise and stretching, regardless of whether it is achieved via yoga
classes or conventional PT supervision, helps improve low back pain.
(Sherman, 2011) Compared with usual care, treatment of new LBP with early
PT resulted in a statistically significant improvement in disability. The PT
involved only four sessions over 3 weeks, consisting of manipulation and
exercise, among patients being seen for LBP in a primary care setting. The
45
authors suggest that the potential benefits of early physical therapy should be
evaluated in light of the time and effort required to participate in physical
therapy. (Fritz, 2015) See also specific physical therapy modalities, as well as
Exercise; Work conditioning; Lumbar extension exercise equipment; McKenzie
method; Stretching; Aquatic therapy; Group physical therapy. [Physical
therapy is the treatment of a disease or injury by the use of therapeutic
exercise and other interventions that focus on improving posture, locomotion,
strength, endurance, balance, coordination, joint mobility, flexibility, activities
of daily living and alleviating pain. (BlueCross BlueShield, 2005) As for visits
with any medical provider, physical therapy treatment does not preclude an
employee from being at work when not visiting the medical provider,
although time off may be required for the visit.]
Active Treatment versus Passive Modalities: The use of active treatment
instead of passive modalities is associated with substantially better clinical
outcomes. In a large case series of patients with acute low back pain treated
by physical therapists, those adhering to guidelines for active rather than
passive treatments incurred fewer treatment visits, cost less, and had less
pain and less disability. The overall success rates were 64.7% among those
adhering to the active treatment recommendations versus 36.5% for passive
treatment. (Fritz, 2007) The most commonly used active treatment modality is
Therapeutic exercises (97110), but other active therapies may be
recommended as well, including Neuromuscular reeducation (97112), Manual
therapy (97140), and Therapeutic activities/exercises (97530). A recent RCT
comparing active spinal stabilization exercises (using the GDS or Godelive
Denys-Struyf method) with passive electrotherapy using TENS plus microwave
treatment (considered conventional physical therapy in Spanish primary care),
concluded that treatment of nonspecific LBP using the GDS method provides
greater improvements in the midterm (6 months) in terms of pain, functional
ability, and quality of life. (Arribas, 2009) In this RCT, two active interventions,
multidisciplinary rehab (intensive, bio-psychosocial PT) and exercise (exercises
targeted at trunk muscles together with stretching and relaxation), reduced
the probability of sickness absence, and were more effective for pain than
self-care advice at 12 months. (Rantonen, 2012)
Patient Selection Criteria: Multiple studies have shown that patients with a
high level of fear-avoidance do much better in a supervised physical therapy
exercise program, and patients with low fear-avoidance do better following a
self-directed exercise program. When using the Fear-Avoidance Beliefs
Questionnaire (FABQ), scores greater than 34 predicted success with PT
supervised care. (Fritz, 2001) (Fritz, 2002) (George, 2003) (Klaber, 2004)
(Riipinen, 2005) (Hicks, 2005) Without proper patient selection, routine
physical therapy may be no more effective than one session of assessment
and advice from a physical therapist. (Frost, 2004) Patients exhibiting the
centralization phenomenon during lumbar range of motion testing should be
treated with the specific exercises (flexion or extension) that promote
centralization of symptoms. When findings from the patient’s history or
physical examination are associated with clinical instability, they should be
treated with a trunk strengthening and stabilization exercise program. (FritzSpine, 2003) Practitioners must be cautious when implementing the wait-andsee approach for LBP, and once medical clearance has been obtained, patients
46
should be advised to keep as active as possible. Patients presenting with high
fear avoidance characteristics should have these concerns addressed
aggressively to prevent long-term disability, and they should be encouraged to
promote the resumption of physical activity. (Hanney, 2009)
(….)
Physical Therapy Guidelines –
Allow for fading of treatment frequency (from up to 3 or more visits per week
to 1 or less), plus active self-directed home PT. Also see other general
guidelines that apply to all conditions under Physical Therapy in the Preface,
including assessment after a "six-visit clinical trial".
Lumbar sprains and strains:
10 visits over 8 weeks
Sprains and strains of unspecified parts of back:
10 visits over 5 weeks
Sprains and strains of sacroiliac region:
Medical treatment: 10 visits over 8 weeks
Lumbago; Backache, unspecified:
9 visits over 8 weeks
Intervertebral disc disorders without myelopathy:
Medical treatment: 10 visits over 8 weeks
Post-injection treatment: 1-2 visits over 1 week
Post-surgical treatment (discectomy/laminectomy): 16 visits over 8 weeks
Post-surgical treatment (arthroplasty): 26 visits over 16 weeks
Post-surgical treatment (fusion, after graft maturity): 34 visits over 16 weeks
Intervertebral disc disorder with myelopathy
Medical treatment: 10 visits over 8 weeks
Post-surgical treatment: 48 visits over 18 weeks
Spinal stenosis:
10 visits over 8 weeks
Sciatica; Thoracic/lumbosacral neuritis/radiculitis, unspecified:
10-12 visits over 8 weeks
Curvature of spine:
12 visits over 10 weeks
Fracture of vertebral column without spinal cord injury:
Medical treatment: 8 visits over 10 weeks
Post-surgical treatment: 34 visits over 16 weeks
Fracture of vertebral column with spinal cord injury:
Medical treatment: 8 visits over 10 weeks
Post-surgical treatment: 48 visits over 18 weeks
Torticollis:
12 visits over 10 weeks
Other unspecified back disorders:
12 visits over 10 weeks
Work conditioning (See also Procedure Summary entry):
10 visits over 8 weeks
MRI would be recommended in certain circumstances:
MRIs (magnetic
Recommended for indications below. MRI’s are test of choice for patients
47
resonance
imaging)
with prior back surgery, but for uncomplicated low back pain, with
radiculopathy, not recommended until after at least one month conservative
therapy, sooner if severe or progressive neurologic deficit. Repeat MRI is not
routinely recommended, and should be reserved for a significant change in
symptoms and/or findings suggestive of significant pathology (eg, tumor,
infection, fracture, neurocompression, recurrent disc herniation). (Bigos,
1999) (Mullin, 2000) (ACR, 2000) (AAN, 1994) (Aetna, 2004) (Airaksinen, 2006)
(Chou, 2007)
(……)
Recent research: More than half of requests for MRI of the lumbar spine are
ordered for indications considered inappropriate or of uncertain value,
pointing to evidence of substantial overuse of lumbar spine MRI scans. For
family physicians, only 34% of their MRI scans were considered appropriate vs
58% of those ordered by other specialties. On the other hand, the vast
majority of MRIs ordered for headaches, 83%, were deemed appropriate.
(Emery, 2013) This study casts doubt on the value of post-op spinal imaging
for patients with sciatica, because it could not distinguish those with a
favorable clinical outcome from those with persistent symptoms. Disk
herniation was visible in 35% of patients with a favorable outcome and in 33%
with an unfavorable outcome, and nerve root compression was present in
24% of those with a favorable outcome and in 26% of those with an
unfavorable outcome. They concluded that the MRI scan does not have any
discriminatory power at all. Irrelevant findings have the potential to frighten
patients and initiate cascades of unnecessary testing or intervention, with
occasional risks. The study showed that neither a herniated disk nor the
presence of scar tissue on MRI was associated with patient outcome, but
these findings may lead to unnecessary further imaging and surgery. (el
Barzouhi, 2013) A JAMA article on worsening trends for low back treatment
found that there was an escalation in the use of MRI or CT, from 7.2% in 1999
to 11.3% in 2010, while imaging in the acute care setting provides neither
clinical nor psychological benefit to patients with routine back pain. The
general feeling among physicians was that patients may equate getting MRIs
with being synonymous with good medical care, which could drive doctors to
try to improve patient satisfaction. (Mafi, 2013) Clinicians should be aware of
the diagnostic limitations of MRI as there is significant variability in the
interrater and intrarater agreements of MRI in assessing different
degenerative conditions of the lumbar spine. (Fu, 2014) The impact of
nonadherent early MRI includes a wide variety of expensive and potentially
unnecessary services, and occurs relatively soon post-MRI, with early MRI
having as much as 55 times the likelihood of advanced imaging, injections, and
surgery within six months post-MR. (Webster, 2014)
Indications for imaging -- Magnetic resonance imaging:
- Thoracic spine trauma: with neurological deficit
- Lumbar spine trauma: trauma, neurological deficit
- Lumbar spine trauma: seat belt (chance) fracture (If focal, radicular findings
or other neurologic deficit)
- Uncomplicated low back pain, suspicion of cancer, infection, other “red
flags”
48
- Uncomplicated low back pain, with radiculopathy, after at least 1 month
conservative therapy, sooner if severe or progressive neurologic deficit.
- Uncomplicated low back pain, prior lumbar surgery
- Uncomplicated low back pain, cauda equina syndrome
- Myelopathy (neurological deficit related to the spinal cord), traumatic
- Myelopathy, painful
- Myelopathy, sudden onset
- Myelopathy, stepwise progressive
- Myelopathy, slowly progressive
- Myelopathy, infectious disease patient
- Myelopathy, oncology patient
- Repeat MRI: When there is significant change in symptoms and/or findings
suggestive of significant pathology (eg, tumor, infection, fracture,
neurocompression, recurrent disc herniation)
Examples of non-recommended treatments for back pain are:
Magnet therapy
Low level laser
therapy (LLLT)
Not recommended. Biomagnetic therapy is considered investigational. The
data from randomized, placebo-controlled clinical trials fails to demonstrate
that biomagnetic therapy results in improved health outcomes for any type of
pain. Biomagnetic therapy has been proposed for the relief of chronic painful
conditions; it is proposed that magnets, worn close to the skin, create an
electromagnetic field within the body that suppresses pain. The theory is that
the magnetic field causes potassium channels to be stimulated, producing
repolarization or hyperpolarization. Biomagnetic therapy has been
investigated for various types of pain, including peripheral neuropathy,
chronic low back pain, carpal tunnel syndrome, plantar heel pain and hip and
knee pain due to osteoarthritis. (Collacott-JAMA, 2000) (Maher, 2004)
(BlueCross BlueShield, 2005) See also the Low Back Chapter.
Not recommended. There has been interest in using low-level lasers as a
conservative alternative to treat pain. Low-level lasers, also known as "cold
lasers" and non-thermal lasers, refer to the use of red-beam or near-infrared
lasers with a wavelength between 600 and 1000 nm and Watts from 5-500
milliwatts. (In contrast, lasers used in surgery typically use 300 Watts.) When
applied to the skin, these lasers produce no sensation and do not burn the
skin. Because of the low absorption by human skin, it is hypothesized that the
laser light can penetrate deeply into the tissues where it has a
photobiostimulative effect. One low-level laser device, the MicroLight 830
Laser, has received clearance for marketing from the U.S. Food and Drug
Administration (FDA) specifically for the treatment of carpal tunnel syndrome.
Other protocols have used low-level laser energy applied to acupuncture
points on the fingers and hand. This technique may be referred to as "laser
acupuncture." Given the equivocal or negative outcomes from a significant
number of randomized clinical trials, it must be concluded that the body of
evidence does not allow conclusions other than that the treatment of most
pain syndromes with low level laser therapy provides at best the equivalent of
a placebo effect. (Naeser, 2002) (Gur, 2002) (Basford, 1999) (Conti, 1997) (de
Bie, 1998) (BlueCross BlueShield, 2005)
Low Level Laser Therapy (LLLT) was introduced as an alternative non-invasive
treatment for Osteoarthritis (OA) about 20 years ago, but its effectiveness is
49
Ultrasound,
therapeutic
still controversial. For OA, the results are conflicting in different studies and
may depend on the method of application and other features of the LLLT
application. Despite some positive findings, data is lacking on how LLLT
effectiveness is affected by four important factors: wavelength, treatment
duration of LLLT, dosage and site of application over nerves instead of joints.
There is clearly a need to investigate the effects of these factors on LLLT
effectiveness for OA in randomized controlled clinical trials. (BrosseauCochrane, 2004) This meta-analysis concluded that there are insufficient data
to draw firm conclusions about the effects of LLLT for low-back pain compared
to other treatments, different lengths of treatment, different wavelengths
and different dosages. (Yousefi-Nooraie-Cochrane, 2007)
Not recommended. Therapeutic ultrasound is one of the most widely and
frequently used electrophysical agents. Despite over 60 years of clinical use,
the effectiveness of ultrasound for treating people with pain, musculoskeletal
injuries, and soft tissue lesions remains questionable. There is little evidence
that active therapeutic ultrasound is more effective than placebo ultrasound
for treating people with pain or a range of musculoskeletal injuries or for
promoting soft tissue healing. (Robertson, 2001)
The tool gives a flag to each treatment, which helps the claims manager to decide whether a
treatment should be approved. There are 4 different flags: green, yellow, red, or back.
Flag
Flag meaning
Example: treatment for low back pain
green
Automatic approval
Physiotherapy
Evidence based treatment. The tool will
automatically approve 6 sessions, which is
based on the number of visits that 50% of
the injured workers with this injury have
Heat/cold packs
Not many randomised controlled trials have
been done to investigate the effect of a cold
pack, but the frequency is 16% and the
costs are low.
Work hardening
It can be effective, but only for some
conditions. Specific criteria need to be
fulfilled.
Treatment is found to be effective
yellow Automatic approval
red
black
Evidence base is not very strong,
incidence and frequency are high, and
the costs low.
Review (It will not be automatically
approved, but that does not mean it is
going to be denied.)
Evidence is not strong, or only strong
for specific cases.
Strong candidate for denial
Incidence and frequency rate are very
low, which means that the treatment
for this injury is very rare.
Artificial disc replacement (ADR)
Studies have failed to demonstrate
superiority of disc replacement over lumbar
fusion, which is also not a recommended
treatment for degenerative disc disease.
The flag system is applied to different treatments, and also to imagery/scans and drugs. For
example, for low back pain, CT scans are not recommended.
50
A distinction is made between whether it is approved for acute and chronic conditions. For
example, antidepressants are not routinely recommended for acute low back pain, but seem to
be recommended for chronic low back pain (i.e. tricyclic antidepressants).
The tool is developed in America. The evidence comes from all available international
literature. A hierarchy of evidence is applied, ranking the type of evidence. The highest
ranking is given to RCTs and meta-analyses, and the lowest ranking is given to case reports.
Literature search is updated every 6 months. Critical appraisal of the evidence is done by an
American, multidisciplinary advisory group, consisting of members representing all medical
specialties.
Q: How do you feel about claims managers making decisions based on this flag system?
Q: What would be the advantages?
 Faster access to treatment? Less overuse and misuse of treatment? Less disputes?
Q: Would you have any concerns, for example, about the evidence?
 Enough evidence? Who is judging evidence? Conflicts with clinical judgement or
patient preferences? Financially disadvantageous?
Another main functionality of the EBM tool is that it provides information about return-towork (RTW) per injury. Per condition, a summary is provided about how many days it will
take for injured people to go back to work. This is based on claims data. A yellow flag is
raised when an injured person is not back at work after the number of days at which 50% of
injured people with this injury are back at work. A red flag is raised when the injured person
is not back at work when 90% of claims with this injury are back at work. The flags can be an
indication for the claims manager that close monitoring is needed.
For example, for low back pain, 50% of injured workers are back at work after 17 days, and
90% is back at work after 39 days:
RTW Claims Data (Calendar-days away from work by decile)
10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Mean
10
12
14
15
17
18
30
35
39
365
24.91
For neck/whiplash complaints, 50% of workers has returned to work after 25 days, and 90%
has returned after 41 days:
RTW Claims Data (Calendar-days away from work by decile)
10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Mean
11
19
21
22
25
27
29
30
41
104
27.15
The RTW expectancy can be adjusted (i.e. extended) based on individual circumstances, i.e.
demographic characteristics (age), job characteristics (i.e. light or heavy duties), comorbid
conditions (e.g. depression, diabetes, obesity, smoking, surgery) and whether the worker has
legal representation.
Q: How do you feel about claims managers monitoring RTW based on claims data?
51
Q: What would be the advantages?
Q: What would be the disadvantages?
3. EBM tool yourself (5 minutes)
Thirdly, I would like to ask whether you would use an EBM tool yourself in your practice.
Q: How/where do you currently look for evidence?
Q: Are you aware of the existence of EBM tools, such as the MDGuidelines or ODG?
The tool would give you access to the same functionalities as described earlier, i.e. to the
overview of all the evidence around certain treatments and injuries, including a
recommendation whether to apply that treatment or prescribe a certain drug. The injuries are
categorised in the following chapters:



















Ankle & Foot
Burns
Carpal Tunnel Syndrome
Diabetes
Elbow
Eye
Fitness for Duty
Forearm, Wrist, & Hand
Head
Hernia
Hip & Pelvis
Infectious Diseases
Knee & Leg
Low Back
Mental Illness & Stress
Neck & Upper Back
Pain
Pulmonary
Shoulder
The tool would also give you access to the average number of days to RTW and the RTW
best practice guidelines. For example, the RTW best practice guideline for low back pain
would be:
847.2 Lumbar sprains and strains
Mild (grade I), clerical/modified work: 0 days
Mild, manual work: 10 days
Severe (grade II-III), clerical/modified work: 0-3 days
Severe, manual work: 14-17 days
Severe, heavy manual work: 35 days
With radicular signs, see 722.1 (disc disorders)
52
847.0 Neck
Whiplash grade 0 (Quebec Task Force grades): 0 days
Whiplash grade I-III, clerical/modified work: 5 days
Whiplash grade I-III, manual work: 21 days
Whiplash grade I-III, heavy manual work: 28 days
Whiplash grade IV: see 805 (fracture)
The annual subscription cost for health care professionals would be around $350 Australian
dollar
Q: How would you feel about using the EBM tool?
Q: What would be the advantages?
Q: Do you see any disadvantages?
The tool could be used in the workers’ compensation setting, optimising the treatment
approval process. The tool could be used more generally, in your overall clinical practice,
informing you about evidence based treatment.
Q: Do you see more advantages using the tool in the workers’ compensation setting
specifically, or in your clinical practice, in general?
Demographic and job characteristics (5 minutes)
Finally, I would like to ask you some demographic and job characteristics, which we might
use in the report to describe the participant characteristics. Your identity will not be revealed.
17. What is your age? ….
18. Gender: …..
19. What is the number of years of work experience in your current field? ….
20. Do you work part time or full time? ….
21. Do you work in an urban or rural clinic or both? ….
22. In what clinical setting do you work? Public or private hospital, Community, Multiple
settings ….
23. How often do you provide services to the workers’ compensation scheme? …..
Closure (2 minutes)
This is the end of the interview.
Q: Do you have further questions?
Q. Would you be interested in receiving the scientific publication?
50 dollar Coles voucher for the participant. Participant needs to sign a receipt
53