DOES LITIGATION INFLUENCE THE OUTCOMES OF SURGERY IN THE WORKERS COMPENSATION ARENA? No conflicts of interest

(1)

DOES LITIGATION INFLUENCE THE OUTCOMES

OF SURGERY IN THE WORKERS COMPENSATION

ARENA?

No conflicts of interest

Jayantilal Govind

Director & Senior Staff Specialist Occupational and Pain Medicine

ACT Health @ The Canberra Hospital Canberra

(2)

Law

Rules of evidence

Beyond reasonable doubt

Case law

Heresy

Circumstantial evidence

Medicine

Evidence based medicine

Clinical epidemiology

Logical

Rational

Biologically plausible

Confounders

“Back pain is an

illness in search

of a disease”

(3)

Low back pain is to workers’ compensation,

As neck pain is to the auto insurance industry.

W.O. Spitzer

For occupational back injury,

“…the evidence that such injuries

actually exist is slight or often non-

existent”

Malleson A,

“The Enigmas of the Human Spine”

(4)

In the beginning……

Compensation Neurosis

Accident Neurosis

LITIGATION

The Prevailing Notion / Expectations

X Y GOOD YES NO O U T C O M E S POOR NO GOOD Irrespective of treatment

(5)

LITIGATION

The Prevailing Notion / Expectations

X Y GOOD YES NO O U T C O M E S POOR NO GOOD Irrespective of treatment Irrespective of treatment

The Prevailing Notion /Expectations

X Y POOR GOOD LITIGATION O U T C O M E S YES NO

(6)

Reasons proffered include

• secondary gain,

• the pursuit of financial gain,

• psychological disturbances,

or

• are symptom magnifiers.

The evidence however is

• sparse

• inconsistent,

• ambiguous, and,

• confounded by a large number of

(7)

THE EVIDENCE ?

Confounded by:

incorrect diagnosis,

financial strain

4

inappropriate treatment and iatrogenesis

1

_{severity of injury}

4

complications of treatment

2,3

_{bias in reporting}

6,7

stress of litigation

4,5

_{physician bias}

8

mistrust by medical personnel

4

_{outcome expectations}

9

1. Balla JI, Moraitis S. Med J Aust. 1970, August 22:355-361.

2. Bednar JM, et al. Clin Orthop Rel Research. 1998; 351:74-77

3. Greennough CG et al. Clin Orthop Rel Research 1994; 300:30-37.

4. Swartzman LC et al. Spine 1996; 21:53-58.

5. Atlas SJ et al. J Bone Joint Surg 2000; 82-A: 4-15.

6. Callaham ML et al. JAMA 1998; 280:254-257.

7. John Flint winner, The Walkley Award,2005. West Australian Sunday Times,” Doctoring Compo-The

Real Cheats Exposed.” Google.Accessed 25.05.06.

8. Lipton RB et al. Neurology 2003; 60:1064-1070.

9. Rainville J et al. Spine 1997; 22:2016-2024.

WA Sunday Times Walkley Award

(8)

2,278 publications

Only 4 that were randomised

None were blinded.

Most studies - considerable heterogeneity (p. <.001)

Major confounders:

publication bias

selection bias

differences in disease severity

Likely that that the negative effects of litigation may have

been over represented in observational studies.

Harris I, Mulford J, Solomon M, van Gelder JM, Young J. Association between compensation status and outcome after surgery. A meta analysis. JAMA 2005; 293:1644-1652

Studies showing no difference between

compensated and non-compensated patients

• Brachial plexus lesion

(8)

(1997)

• Carpel tunnel decompression

(7)

(1999)

• Anterior cervical fusion

(10)

(2002)

• Ulnar nerve transposition

(6)

(2002)

(9)

Are not mentioned

Curtin University

2001

Does Workers’ Compensation influence

recovery rates?

A critical review of the

literature

(10)

Findings:

• Negative attitudes and

biases of health professionals

Lack of knowledge

or commitment to injury management

• Secondary gains of service providers

abnormal treatment behaviour

• Complex paper work delaying treatment

• Unavailability of suitable duties

• Disillusionment with system

The influence of legislation

on outcomes

• Suspicion and

dissatisfaction with service providers

• Poor outcomes associated with prolonged exposure to

non-proven treatment

• Limitation in methodology and data analysis

• The effect of legal representation and litigation are contradictory

• and equivocal

Lack of consistent standard criteria

between studies

• No controlled studies

Findings:

• Negative attitudes and

biases of health professionals

Lack of knowledge

or commitment to injury management

• Secondary gains of service providers

abnormal treatment behaviour

• Complex paper work delaying treatment

• Unavailability of suitable duties

• Disillusionment with system

The influence of legislation

on outcomes

• Suspicion and

dissatisfaction with service providers

• Poor outcomes associated with prolonged exposure to

non-proven treatment

• Limitation in methodology and data analysis

• The effect of legal representation and litigation are contradictory

• and equivocal

Lack of consistent standard criteria

between studies

(11)

Price Waterhouse Coopers 2001

Legal Aspects

•Perceived advice to follow treatment plans

•Stressful/uncertain/lengthy process

•The skill of the lawyer

•The skill of the claimant as a witness and

•not the severity of the injury

• Judges who hold different views on work injuries

Does the nature of treatment

generate

…….

• Positive

or

• Negative outcome

(12)

chronic low back pain

Surgery

Characteristics

N

WCC

Non-WCC

AIF

151

106

45 Psych Disturbance

51 ?

?

Fusion

Single level

87 ?

?

Multi-level 64

?

Instrumentation 30

?

Complications 30

?

Patients with complications

26 ?

?

Additional surgery

24 ?

?

Failed fusion

30%

38%

11%

Greennough CG, Taylor LJ, Fraser RD. Anterior lumbar fusion: a comparison of non-compensation patients and non-compensation patients. Clin Orthop Rel Research 1994; 300:30-37.

(13)

Characteristic

N

Microdisc

Fusion

Operated

87 Follow up

73

37

36 Oswestry

VAS

Return to work

72%

43%

SF-36

Physical Functioning

Bodily pain

Mental health

(p=<05)

Hodges SD,Craig-Humphreys S,Eck JC, Covington LA, Harrom H. Predicting factors of successful recovery from lumbar spine surgery among workers’ compensation patients. JAOA 2001;101:78-83

(14)

Comparative analysis of insured and

non-insured patients undergoing IDETA for IDD

Characteristics

N

WCC

Non-WCC

Inception cohort

34

10

24 Follow-up

32 ?

?

Discograms:

+ve single level

24 ?

?

+ve 2

level 10

?

Ref: Mekhail et al; Pain Pract 2004; 4: 84-90

WCC

Non-WCC

Pain Relief

100%

50-100% <50%

100%

50-100% <50%

Number

4

5

8

3

7

8 Working

4

5

4

3

7

4 Opioids

0

5

0

1

6 Success

9

10 Failure

8

8 Fusion

2

Karasek M, Bogduk N. Twelve-month follow-up of a controlled trial of intradiscal thermal anuloplasty for back pain due to internal disc disruption. Spine 2000; 25:2601-2607

ns

IDETA

(15)

Chronic neck pain

Engineering Design

& Safety

(16)

Kaneoka et al Spine 1999;24:763-770

(17)

#superior articular

process haemarthrosis

Courtesy: Prof J Taylor, Perth

Nerve blocks

• Identifies the nerve that mediates the pain

• Infers the anatomical source of pain

(18)

(19)

Characteristics

Litigants

Non-Litigants

Number

32

18 Followed

28

18 VAS

Pre-RF

8.1

8.4 12 months

4.0

2.9 VAS = 0

50%

61%

Satisfaction

97%

100%

Opioids

- 52%

- 50%

ns

Sapir DA, Gorup JM. Radiofrequency medial branch neurotomy in litigant and non-litigant patients with cervical whiplash. Spine 2001;26:E268-E273.

CERVICAL RF NEUROTOMY

Status

N

Success

Failure

Duration of Relief

(complete

median days

relief)

(interquartile range)

Litigation

14

9

5

500 (250 - 779)

No Litigation

14

10

4

735 (632 – 1,125)

P

0.686 0.1771

McDonald GJ, Lord SM, Bogduk N. Long -term follow- up of patients treated with cervical radiofrequency neurotomy for chronic neck pain. Neurosurgery 1999; 45:61-68

(20)

Status

N

Success

Failure

Duration of Relief

(complete

median days

relief)

(interquartile range)

Litigation

33

28

5

249 ( 94-312)

No Litigation

16

15

1

297 (127-363)

P

0.373

0.299

Govind J, King W, Bailey B, Bogduk N. Radiofrequency neurotomy for the treatment of third occipital headache. J Neurol Neurosurg Psychiatry 2003; 74:88-93

CERVICAL RF NEUROTOMY

Irrespective of litigation

• Positive outcomes are achievable

• 3 independent and unrelated studies show that

• Litigation makes no difference

when proven z

(21)

O U T C O M E S Irrespective of litigation TREATMENT WORKS WORSE EQUAL NO fusion discectomy IDET RF YES O U T C O M E S LITIGATION Despite treatment YES no GOOD POOR Despite litigation TREATMENT WORKS YES no FUSION discectomy IDET _RF