Prognosis or Diagnosis – that is the REAL question!

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BMC Medicine recently published an open access “Opinion” entitled:

The science of clinical practice: disease diagnosis or patient prognosis? Evidence about “what is likely to happen’ should shape clinical practice.

This question is highly relevant in the workers compensation context. The following statement in the paper could not be more relevant to work-related injury:

‘The multiplicity of biological, clinical, and social factors that inform the likelihood of an individual’s future outcome challenges the idea that prognosis and treatment selection are exclusively determined by diagnosis’

and, specifically related to back pain:

‘Evidence that clinicians and patients can integrate disease-based explanation within a broader framework of prognosis is provided by back pain. Primary care practitioners undertake initial triage in a diagnostic framework to identify rare underlying conditions which have a poor immediate prognosis unless treated (e.g. cord compression from a tumour). Once these are excluded, the task diverts from diagnosis and considers the clinical problem as the risk of poor long-term outcomes (work loss, persistent pain). Activity limitation, psychological distress, and capacity to cope are used to classify people into prognostic categories that drive treatment decisions. The many at low risk of a poor outcome are managed without referral or investigation, whereas more intense care is targeted at those with poorer prognosis. This exemplifies the principle of ‘stratified care’. Use of this prognostic approach to select back pain patients for different treatment programmes was effective and cost-effective in a randomised controlled trial.’

The AMA Tasmania Workers Compensation Reform Committee has put forward the concept of a “Complex Case Management Model” which utilises the “stratified care” concept above.  This model relies heavily on the principles expounded in the paper referred to above and is supported by Committee recommendations to alter the information on certificates so that the doctor documents the prognosis as early as possible.

The principle of the “Complex Case Management Model” is:

‘…….. the doctor involved in the early stages of management of a work injury is empowered to consider prognostic factors and identify ‘complex’ cases at the earliest opportunity. The cases flagged as complex could be streamed into an alternative management pathway managed by a medical practitioner with enhanced skilled in “complex case management” ‘

The insurance industry in Tasmania has expressed interest in working with the medical profession to work out the detail about how such a system might work in practice.

The treating medical practitioner can consider prognosis taking into account biomedical and psychosocial factors. The employer and insurer could also contribute  to the identification of poor prognosis cases with information not available to the treating doctor that might impact on prognosis. The risk with this approach is that the insurer might respond by measures to avoid liability, rather that be prepared to put the necessary resources into those cases.

Further issues might arise if a referral to another practitioner for “complex case management” is seen to be contrary to the principle that the worker can choose their treating doctor. The solution is that the referral for “complex case management” be managed like any other referral within the medical system with the general practitioner conferring with their patient (the injured worker) about the choice of doctor. Problems are only likely to arise if there is interference by other parties in that choice.

While biomedical diagnosis remains important, the evidence suggests:

An informed assessment of prognosis is a key ingredient to considering resources necessary to improve health outcomes in our workers compensation systems.

Incorporating that concept into Workers Compensation System design should be carefully considered.

 

 

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About Tasworkdoc

As an occupational physician in private medical practice in Hobart, Tasmania - the southernmost state of Australia, I see workers referred by their general practitioners with various types of work-related injuries and diseases. These are mostly musculoskeletal injuries, both of traumatic and gradual onset as well as various associated psychological disorders. With interaction with patients for treatment and providing advice about rehabilitation, I have the opportunity, first-hand, to observe interactions between individual patients and compensation systems. I also conduct independent medical assessments, including impairment assessments for musculoskeletal injuries and asbestos-related disease compensation. This provides another perspective of workers within compensation systems.
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2 Responses to Prognosis or Diagnosis – that is the REAL question!

  1. Peter I appreciate the article, but what you haven’t taken into consideration is the way the claims agents handle the claims.
    It matters not whether or not the doctor has a prognosis or a diagnosis what matters to the claims agents is the dollar impact of the claim.
    Before the claim is put onto the desk of a case manager the agent runs the claim through their algorithm process that breaks everything down to costs factors for the claim to run from date of claim to date of retirement, age, gender, married single even postcode information is included in the information to decide whether or not to accept the claim or to reject it. Everything from cost of medical cost of legal cost of income payments is there.

    It is not the number of third parties involved that determine the outcome of a claim, it is the people who run the algorithm at the start of the claim that set the parameters in place.

    Should I ever win Lotto (which would mean I would have to buy a ticket) I would buy shares in every insurance company just so I could attend the shareholder meetings and ask the questions that they have never been asked about how they treat injured workers.

  2. Tasworkdoc says:

    Thanks Rosemary
    It might be a bit different here in Tasmania with our ‘underwritten’ scheme, but I am aware of how an insurer’s estimate of liability might influence their approach. The challenge is to get the insurers to see the benefit into putting resources into appropriately resourcing treatment and rehabilitation in consultation with treating practitioners to get better outcomes, rather than automatically going into dispute mode on ‘difficult cases’. Disputation can also be very expensive and damaging to the health outcome, especially at the start of a claim. I am not suggesting that is going to be easy, but worth a try. The advantage of a small state like ours is that the ‘key players’ can potentially have better communication to discuss the issues.

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