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.