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

MBChB (Cape Town). DPH. M.Med (Syd) FAFOEM.

Law

Rules of evidenceBeyond reasonable doubt

Case law

HeresyCircumstantial evidence

Medicine

Evidence based medicineClinical epidemiology

LogicalRational

Biologically plausible

Confounders

“Back pain is an illness in search

of a disease”

Williams ME, Hadler NM. N Engl J Med 1983;308:1357-60

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”

(2002)

In the beginning……

Compensation Neurosis

Accident Neurosis

LITIGATION

The Prevailing Notion / Expectations

X

Y

GOOD

YES

NO

OUTCOMES

POOR

NO

GOOD

Irrespective of treatment

LITIGATION

The Prevailing Notion / Expectations

X

Y

GOOD

YES

NO

OUTCOMES

POOR

NO

GOOD

Irrespective of treatment

Irrespective oftreatment

The Prevailing Notion /Expectations

X

Y

POOR

GOOD

LITIGATION

OUTCOMES

YESNO

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

unaccounted variables, such as…

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 TimesWalkley Award

2005

2,278 publicationsOnly 4 that were randomisedNone were blinded.

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

Major confounders: publication biasselection biasdifferences 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)• Arthroscopic arthroplasty (9) (2003)

Are not mentioned

Curtin University2001

Does Workers’ Compensation influence

recovery rates?

A critical review of the literature

Findings:

•Negative attitudes and biases of health professionalsLack of knowledge or commitment to injury management

•Secondary gains of service providersabnormal 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 tonon-proven treatment

•Limitation in methodology and data analysis•The effect of legal representation and litigation are contradictory

•and equivocalLack of consistent standard criteria between studies

•No controlled studies

Findings:

•Negative attitudes and biases of health professionalsLack of knowledge or commitment to injury management

•Secondary gains of service providersabnormal 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 tonon-proven treatment

•Limitation in methodology and data analysis•The effect of legal representation and litigation are contradictory

•and equivocalLack of consistent standard criteria between studies

•No controlled studies

Price Waterhouse Coopers2001

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…….

• Positiveor

• Negative outcome

..…irrespective of litigation?

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 compensation patients. Clin Orthop Rel Research 1994; 300:30-37.

Characteristic N Microdisc Fusion

Operated 87Follow up 73 37 36

Oswestry �� �

VAS �� �

Return to work 72% 43%

SF-36Physical 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

IDET catheter inserted into disc

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 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 0 5 0 1 6

Success 9 10

Failure 8 8Fusion 2 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

Chronic neck pain

EngineeringDesign

&Safety

Insurance Institute for Highway Safety

Kaneoka et al

Spine 1999;24:763-770

Swartz EE. J Athletic Training 2005;40:155-161

#superior articularprocess haemarthrosis

Courtesy: Prof J Taylor, Perth

Nerve blocks

•Identifies the nerve that mediates the pain

•Infers the anatomical source of pain

•Knowledge of neural pathways

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

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

CERVICAL RF NEUROTOMY

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 joint pain is treated with RFN

OUTCOMES

Irrespectiveof litigation

TREATMENT WORKS

WORSE

EQUALNO

fusion

discectomy

IDET

RF

YES

OUTCOMES

LITIGATION

Despite treatment

YESno

GOOD

POOR

Despite litigation

TREATMENT WORKS

YESno

FUSION

discectomy

IDET RF

Conclusion

Observational studies have a tendency to over-represent negative outcomes

Qualitatively, studies are confounded by multiple variables

including bias,lack of comparative data and iatrogenesis

There are no controlled studies to validate the prevailing view

that litigation promotes negative outcomes

Observational studies have a tendency to over-represent negative outcomes

Qualitatively, studies are confounded by multiple variables

including bias,lack of comparative data and iatrogenesis

There are no controlled studies to validate the prevailing view

that litigation promotes negative outcomes

Observational studies have a tendency to over-represent negative outcomes

Qualitatively, studies are confounded by multiple variables

including bias,lack of comparative data and iatrogenesis

There are no controlled studies to validate the prevailing view

that litigation promotes negative outcomes

Correct treatment

Correct patient

Better outcomes

Irrespective of

Litigation.