1. L&I Guideline Development
Lee S. Glass, MD
Associate Medical Director

2. Conflicts Disclosure
Conflicts of Interest: None
Biases: Many

3. Time loss duration (months)
Disability Prevention is the Key Health Policy Issue
70% Return to work in first 3 months
Disability and Chronic pain coincide at 3 months
% of cases on time loss
8% account for 85% of cost
Less than 1% catastrophic injury
Reduce disability by providing high quality medical care.
Identify the last month in which we paid time-loss on a given claim and count the length of time between date of injury and that month of last time-loss payment. (not cumulative)
Includes time-loss and LEP claims.
The length of time from date of injury in capturing the data was 4 years 5 months. Study has longer development on the claims durations.
2009 to 2011 fiscal years,  
Time loss duration (months)
2014 L&I Actuarial Services Analysis (for fiscal accident yrs ).

4. Challenges/Opportunities for Quality Improvement and Savings
Estimates are that 1/3 of current per person premium expenditure is on treatments, procedures, or tests that have no positive impact on health outcome
Only approved drugs are based on high level scientific studies. Devices based on lower, engineering standard. No regulation whatsoever of surgical procedures. Thus, poor evidence basis for many things.

5. Purpose of Guidelines Medical Treatment Guidelines (“MTGs”)
Reflect a melding of
Best available scientific evidence
Community medical practice advice
This combination provides face validity as to what is meaningful to practicing providers To
Educate and inform the medical community as to what is most likely to benefit patients, and
To provide a basis for utilization review

6. Workers’ Compensation MTGs
Prior to 1990’s: very few MTGs
Guidelines were proprietary
Developed without transparency
Used for utilization review
Not an educational tool

7. MTGs: Late 1980’s to mid-1990’s
American College of Occupational and Environmental Medicine, 1st edition
Guidelines to treat common occupational disorders
AHCPR (Agency for Health Care Policy & Research
Back pain treatment guidelines
HUGE backlash – almost caused the abolition of that agency
Now “AHRQ” –Agency for Healthcare Research & Quality
Note the absence of “Policy” in the new name

8. 1988 - L&I’s first Guideline
Hospitalization for Low Back Pain
Developed in conjunction with L&I’s then new utilization review process
Admissions for low back pain decreased 60% within one year from implementation of the guideline in utilization review
L&I sought assistance from the Washington State Medical Association
Industrial Insurance Advisory Committee formed in 1989-basis in regulation

9. MTGs: 1990’s to mid- 2000’s
Institute of Medicine-1992-Guidelines purposes
Physician education
Review criteria for UR
Nationally, legislative recognition of workers’ compensation guidelines
e.g. California (ACOEM); Texas (ODG)
Legislative establishment => need for quality standards
AGREE (Appraisal of Guidelines for Research & Evaluation): Process standards
Institute of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines

10. MTGs: Late 1990’s to mid- 2000’s
The Guideline Subcommittee of WSMA’s Industrial Insurance Advisory Committee played active role in guideline development
Members from parent committee
Subject matter experts
2004: WSMA re-organized its committee structure, and eliminated the IIMAC

11. Industrial Insurance Medical Advisory Committee (“IIMAC”)
Created by statute in 2007
Composition prescribed by statute
14 members
Nominated by specialty societies, associations, statewide groups, etc., appointed by L&I director
Duties specified by statute
“Advise the department on matters related to the provision of safe, effective and cost-effective treatments for injured workers…”

12. IIMAC Governed by administrative regulations
Organized according to by-laws suggested, debated, potentially amended, and approved by the committee
Meetings are quarterly
Guideline subcommittee meetings are monthly other than during the months of parent committee quarterly meetings

13. IIMAC
Agenda for quarterly meetings are discussed in advance by committee chair and department representative
Meetings are publicly advertised, and open to the public
Opportunity for public input on all matters being considered for consensus vote such as Guidelines; all communications are public
NO business of a quorum (not even discussion by members about pending matters) can be held outside of public meetings

14. Hierarchy of Evidence
Best: Meta-analysis of large randomized head-to-head trials.
Large, well-designed head-to head randomized controlled clinical trials (RCT):
Long-term studies, real clinical endpoints
Well accepted intermediates
Poorly accepted intermediates
Smaller RCTs, or separate, placebo-controlled trials
Well-designed observational studies, e.g., cohort studies, case- control studies
Safety data without efficacy studies
Case series, anecdotes
Least: Expert opinion, non-evidence-based expert panel reports, and other documents with no direct clinical evidence

15. Evidence-based Medicine Efforts to Improve Health Outcomes in WA
2005, SHB1512
2003 Prescription Drug Program
2003 ESHB 1299
• coordinate formal
assessment
2005 Agencies develop common
EB guidelines
2006 Governor’s Health
Initiative
Develop incentives and quality improvement tools
• e.g., improved coordination
of care
• quality indicators
(performance measures)
• aimed at chronic disease,
preventive health services,
reduced errors
WA State Prescription drug program
WA State Health Technology
Assessment Program
Interagency Treatment Guidelines

16. Evidence-Based Decisions in Workers Compensation - A Conceptual Framework
Coverage No
Yes
Treatment Guideline
Medical Necessity
Yes No

17. Guideline Development
Starts with a request from our department after prioritizing topics based on criteria, eg, prevalence, controversy, potential harm
Committee creates an ad hoc guideline subcommittee
Composition
Several members (not a quorum) from parent committee
Many informed stakeholders / subject matter experts
University clinicians and researchers
Private sector subject matter experts
Participation by department’s medical staff
Attendance by Qualis UR clinical leads
Subcommittee meetings not public; approximately monthly

18. Guideline Development
Subcommittee logistical support provided by department:
Logistical support, eg, Meeting room, all necessary printed materials, scribe
Snacks or “meal” provided
Payment
Only to IIMAC members
To subcommittee members and invitees for participation -- $150/hr
Reimburse travel expenses
Dept medical staff are non-voting

19. Guideline Development
Professional assistance provided by department to subcommittee:
High quality medical literature review by department masters-level epidemiologist
Notes compiled and distributed by masters-level nurse
Nurse also watches for:
Potential conflicts with other policies
Calendar issues
All logistical complexities

20. Guideline Development
Subcommittee considers:
Diagnosis
Symptoms, signs, ancillary testing
Treatment
Non-surgical; surgical
Return to Work
Work-relatedness / “Causation”
BUT, the main focus of the guidelines are to provide evidence-based review criteria for implementation in UR to determine allowance/denial of procedures, injections, tests, and physical therapy

21. Guideline Development
Subcommittee develops draft guideline
Two major portions:
1) A table that can easily be used in the utilization review process, showing the criteria that should be met for each respective surgical procedure requested
2) A text portion that serves as an educational tool that can assist clinicians in understanding the basis for the guideline’s criteria
3) Where necessary, case definitions for what constitutes a case (eg, carpal tunnel, TOS, unstable spine) for which the requested procedure is likely to improve outcome

22. Guideline Development
Subcommittee submits draft guideline to parent committee (IIMAC)
IIMAC considers draft; likely places matter on next meeting agenda for discussion
Public comment offered following discussion
Committee takes a consensus vote
If approved, effective date set by our department

23. Guideline Implementation
Educational component: self-implementing
Department implementation
Qualis Health is our department’s utilization review entity
Guideline is integrated into utilization review process
If request for payment comports with the guideline, UR nurse can recommend approval
If request does not comport with guideline, UR physician resolves issue of medical necessity in each instance. If denial, appeal must provide compelling clinical evidence to overcome the denial

24. Utilization Review Services
Critical to success of utilization review
Need to be able to work closely with persons providing the services
Qualis is extremely high quality UR provider with quality improvement as a core corporate principle
Process is fully compatible with national standards (older term Utilization Review Accreditation Commission)
Degree of transparency is much higher than usually present in private insurer UR process