ACOEM Practice Guidelines

Perspectives on their use in

guiding clinical care and
utilization management

John P. Holland, MD, MPH

Past-President, ACOEM
Chair, Guidelines Steering Committee

California Division of Workers Compensation

12th Annual Educational Conference
February 23 - 24, 2005 Los Angeles
February 28 March 1, 2005 Oakland
Presentation Overview
Overview and Current Issues
1. ACOEM perspective and
why EBM matters
2. Use of evidence in developing APGs
New Initiatives
1. APG Insights newsletter
2. Utilization Management Tool (UMT)
3. Plans for the next generation of
clinical practice guidelines

John P. Holland, MD, MPH

The ACOEM Perspective -
and why evidence-based
medicine is important

3
The ACOEM Perspective
Our core mission -
Promote the health and productivity of
workers, workplaces and the environment
Our core values -
Use science to guide practice, programs
and policy
Promote fairness for individuals, employers
and society
Use processes that are inclusive, transparent
and rationally consistent
John P. Holland, MD, MPH
What is evidence-based
medicine (EBM)?
Evidence-based medicine is the conscientious,
explicit, and judicious use of current best
evidence in making decisions about the care
of individual patients.
- David Sackett

John P. Holland, MD, MPH

Evidence-based medicine

Evidence-based
Medicine

Gathering Evaluating quality Making medical

medical of medical decisions using
information information best evidence

John P. Holland, MD, MPH

Elements of EBM
- identify relevant best evidence
Define clinical question to be answered
(for a specific clinical situation)
Find best scientific evidence relevant to the
specific clinical question
(using systematic methods)
Rely on best evidence to guide
clinical decision-making

John P. Holland, MD, MPH

Elements of EBM
- identify relevant best evidence
Original evidence
clinical epidemiology (e.g. clinical) trials
descriptive epidemiology
outcomes research / economic studies
Literature synthesis / analysis
systematic literature reviews / meta-analyses
clinical practice guidelines
cost-effectiveness studies
John P. Holland, MD, MPH
Elements of EBM
- focus on clinical outcomes
Clinical outcomes (things that matter to
patients and families)
survival
impairment / disability / disfigurement
symptom severity
quality of life (QOL)
cost / convenience

John P. Holland, MD, MPH

Elements of EBM
- use standard measures of effect
Evaluate therapies using standard measures:
How does it affect rate, degree or timing of:
Physical impairment, disfigurement or death
Return to normal functioning
Symptom resolution
Potential harms (from therapy)
Total costs (for patient, employer and society)
Allows comparisons of benefits and harms of
different clinical methods

John P. Holland, MD, MPH

Elements of EBM
- assess likely benefits / harms
Evaluate clinical methods on benefits / harms
Beneficial
Likely to be beneficial
Trade off between benefits and harms
Unknown effectiveness
Unlikely to be beneficial
Likely to be ineffective or harmful
Promotes informed decision-making by
clinicians and patients

John P. Holland, MD, MPH

Elements of EBM
- base decisions on best evidence
Find best scientific evidence that is
applicable to the specific clinical situation
individual patients clinical situation
program or policy decision

Use evidence to guide decision-making

does the likelihood of benefit outweigh likelihood
of harm enough to justify the cost?
same question applies to individual and society

John P. Holland, MD, MPH

EBM is important because -
provides a science-based method for
Improving physician practice
increase effectiveness / decrease harms
(better clinical outcomes / cost-effectiveness)
Increasing consumer knowledge
understand potential benefits / harms
Building quality into healthcare systems
using practice guidelines, quality indicators
Guiding government / employer policies
guide programs / policies on healthcare

John P. Holland, MD, MPH

Use of Evidence in Developing
the ACOEM Clinical Practice
Guidelines (APGs)

14
What are
clinical practice guidelines?

Clinical practice guidelines are

recommendations for clinicians and
consumers about optimal and appropriate
care for specific clinical situations

John P. Holland, MD, MPH

Formal or informal guidelines are
the basis for all clinical practice
Basis for most clinical decisions
Foundation of clinical teaching
Mental short-cuts and memory aids for
common or complex problems
Primary method to evaluate care patterns
and monitor standards of care

John P. Holland, MD, MPH

Types of guidelines - major focus
clinical assessment / treatment
management of cardiac arrest (ACLS)
risk assessment / prevention
drugs to use in pregnancy (ACOG)
administrative
insurance pre-approval for surgery

John P. Holland, MD, MPH

When are guidelines needed ?
Institute of Medicine (IOM) criteria clinical
practice guidelines are useful when:
the problem is common or expensive
there is great variation in practice patterns
there is enough scientific evidence to
determine appropriate and optimal care
(IOM , 1992)

John P. Holland, MD, MPH

Types of guideline development
approaches
Single author - expert opinion

Single author - systematic literature review

Consensus panel using expert opinion only

Consensus panel using evidenced-based

approach (AHCPR methodology)

John P. Holland, MD, MPH

Steps in developing
guideline recommendations
define clinical questions of interest
develop summary of evidence on:
clinical efficacy (potential benefits)
potential harms / projected costs
weigh likelihood of benefit versus
likelihood of harms, and consider costs
develop finding / recommendation statements
document all aspects of the process

John P. Holland, MD, MPH

Evidence-based guidelines
- need to explicitly document
methodology and assumptions
evidence reviewed
summary of findings
decision-making rules for recommendations
rationale for each conclusion and
recommendation statement

John P. Holland, MD, MPH

Types of guideline statements
Based on AHCPR guidelines, the types of
guideline statements are:

Recommendation for use

Option for use

Recommendation against use

John P. Holland, MD, MPH

Strength of evidence ratings for
guideline recommendations
A = Strong research based evidence
multiple relevant, high quality studies
B = Moderate research based evidence
one relevant, high quality study
C = Limited research based evidence
one adequate study, somewhat relevant
D = Panel opinion
based on information not meeting criteria for A-C

John P. Holland, MD, MPH

Criteria for determining is a study
contains High quality evidence
Clinical epidemiology is the study of the
effectiveness of clinical assessment and
treatment methods
There is general consensus among experts
on what constitutes a high quality study but
specific criteria vary on subtle details
APGs relied on criteria for determining high
quality studies used by the AHCPR low back
guideline and Cochrane Reviews
ACOEM Practice Guidelines, 2nd Ed., page 501)

John P. Holland, MD, MPH

ACOEM New Directions -

APG Insights

25
APG Insights - newsletter
Newsletter devoted to discussing issues
relevant to use of the ACOEM Practice
Guidelines (APGs)
Separate editorial board
Anticipate about 6 issues per year
First issue was in fall of 2004,
next issue in March 2005
For information go to acoem.org
John P. Holland, MD, MPH
APG Insights - purpose
APG Insights will
Provide suggestions and examples on how APGs can
be used in clinical care / utilization management
Provide summaries of scientific evidence (systematic
reviews) on clinical topics relevant to the APGs
APG Insights will not
Explain or justify how APG were developed (APGs
must speak for themselves)
Be a revision or update of the guideline
(no presumption of correctness in California)

John P. Holland, MD, MPH

APG Insights Fall 2004
- APG guidance on chronic conditions
States Unequivocally that APGs do apply to
conditions after 90 days (chronic conditions)
APGs - Mostly focus on the first 90 days following
workplace injury because approximately 90% of
injuries are resolved during this time period.
Chapters 1-7 of APGs give general approach for
assessment and treatment of injured workers -
These basic components remain constant
throughout the life of the claim
Chapter 6 deals extensively with chronic pain
(generally defined as pain lasting over 3-6 months)

John P. Holland, MD, MPH

ACOEM New Directions -

Utilization Management
Tool (UMT)

29
Utilization Management Tool
Purpose of UMT is to provide
Accurate interpretation of APG recommendations
claims staff can rely upon in making decisions
Consistent interpretations to reconcile perceived
inconsistencies within APG
Easy to use tool to foster efficient and consistent
utilization management based on APG
Create written summary of relevant APG guidance
relied upon in making claim decision (based on UMT)

John P. Holland, MD, MPH

ACOEM New Directions -

Next Generation of
Clinical Practice Guidelines

31
Next Generation of
Clinical Practice Guidelines
ACOEM is committed to moving to the next level in
working to develop a new generation of clinical
practice guidelines
We continue to learn about how guidelines are best
used in WC settings
We are committed to increasing scientific rigor,
documentation and usefulness in future guideline
development efforts
In our work on developing a new generation of
practice guidelines we are committed to following
our core mission and core values in these efforts

John P. Holland, MD, MPH

The ACOEM Perspective
Our core mission -
Promote the health and productivity of
workers, workplaces and the environment
Our core values -
Use science to guide practice, programs
and policy
Promote fairness for individuals, employers
and society
Use processes that are inclusive, transparent
and rationally consistent
John P. Holland, MD, MPH
References
Evidence-based medicine
and practice guidelines

34
References Evidence-based
medicine and practice guidelines
Book chapters and journal articles
1. American College of Occupational and Environmental
Medicine (2004). ACOEM Clinical Practice Guidelines, 2nd
Edition. Glass L (Ed.). (Beverly Farms, MA; OEM Press).
2. Bigos SJ, et. al. (1994) U.S. Agency for Health Care Policy
and Research (AHCPR) Clinical Practice Guideline #14:
Acute low back problems in adults. Pub. 95-0642 (U.S.
Department of Health and Human Services, Public Health
Service, Rockville, MD).
3. Holland JP. (1995) Developing evidence-based clinical
practice guidelines. Current Opinion in Orthopedics. 6: 63-69.

John P. Holland, MD, MPH

References Evidence-based
medicine and practice guidelines
Book chapters and journal articles (continued)
4. Holland JP, Holland CL, Webster JS, Bigos SJ. (2003)
How to critically evaluate the literature on low back problems:
The foundation for an evidence-based approach to care.
Seminars in Spine Surgery. 15: 54-67.
5. Institute of Medicine, Committee on Clinical Practice
Guidelines. (1992) Guidelines for Clinical Practice: From
Development to Use. Field M, Lohr K (Eds). (Washington,
DC; National Academy Press).
6. Sackett D, Haynes R, Guyatt G, et al. (1991). Clinical
Epidemiology: A Basic Science for Clinical Medicine, 2nd
Edition. (Boston, MA; Little, Brown).

John P. Holland, MD, MPH

References Evidence-based
medicine and practice guidelines
Book chapters and journal articles (continued)
7. Sackett D, Straus S, Richardson W, et al. (2000). Evidence-
based Medicine: How to Practice and Teach EBM. (New York,
NY; Churchill Livingstone).
Websites
8. www.acoem.org - ACOEMs website. For information on
APG Insights, a newsletter on issues relevant to the ACOEM
Clinical Practice Guidelines.
9. www.cochrane.org - The Cochrane Collaboration website;
a source for systematic reviews on medical intervention

John P. Holland, MD, MPH