Understanding Geographic Variation in the Use of Treatment Guidelines for Occupational Injuries

Greater medical consensus could reduce geographic variability

A recent study published by the Journal of Occupational and Environmental Medicine suggests that there is geographic variation in the use of medical treatment guidelines that reaches beyond differences in population characteristics, such as age, sex, and insurance coverage [See Trujillo, A., et al., “Geographic Variability of Adherence to Occupational Injury Treatment Guidelines,” JOEM, 56:12, December 2014, pp. 1308–12]. The study also indicates that there may be inefficiencies within the American health system that lead to overuse of some types of health services or provision of low quality care in the case of occupational injuries involving the shoulder and/or back. According to the study, however, there was little correlation between the guidelines used. That is to say that with regard to some guidelines, there was a significant geographic variation in use, whereas with other guidelines this was not the case. The study suggests that additional research is needed to better understand the design and implementation of effective policy interventions to reduce the variability. The study posits, however, that greater medical consensus could reduce geographic variability.

Core Questions Addressed in the Study

The study sought to examine three questions:

1. Is there geographic variability in adherence to practice guidelines for occupational injuries?

2. Do geographic areas with low compliance for one treatment guideline show low compliance for other treatment guidelines?

3. Do guidelines with high variability in compliance have lower levels of consensus?

Initial Data Sample Contained Information on More than a Million Claims

Utilizing a database of workers’ compensation benefits from a large, national insurance company, the researchers initially examined more than one million claims from the year 2000 to 2010. Only those claimants that received both medical and indemnity payments were ultimately included and the group was further limited to those who had sustained either a back or a shoulder injury. As a result of the filtering processes, the study focused on 117,084 patents classified as having back injuries and 53,223 patients classified as having shoulder injuries.

Development of Relevant Guidelines

Quality of care guidelines were developed for shoulder and back injuries through review of the American College of Occupational and Environmental Medicine and the Official Disability Guidelines and consultation with a panel of experts. Initially, 21 shoulder injury guidelines and 23 back injury guidelines were examined. Of these, six for shoulder and five for back were used. These were then pooled to produce six overall guidelines for the study:

1. Inappropriate shoulder bracing

2. Excessive time on opioids

3. Excessive surgeries

4. Unnecessary steroid injections

5. Unnecessary home care

6. Excessive physical therapy (“PT”)

Each claimant was assigned to a hospital referral region (HRR) on the basis of zip code. The percentage in compliance with each guideline was then calculated for each HRR and adjusted for age and sex, using standard linear models. For each guideline, the 10 HRRs with the lowest compliance were identified.

Overall Compliance With Guidelines Was High

Aside from excessive PT, the overall level of compliance with the guidelines was quite high, with five of the six guidelines having mean compliance by HRR more than 75% and two of the guidelines more than 90%. For example, compliance to the unnecessary home care guideline was greater than 97%. By and large, HRRs on the lowest compliance “bottom 10 lists” were different across guidelines. The researchers suggest that there seemed also to be a clustering of lower compliance in some geographical regions for specific guidelines. For example, shoulder-bracing compliance tended to be lower in the Western states. Louisiana had several HRRs with low compliance for the opioid guideline, and Texas had several HRRs with low compliance for home health care guideline. The researchers noted, however, no strong geographic trends for three guidelines—unnecessary steroid injections, the excessive surgery guideline or excessive PT guidelines. With these three guidelines there were, nevertheless, some outliers.

The researchers concluded that the correlations among treatment guidelines tended to be weak and not consistently positive. The researchers noted some of this could be caused by “supply side” factors. For example, some HRRs might have a surplus of surgeons and a dearth of say, physical therapists.

The researchers posit that one factor that could explain the level of variation is the extent of medical consensus regarding a specific type of treatment. While the experts utilized in crafting the studied guidelines endorsed all the guidelines tested, there were varying degrees of consensus around those treatments.

Five-Step Approach to Understand Geographic Variation in Treatment Guidelines

In spite of the lack of overall correlation between the guidelines, the study does offer a conceptual framework to understand geographic variation in treatment guidelines for occupational injuries. The researchers suggest a five-step process:

1. Use treatment guidelines for specific injuries;

2. Model the cost implications of these guidelines;

3. Identify those guidelines that are cost saving;

4. Investigate the level of medical consensus behind these treatment guidelines;

5. Identify markets with high levels of use of services outside of practice guidelines.

The researchers point out that these markets would be geographic areas to target interventions that had the potential to reduce both the cost of and the variability of health outcomes.

Study Limitations

As with any study, this one is not without its limitations. The researchers noted some inconsistency in the underlying data related to the home care variable. They noted as well that, as is typical in this sort of analysis, small numbers of claimants in some HRRs might compromise the external validity of the study results. Finally, the researchers observed that, as with any clinical practice guidelines, there were always exceptions. That is to say that treatment that might be inappropriate or excessive for the majority of patients in a given group might still be warranted given test results or patient history not captured to the claims data.

Additional Studies Needed

In spite of the limitations, the researchers indicated that the study framework might motivate other researchers to develop clinical guidelines for the treatment of other occupational injuries and to explore their geographic variability. The result could be the discovery of creative ways to reduce variability in spending for occupational injuries and ensure optimum treatment for injured workers.

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