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.