The AMA Guides to the Evaluation of Permanent Impairment, by sjh18818


									John Kuhnlein ,DO, MPH, CIME, FACPM, FACOEM
           Medix Occupational Health
                  Ankeny Iowa
       “Energy in the executive is a leading
       character in the definition of good
       government. A feeble executive implies a
       feeble execution of government.

       A feeble execution is but another phrase for
       a bad execution: and a government ill
       executed, whatever it may be in theory, must
       be, in practice, a bad government.”

                       Alexander Hamilton, Federalist Papers, No. 70

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       “Energy in editorial control is a leading
       character in the definition of a good Guides.
       A feeble or misguided editorial control
       implies a feeble execution of the Guides.

       A feeble execution is but another phrase for
       a bad Guides: and a Guides ill executed,
       whatever it may be in theory, must be, in
       practice, a bad Guides.”

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So what do you need to know
about the 6th Edition?
 The Iowa Task Force regarding the use of
  the 6th Edition voted against it’s use in
  Iowa, and I’ll try to explain my thoughts
  about this. You can view the report at the
  Iowa Workforce Development website.
 One can look at this position in a number of
        Wait and Watch what happens in other states
         prior to considering implementation
        Not never, just not now
        Never in it’s current iteration and format
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The 6th Edition uses 5 new
axioms for impairment rating (2)
 The Guides adopts the terminology and
  conceptual framework of the
  International Classification of
  Functioning, Disability and Health (ICF)
  Fig 1-1 (3) Old model 5th Fig 1-1 (8)
 The Guides becomes more diagnosis

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The 6th Edition uses 5 new
axioms for impairment rating (2)
 “Simplicity, ease-of-application, and
  following precedent, where applicable,
  are given high priority, with the goal of
  optimizing interrater and intrarater
  reliability” (italics added)
 Rating percentages “functionally based”
 “Conceptual and methodological
  congruity within and between organ
  system ratings”

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Some of the basics -
 The Guides originally came from a
  series of articles in JAMA from 1958-
  1970         The First Edition of The
 Subsequent Editions have been
  evolutionary in approach; the 6th is
  revolutionary, using a very different
  model, not only conceptually, but in how
  ratings are practically derived.

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So what’s different?
     In the other Editions, we took the injury
      apart into range of motion, motor,
      sensory, ligamentous structure,
      sometimes DRE and then combined
      them back into the impairment-it was
      mostly based on the physical
      examination regardless of diagnosis,
      most of the time

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So what’s different?
Remember this is simple and easy.
 Radically different methodology based
  on a Clinical Diagnostic Class (CDX),
  which assigns impairment to the median
  value in a grid of impairments, with
  several exceptions.
 The CDX is then modified using the Net
  Adjustment Formula (NAF) using
  modifiers for functional history, physical
  examination, and diagnostic studies
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So what’s different? Remember
     This model is used most of the time,
      except for:
        mental health,
        carpal tunnel syndrome, Table 15-23, (449)
        sometimes upper extremity, (amputation,
         some CDX 3 and 4 injuries) (461) and
        sometimes lower extremity (amputation,
         some CDX 3 and 4 injuries) (543)

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The 5th is far from perfect
 No real scientific support for impairment
  rating values – always has been a
  consensus process.
 If the doctor doesn’t read the book,
  significant errors may ensue.
        Open the book, look at a few tables and use one
         of the numbers to assign a rating. Some docs
         don’t even do this much.
        The doctors don’t mention the tables and pages
         so the reader can follow where the numbers are
         coming from.

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The 5th is far from perfect
 Lack of internal consistency-visual
  system ratings aren’t consistent with the
  MSK chapter ratings.
 Sometimes there are significant gaps
  between DRE impairments-what’s wrong
  with 3%? It jumps from 0 (DRE I) to 5%
  (DRE II) Fig 15-3, page 384
 Sometimes major nerves are missing,
  e.g. in the lower extremity, Table 17-31,
  Page 544

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The 5th is far from perfect
 In the case of multiple spine surgeries-
  you use the ROM method (379-380), but
  the numbers come out LOWER than if
  you only have one surgery. With one
  surgery only cervical fusion is minimum
  25% BAW Fig 15-5 392
 Mental health issues have no ordinal

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The 6th has some advantages
     The spine gaps are filled in
     Nerves are addressed that weren’t before
     There is a methodology for rating mental
      health issues-although in error originally.
      Recently corrected in the first 52 page
     Tendinitis/epicondylitis handled now
     May be a bit more straightforward if the
      strict methodology is followed, although the
      exceptions are significant and confusing.
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The 6th Edition has issues
     So many issues, so little time
        What is a paradigm shift
        Who voted to say we needed a paradigm shift in
         the first place?
        “By physicians for physicians” but:
           ○ AMA was threatened by lawsuit by ACA if the
             wording didn’t change
           ○ No one asked the end users (e.g. the worker’s
             compensation users) if needed or wanted at all. It
             doesn’t appear that the true impact on the end users
             was considered
        Methodology includes disability issues so mixing
           impairment with disability measures

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The 6th Edition has issues
        Despite the editors assertions that this
           edition of the Guides will “move the process
           forward” there are still practical issues of
           implementation that, if considered, don’t
           seem to have been considered important.

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The 6th Edition has issues
        May produce untoward and unexpected
         outcomes or harm to either party – the 2006
         injury vs. the 2008 and outcomes. 25 v. 6,
         MH issues
        There doesn’t seem to be a mechanism in
         place to assess +/- impact for adaptation.
         Rondinelli comment 2/1/08 re AMA

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The 6th Edition has issues
        “Do No Harm” principle - issues of harm to
         employee, multistate employer, physicians
        Physicians who write Guides forget common
         sense. They get bound up in methodology,
         testify as to science, and studies, but forget
         to step back and look at this as a social
         process. We hear about studies and
         evidence based medicine, but no comment
         upon real implementation problems and
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The 6th Edition has issues
        My view – intriguing concept, but
        Iowa should wait and watch. Let sister
         states who mandate use find out if this
         paradigm is usable and then reevaluate.
        Not never, just not now.

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The 6th Edition has issues
     Changes in Ordinal Values- Untoward
      and Unexpected Outcomes
        Cervical Fusion ratings may be dramatically
         different. 5th = 25-28% DRE. 6th may be 6%
         or 0% BAW. Table 17-2 page 564.
        Mental health now present so ratings here
         may go up. You have numbers where you
         didn’t before.
        Tendinitis
        Uncertain whether certain conditions change
         dramatically, if overall ratings go up/down
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The 6th Edition has issues
     Cultural and Racial Issues
        Reported to Task Force that QuickDASH,
         AAOS, PDQ not culturally sensitive.
        People of culture are often also people of
         different race.
        Because of the way the questionnaires are
         used, there may be either an advantage or
         disadvantage to people of culture and color.
         See pp. 446-447 6th Edition re QuickDASH

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The 6th Edition has issues
     Physician Issues
        Carpal Tunnel syndrome can be diagnosed
         using one set of EMG/NCV criteria but is rated
         using another set of EMG/NCV criteria. This
         creates a double standard. (446)
        Physicians may see complaints to state Boards
         of Medicine for “unnecessary surgery”. Maybe
        Task Force was told that the EMG/NCV
         standards outlined in Appendix 15-B were
         determined by consensus. They are not the
         criteria from AMA component societies. But AMA
         says it wants Guides to be more objective.
         Seems this is not.

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The 6th Edition has issues
     Physician Issues
        The learning curve
         ○ 8 hour course work at several hundred dollars
           expense if not more because of travel
         ○ Dr. Melhorn indicated about 25-30 hours
           necessary to learn on your own.
         ○ If physicians simply pick up the book and look
           at tables and figures, the errors will increase,
           with increased case cost.
        Will fewer physicians do ratings?

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The 6th Edition has issues
     Physician Issues
        52 page errata took 3.5 hours for one Task
         Force member to correct with the 6th Edition,
         i.e., the 11 cm PDQ line, the MH BPRS
        More errata may be coming, uncertain now.
        If physicians who rarely use the book don’t
         review and correct with the errata, error rates
         will go up
        If the reader doesn’t know if the physician was
         aware of the latest errata, confusion will ensue
         as to whether the rating is incorrect. Was the
         reader aware of the most recent errata?
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The 6th Edition has issues
     Consensus
        Editorial Issues
         ○ Dr. Rondinelli 85/15 issues
         ○ Dr. Mueller listing issues
         ○ Dr. Colledge issues
         ○ Dr. Douglas Martin issues brought to Task
              “hidden agendas and biased allegiances which many
              physicians (involved in the development of the Sixth
              Edition) cannot say”
           ○ Dr. Brigham issues

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The 6th Edition has issues
     Bias? Unattributed statements in the
      text, unrelated to impairment issues per
        Mental health impairment limited to one
         diagnosis(349) Malingering T. 14-3, (350)
        UE three nerve issue (448)
        MMI at two stable OV’s one month apart
         after CTR (447)

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The 6th Edition has issues
     Bias? Unattributed statements in the
      text, unrelated to impairment issues per
        Unreferenced LE CRPS comments re
         “incorrect” (539) Table 16-15 (541), also see
         bibliography “preliminary”, “proposed”
        Issues related to excluding GMFH (LE 516),
         GMPE (LE 517), and GMCS values (UE 448
         re postop EMG/NCV)

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The 6th Edition has issues
     Consensus and bias
              Who wrote the chapters? We couldn’t find out.
              Who were the authors who
           •    Might have “hidden agendas and biased allegiances”
           •    Made up the consensus that
           •    Created the paradigm shift with the
           •    Potential cultural/racial issues that
           •    Might create problems for physicians?
           •    And why did this book get hurried in the rush to publish,
                and who made the corrections
           •    Published in the 52 page errata that had to be
           •    Rushed to publish because of the original
           •    Rush to publish a version we’ve been told is
           •    A beta version?

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The 6th Edition has issues
     Interrater Reliability
        Editors mentioned this several times in
         discussions with the Task Force
        So what? The deck is stacked anyway.
        There will be greater interrater reliability
         because there are essentially only five
         choices anyway based on the CDX

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The 6th Edition has issues
     Interrater Reliability
        Problem is accuracy in ratings not interrater
         reliability which comes back to the
        If the consensus is biased, the data in the
         grids is bad.
        If the data in the grids is bad then the ratings
         are bad. Physicians can all come up with
         the same number but if the data is bad, then
         the rating is bad, it will still be an incorrect

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The 6th Edition has issues
     Simplicity and ease of use
        Remember that there are occasions when
         the GMFH, the GMPE, and the GMCS can
         be disregarded, based on the particular
        Remember that you can have objective
         physical findings that can DECREASE the

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 Wait and Watch the 6th implementation
  in other states. Basically let other states
  find out if these are all valid concerns.
 There is no harm in waiting.
 Not never, just not now.

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