Background
Timely access to appropriate treatment and support after injury is crucial for optimal outcomes. Appropriate treatment is usually provided through the regular public or private health care system. In case of a compensable injury, for example a work-related or transport injury, injured people may receive treatment funded by the compensation system. In Australia, work injuries are covered and compensated by state regulated workers’ compensation systems. The workers’ compensation system compensates medical and vocational rehabilitation and income support for workers during incapacity. In New South Wales (NSW), the workplace injury management system is called SafeWork, and is mandated by Workers’ Compensation Legislation NSW, Australia [
1]. In general, the aim of the system is to provide prompt, effective and proactive management of work-related injuries.
The approval process for a compensable work injury, however, can be onerous and take a significant amount of time, particularly in complex cases. It is burdensome for health care professionals, due to the amount of paperwork required in order to get treatment approved. Claims managers, who often have a high caseload, have to review the request and investigate the adequacy, appropriateness, and effectiveness of the recommended treatment before making a decision. This means that it often takes more time before a treatment can be delivered in comparison to care delivered outside the workers’ compensation setting (for which no approval is needed). The decision-making and approval processes needs thought and reason and is not automated. Disputes can arise when a claims manager denies certain treatments on the basis of a perceived lack of evidence, which may be due to lack of knowledge about the evidence, conflicting evidence, or different interpretation of the evidence. Additionally, some treatments may be provided at a frequency greater than is clinically justified and this may represent over-servicing. Approval of non-evidence based treatments also occurs [
2], for reasons outlined above where the claims managers may not be aware of the evidence of harm (such as, collars for whiplash injury), or because they recognise that some treatments are already common practice even though clear evidence is not available (for example, hot/cold packs for low back pain). In summary, delays in treatment approval, disputes, controversial denial of treatment, overtreatment and approval of non-evidence based treatment are undesirable, can be harmful to injured people and are costly to the health care system, compensation system, workplaces and society.
In response to challenges experienced in the treatment approval process, the workers’ compensation scheme in NSW Australia is considering implementing an electronic Evidence Based Medicine (EBM) guideline tool. The tool is a North American tool but it is used worldwide. In general, EBM guideline tools provide an extensive overview of evidence based treatments and guidelines for a condition. Each referenced study is evaluated using a 30-step grading system, including evaluating sample size, conflict of interest, study design, potential bias, and statistical significance (described in the tool’s user manual, accessed March 2016, not publicly available). The summary of evidence includes an evaluation of 1) trade-off between risks versus benefits, 2) magnitude of effect of an intervention, 3) availability of dependable sources of the treatment, 4) education and experience of providers, 5) consistency of study outcomes, and 6) variability of treatment parameters being studied. The conclusion about whether the health care service is recommended or not, is made by a multidisciplinary advisory board convened by the company that has developed the tool. The names and backgrounds of the board members are provided in the tool’s user manual (accessed March 2016, not publicly available). Claims managers can use the summary and conclusion to make a decision about whether or not to (automatically) approve the treatment. In addition to an overview of recommended treatments, the EBM tool also provides an average number of calendar days of return to work (RTW) by tenth percentiles per injury type, based on the average (local, national, or international) claims data.
The workers’ compensation scheme expects that such a tool could reduce the uncertainty about the appropriateness and effectiveness of a treatment. Reducing the uncertainty could speed up the decision-making process and reduce the need to seek second opinions from medical examiners. Health care practitioners would no longer have to complete additional paperwork for those evidence-based treatments. In general, it could facilitate a common understanding across those requesting treatment/services and those reviewing the services requested.
The tool is primarily developed to be used by claims managers. However, the treatment approval process is an interaction between claims managers and health care professionals. Therefore, it is of interest to investigate how NSW health care professionals think about an EBM tool applied to the workers’ compensation setting in NSW, Australia.
Investigating health care practitioners’ opinion about an EBM tool implies investigating perceptions about EBM in general. “Evidence Based Medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” [
3]. EBM is now an accepted part of clinical practice, however, not without polarized standpoints [
4,
5]. The supporters claim that adopting an EBM approach includes positive changes in health professional behaviour, improvements in treatments, less variability between health care provided by different practitioners, and potential cost containment. The critics take the position that EBM is “cookbook medicine”, is unable to account for individual patient factors and involves decreased professional freedom [
4,
5]. Several barriers to using EBM have been identified, concerning a lack of awareness of and/or familiarity with the evidence, a lack of agreement, reduced self-efficacy, and/or motivation to apply, and the inability to reconcile EBM with patient preferences, or lack of time and resources [
6]. Barriers might be perceived differently for different health care specialties. Furthermore, it is not known how health care professionals think about EBM being applied in the workers’ compensation setting, in which another person (that is, a claims manager) is deciding what treatment should be approved.
The aims of the current study are twofold: to explore health care professionals’ attitudes to (1) EBM, in general, and (2) an EBM tool applied in a workers’ compensation setting, specifically. For attitudes to EBM in general, it was investigated whether clinical specialties differ in self-reported knowledge, attitudes, and behaviour to EBM. The attitudes to an EBM tool applied in the workers’ compensation setting were investigated without any pre-set hypotheses or direction other than investigating the advantages and disadvantages.
Discussion
This study investigated health practitioners’ perceived knowledge, attitudes and behaviours with reference to 1) evidence-based medicine in general, which was investigated by a quantitative study, and 2) an EBM tool in the workers’ compensation setting specifically, which was investigated by a qualitative study. The data collected from the health professional sample involved in the quantitative study revealed that NSW health care practitioners believe 76% of their clinical practice is evidence based. This percentage is comparable to a recent study among Australian physiotherapists and chiropractors showing that, after an intervention, 79% of participants were compliant with clinical whiplash guidelines (whereas before the intervention compliance was 58%) [
11]. On the other hand, 76% is high compared to a study among Australian general practitioners, showing that only about 20% of low back pain patients received the care that is recommended by low back pain guidelines [
12]. Our study investigated EBM practices in general, rather than being related to a specific condition, and the percentage of evidence based treatment was self-reported, so it is not possible to draw objective conclusions about the finding.
The study found differences between clinical specialties and EBM behaviour. General practitioners perceived more barriers than other clinical practitioners. This difference may be partially due to different treatment contexts. For example, general practitioners are more aware of the injured worker in their wider context, meaning their family, past health and coping styles. They might therefore perceive more barriers around applying EBM due to the concern that an EBM (tool) does not take into account individual patient differences and complex psychosocial factors. On the other hand, psychologists also treat injured persons within a wider context, but they scored highly on self-reported EBM adherence. General practitioners also deal more with a wider spectrum of diseases, so perhaps it is more difficult to keep abreast of with guidelines across all conditions [
13]. Finally, general practitioners have a gatekeeper role in the compensation system, which can create significant pressure for the professional involved [
14].
In the qualitative study, the themes identified about the EBM tool being applied in the workers’ compensation setting supported a range of views that have been published about evidence based health care, such as the importance of patient preferences and clinical judgement, influential critical appraisal of the evidence, lack of quality evidence, and the lack of evidence for the majority of care [
4,
15‐
18]. Interviewees particularly emphasised the importance of clinical judgement when applying the evidence to individual patients, reflecting Sackett’s original and widely accepted definition of evidence based medicine [
19]. Notably, participants in the qualitative study seemed much more critical of an EBM tool applied in the workers’ compensation setting than the participants in the quantitative study. One explanation maybe that many clinicians will feel threatened by such a tool, given EBM decisions are being made by an external party (the claims managers). In addition to claims managers being an external party, clinicians regard their decisions on treatment with scepticism since claims managers are often junior without a health training background.
Another important theme that was mentioned in relation to the EBM tool applied to the workers’ compensation setting, was the lack of screening tools and lack of acknowledgement of the influence of environmental and psychosocial factors, such as work dissatisfaction, family dynamic problems at home and coexisting illness in older workers. Psychosocial factors are important determinants of outcome after work injury [
20,
21]. The biopsychosocial approach has been widely advocated in medicine, but, based on communication with insurance companies, the biopsychosocial model does not seem to have been fully adopted into the compensation systems as yet. As far as we know, there is no general insurance policy for screening for the influence of psychosocial factors. Anecdotal evidence suggests that claims managers may be hesitant to provide early treatment due to the belief that this would increase the costs. However, studies in a workers’ compensation setting have shown that early screening and intervention in people with musculoskeletal injuries with high chances of poor recovery resulted in significant cost
reduction [
22,
23]. This approach has also been shown to result in improved outcomes and reduced cost in low back pain in the UK [
24], and is now being investigated in Australia for the management of whiplash [
25]. For an optimal treatment approval process, it is recommended that claims managers in the compensation system not only approve evidence based treatment, but also encourage the use of psychosocial assessment tools, that for example, predict chronic pain and disability, after which they should offer the earliest intervention available.
A meta theme that was developed from the interviews, that could explain some of the concerns about the EBM tool, may be the significant negative experiences some health professionals have had with the workers’ compensation system. Several interviewees were sceptical of an EBM tool, reporting that similar initiatives to improve the scheme had been undertaken in the past and these did not succeed (either). A recent paper about the scheme argued that ‘in spite of an abundance of government recommendations and scholarly evidence prioritising timely return to work for injured workers, the NSW Workers’ Compensation Scheme systematically fails to support this objective’ [
26]. The interaction between HCP and the claims managers in the workers’ compensation scheme has been found challenging [
27]. It seems that, besides or before implementing an EBM tool, the interaction between HCP and claims managers, and claims manager training should be improved. Early case conferencing, in which HCP, claims manager and patient are sitting in the room to discuss realistic goals and concerns, may lead to better understanding of the complexities associated with workplace injuries. Preferably, the workplace needs to be involved too [
28]. This study focused on the interaction between HCP and the compensation system only, but it should be emphasised that the employer also plays an important role in the success of treatment and the return to work process. In order to achieve an effective and sustainable compensation system, all stakeholders should be involved [
15].
Strength and limitations
A strength of the study was the moderately large sample of practitioners surveyed, providing sufficient statistical power to determine differences. Participants had substantial clinical experience, including experience within the workers’ compensation system. Potential limitations included the relatively small number of responses from some professional groups. Findings, especially in relation to general practitioners, should be interpreted with caution. While effort was made to ensure representative opinions, the study could have been limited with respect to generalisability of the clinical groups surveyed. Furthermore, the questionnaire was self-report based and self-reporting of EBM practise (or knowledge thereof) does not necessarily mean clinicians are actually practising EBM. Also, the possibility of selection bias of the participating practitioners is acknowledged and this may have resulted in respondents having a greater knowledge and use of EBM than practitioners generally.
Conclusions
Overall, it is concluded that HCP in NSW, Australia, were supportive of EBM, however, many had concerns about the implementation in clinical practice, when operating in workers’ compensation settings. It is concluded that EBM should be applied in a flexible manner, taking substantial account of the clinical expertise and judgement of the practitioners, patient differences and psychosocial contexts. If an EBM tool is going to be implemented, adequate training of claims managers is recommended as well as an introduction to the tool for clinicians. It is also concluded that special attention should be given to general medical practitioners before an EBM tool is implemented. Lastly, it is recognized that the treatment approval process in the Workers’ Compensation system in NSW is a complex and sensitive process, which could be improved if interactions between claims managers and HCP were enhanced. It is important that careful, well-informed decisions are made about treatments for those people with injuries proceeding through the system.
Acknowledgements
We thank all participants for their contribution to the study.