Adoption and use of guidelines for whiplash: an audit of insurer and health professional practice in New South Wales, Australia

In primary musculoskeletal health care, many elements of practice have been identified as being ineffective and costly. Such practices include overuse of imaging and overuse of passive interventions [1‐5]. Accordingly, clinical practice guidelines have been developed and implemented to promote an evidence-based approach to patient care. These guidelines advocate a biopsychosocial approach with emphasis on secondary prevention of disability and promotion of self-management [6]. Recommendations therefore include; diagnosis based on triage, limited and targeted use of imaging, provision of active (performed by the patient requiring volitional effort) rather than passive (performed by a therapist with no patient effort) treatments, defined timeframes for review for an episode of care and appropriate referral of people who are not recovering. However, guideline implementation and changing professional practice remain a challenge in health care [7‐9]. Prior research has shown that implementation strategies had variable effects in changing practice and where effective, these strategies appeared to influence only a few elements of practice [10‐15]. Further, effectiveness of these strategies has been evaluated between 3 to 12 months after the intervention and long-term practice change has not been assessed. This is important because sustaining change in practice ensures quality care through continued provision of best treatments and efficient use of allocated resources [16‐18].

Implementation strategies for musculoskeletal guidelines have shown positive effects on practices such as referral for imaging and provision of active treatments. Requests for x-rays have reduced with strategies such as distribution of educational materials, educational meetings and reminder messages [19‐24]. .Health professionals more frequently advised active treatments in the management of neck pain and low back pain after delivery of a multi-faceted strategy involving educational meetings [13]. Further, the number and duration of physiotherapy visits decreased after a continuing education course and subsequent educational meetings on evidence-based management for neck pain were implemented [25]. Similarly, in arthritis management, improvements in provision of education, joint protection, social support, weight management, onward referral and prescription of medication have been observed [26].

In New South Wales (NSW) Australia, clinical practice guidelines for whiplash associated disorders (WAD) have been developed, updated and implemented over the past 17 years by the state insurance regulator, State Insurance Regulatory Authority (SIRA) [27‐29]. WAD is a huge health and economic burden in Australia with 50% of people with WAD experiencing persisting pain and disability [30]. Annual costs for WAD are more than $950 million [31] and in NSW, 46% of all claims lodged since 2007 were attributed predominantly to WAD [29]. The WAD guidelines assist health professionals to deliver best care and insurers in their decision about funding best care [27‐29]. The key guideline messages about assessment, interventions, prognosis, review and referral have been consistent through all iterations of the guidelines [27‐29]. The WAD guidelines have been disseminated since their inception with an extensive and strategic implementation program. This program has included dissemination through professional associations [32, 33], educational workshops in insurance companies [34], education by opinion leaders [35, 36] and online education [37].

Consistent with results of studies in other musculoskeletal conditions, implementation strategies for WAD guidelines to date have resulted to varying success in changing professional practice of insurers and health professionals. Awareness of and compliance with the guidelines have increased among insurance staff and health professionals have improved provision of active treatments, reassurance and classification of WAD following an educational session led by opinion leaders [34‐37]. However, there was no change demonstrated on use of appropriate outcome measures and identification of poor prognosis [36]. Compliance with recommendations on use of imaging, passive interventions and providing associated clinical care pathways have also not been explored. These elements of practice have therefore been targeted in the implementation of the most recent version of the WAD clinical practice guidelines released in 2014 [29].

Full implementation of guidelines typically takes 3 years [9] and the WAD guidelines have been actively implemented since 1999. It is therefore timely to ascertain whether insurers and health professionals continue to provide guideline-based care to people with WAD. One method to evaluate compliance with guidelines is through an audit of practice. Audit of practice has been utilised in previous studies to measure professional practice change [21, 35, 36, 38‐40], with this method argued as one of the more robust methods to evaluate quality of the process care [41, 42]. Process of care data involve aspects of the health professional-patient encounter and can be obtained from various sources including clinical notes, patient forms and insurer records [43]. Audit of insurer approvals and disapprovals and the timing of these decisions can also provide insight into indicators of scheme performance.

In NSW Australia, submission of claim-related documentation such as claim forms (e.g. accident notification form (ANF), personal injury claim form (PICF)) and physical treatment request forms (notification of commencement (NOC) form, review form) are the primary mechanisms for communicating details of management to insurers and accessing treatments after WAD. A systematic evaluation of claim-related documentation provides a picture of the extent to which insurers and health professionals are implementing the WAD guidelines. An audit of claim-related documentation will also allow for exploration of other factors that could influence change in clinical practice. Factors such as legal representation, compensation and claim type have been associated with increased health care utilisation following a motor vehicle crash (MVC) [44‐46]. Further, comparing cross-sectional audits of practice conducted in similar cohorts across different time points will also help determine which changes in practice have been sustained over time.

This study therefore aimed to determine compliance of insurers and health professionals with the recommendations of the 2014 clinical practice guidelines for WAD and examine whether changes in professional practice have been sustained over time in light of previous investigations of WAD guideline implementation. In addition, this study aimed to explore claim-related factors associated with guideline compliance. Knowledge of compliance with guidelines in practice will form the basis for improving injury management processes and informing future implementation strategies.

Data extraction occurred from March until October 2016 (Additional file 1: Appendix 3). Demographic, claim and injury details are summarised in Table 1.

This study shows that health professionals have adopted some of the guideline recommendations when assessing and treating people with WAD. However, there are some aspects of insurer and health professional practice that are not aligned with key recommendations of the guidelines. Specialised imaging and passive treatments are being provided and approved in a large proportion of claims and monitoring of prognosis and appropriate specialist referral are not being sought by providers or insurers in a large proportion of claims. These practices have been identified as priority areas for improvement in light of the new legislation, the Motor Accidents Injuries Act 2017, which limits benefits for minor injuries such as WAD to 6 months. In the following discussion, suggestions will be made regarding strategies to facilitate compliance with recommendations of the WAD guidelines to ultimately improve outcomes for WAD.

These findings suggest that previous implementation strategies and guideline review since 1999 have been effective in changing aspects of WAD management [10, 34‐37]. Rates of x-ray investigation in this study (21.5%) were relatively low compared to the rates reported from the year 2000 to 2009 (30.0%) [54]. This is consistent with previous work in Canada and Australia where rates of x-ray investigations following WAD reduced following education and training of physicians, ED staff and nurses on use of the Canadian C-spine rule [55]. In addition, neck exercises and advice to keep active are being provided by health professionals and approved by insurers for the majority of claimants, demonstrating widespread acceptability of these guideline recommendations. Positive results of implementation strategies support the value of continuing education among insurers and health professionals about WAD guidelines.

These results also reveal that insurer claims management processes can facilitate early access to and approval of treatments and contribute to improved scheme performance. Claimants are using the ANF type of claim effectively, with 56% of claims lodged initially through this system and approved by insurers. Moreover, the median time to commencing physical treatment was 3 weeks post-MVC. These results show that claimants are taking advantage of provisional liability and accessing treatments earlier than they would have if they had to wait for full admission of liability. In a study comparing outcomes and costs for WAD pre and post the 1999 legislative reform in NSW, medical expenses in the first 6 months post-injury were higher at 2 and 4 years after the reform, indicating early access to treatment was achieved [56]. This study suggests compliance with legislative intent of the Motor Accidents Compensation Act 1999 to provide early access to treatments for people with WAD.

Whilst the current study found evidence of compliance by insurers and health professionals with some guideline recommendations, other observed practices such as not using the QTF WAD classification system and unnecessary specialised imaging demonstrate non-compliance. Health professionals commonly used “whiplash injury” (54.2%) or patho-anatomical diagnoses (26.7%), rather than the QTF classification. Further, high rates of MRI were observed despite majority of claimants being classified as Grade II, which is consistent with pursuing a patho-anatomical diagnosis. Use of unnecessary imaging in WAD has also been observed in Victoria, Australia [54], and in American and Australian cohorts investigating low back pain [57, 58]. This practice is not recommended given the lack of association between imaging findings and clinical symptoms [59‐65], and adverse outcomes associated with unnecessary imaging [66‐69]. The patterns observed in the current study and that of others suggest a dominant biomedical approach to management, which conflicts with the biopsychosocial approach advocated by the guidelines.

The high proportion of claimants receiving passive treatments beyond the acute phase of injury (> 12 weeks) may also reflect an approach that is inconsistent with guideline recommendations. Manual therapy is often provided for people with WAD in other countries [70, 71], suggesting that a proportion of health professionals continue to utilise a symptom-focused approach in management. Whilst the provision of manual (passive) therapy is recommended as an adjunct to active treatment in the acute phase of WAD, the persistence of providing this without evidence of benefit is not recommended as it promotes passive coping strategies and poor self-efficacy [29, 72‐74]. Given both these factors are associated with non-recovery [75, 76], empowering the injured person to manage their symptoms is recommended to improve health outcomes [6].

Further, both insurer and health professional practices demonstrate non-compliance with identification of claimants at risk of non-recovery and acting on this with timely and appropriate referral. Health professionals and insurers inconsistently used validated prognostic tools and rarely reported on expectation of recovery. Most referrals were made to surgical specialists, arguably too late (> 13 weeks) to influence the course of recovery as studies on WAD recovery trajectories demonstrate that most recovery occurs within 12 weeks of injury [30, 77‐79]. Additionally, recent legislative reform in NSW (Motor Accidents Injuries Act 2017 No 10) will limit access to benefits to 6 months for people with minor injuries such as WAD. Thus, the recommendation in guidelines is for onward referral between 3 and 6 weeks to address non-recovery [29]. The change in the scheme, guideline recommendations on referral and data on recovery trajectories emphasize the importance of ensuring treatments maximise the potential for recovery and limit chronicity.

Given that implementation strategies to date (e.g. dissemination of guidelines, educational workshops, online education) have not been completely successful in promoting compliance with all of the recommendations in the guidelines, alternative strategies may need to be considered. One strategy may be to implement organisational changes such as mandating practice through policy or within insurer claims management processes. Regulatory or legislative changes may also be implemented by the insurance regulator to involve restrictions in payment of treatment requests or having a reasonable cap for number of treatments provided. Evidence in other settings showed that changing policies at the level of the organisation resulted to changes in practice. Reimbursement restriction policies decreased inappropriate medication prescribing [80], and promoted better use of medications with reduced costs without an increase in utilisation of other health services [81].

At the level of the insurers, changes in claims management processes may include mandated use of validated risk screening tools, such as the clinical prediction rule for WAD [82, 83], and mandated peer review by WAD specialists based on risk of non-recovery. Such practices have demonstrated effect; implementing use of screening tools such as the Canadian C-spine rule as a policy within a community hospital ED led to a significant reduction in x-ray requests [84]. Further, results of a study among injured workers showed that mandated risk assessment and early referral to psychologists of those at high-risk of delayed recovery improved outcomes and reduced costs [85]. A qualitative study exploring the perceptions of health professionals on WAD specialist referral also suggested that a standardised process for specialist review mandated by the insurers might promote good referral practices [86]. Another strategy could be to use WAD-specific standard reporting and referral forms, a strategy shown to improve compliance in other health populations [87, 88].

Professional implementation strategies have been effective in instigating practice change; however, there are entrenched behaviours remaining unchanged and appeared to be influenced by scheme and compensation factors. Results of the current study showed that having legal representation and full, ongoing claims were associated with higher number of medical visits, specialised imaging and cost of treatment. Although associations were weak to moderate, these results highlight that organisational and regulatory changes, in addition to professional implementation strategies, may be necessary to change practice.

In summary, there is evidence of insurer and health professional practices that are compliant with recommendations from WAD guidelines. Claimants receive early access to and approval of appropriate care. However, there is also evidence of practices that are not compliant and might lead to poor health outcomes and greater treatment costs. Alternate implementation strategies may need to be considered to reduce unnecessary imaging and the persistent provision of passive treatments; promote use of validated prognostic tools; and maximise early referral to WAD specialists and psychologists. It appears that multiple strategies involving organisational, regulatory and professional interventions may be necessary to successfully implement the recommendations of the WAD guidelines to change practice, improve scheme performance and ultimately improve outcomes for people with WAD.