Cover: Technical Quality and Clinical Acceptability of a Utilization Review Guideline for Occupational Conditions

Technical Quality and Clinical Acceptability of a Utilization Review Guideline for Occupational Conditions

ODG® Treatment Guidelines by the Work Loss Data Institute

Published Jul 18, 2017

by Teryl K. Nuckols, Kanaka Shetty, Laura Raaen, Dmitry Khodyakov

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The Official Disability Guidelines (ODG) Medical Treatment Guidelines by the Work Loss Data Institute (WLDI) are widely used by payers to review workers' compensation claims. However, the ODG's quality does not appear to have been comprehensively evaluated in recent years. In light of new, more rigorous standards for developing guidelines and for performing the systematic reviews that underlie guidelines, this report assessed the ODG's technical quality and clinical acceptability. Expert clinicians gave favorable ratings to most of the content that they reviewed on common occupational disorders, despite notable limitations to the methods that WLDI uses to develop the ODG. ODG's development methods received a score of 58 percent on the AGREE II instrument, a widely used tool for appraising guidelines, and a fair/good score on the AMSTAR instrument, an established tool for assessing underlying systematic reviews. These quality scores reflect strengths and weaknesses in ODG's development methods. Strengths include an expansive scope, clearly written recommendations, frequent updating, regular and extensive input from clinicians, and a well-designed tool for applying recommendations. Weaknesses include limited input from workers with occupational conditions and inadequate information about the methods used to identify and synthesize evidence. After technical quality was evaluated, a multidisciplinary panel of eight expert clinicians rated the validity of selected topics in the ODG related to common types of occupational disorders. Reflecting a relatively high degree of confidence in its clinical acceptability, panelists agreed that the material in the ODG related to 41 of 47 topics was clinically valid; the remaining topics were of uncertain validity.

Key Finding

The Official Disability Guidelines (ODG) Medical Treatment Guidelines received overall favorable ratings from expert clinicians on content related to common occupational conditions, despite notable limitations to the methods used to develop the guidelines. ODG's strengths include an expansive scope, clearly written recommendations, frequent updating, regular and extensive input from clinicians, and a well-designed tool for applying recommendations. Weaknesses include limited input from workers with occupational conditions, inadequate information about the process by which evidence is identified and synthesized, and lack of documentation that ODG chapter development teams were free of conflicts of interest and had editorial independence. Of note, however, expert panelists in diverse clinical specialties found material related to 41 of the 47 topics that they considered in the ODG to be clinically valid, reflecting a relatively high degree of confidence in the clinical acceptability of the guideline. For the six remaining topics, including medications and nonoperative procedures for neck and upper back injuries as well as nonoperative procedures for hip injuries, content was of uncertain validity. Several panelists also noted that the evidence basis for numbers of allowed physical therapy sessions was uncertain.

Recommendations

  • Payers, policymakers, and clinicians who are considering implementing the Official Disability Guidelines (ODG) should note that diverse clinical experts from the United States and Australia agreed that most of the guideline content related to common occupational disorders was valid. However, to ensure patients with occupational conditions achieve the most favorable clinical and occupational outcomes possible, workers' compensation stakeholders -- such as ODG users, employers, and workers -- may want to consider whether WLDI takes future steps to address ODG's limitations, including limitations to technical quality and on specific clinical topics.
  • WLDI can improve ODG by engaging workers or their representatives; ensuring that experienced methodologists are involved in guideline development; improving documentation of search terms, selection criteria, and numbers of studies identified and eligible, and creating evidence tables that describe published literature for each recommendation; documenting and mitigating any conflicts of interest among ODG chapter development teams and ensuring that they have editorial independence; and continuing to seek and incorporate regular feedback from clinicians and others as to the optimal formulation of individual guideline recommendations.

The research described in this report was conducted by RAND Labor and Population.

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