John Kuhnlein ,DO, MPH, CIME, FACPM, FACOEM

Medix Occupational Health

Ankeny Iowa

04/18/23 2

“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

04/18/23 3

“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.”

04/18/23 4

04/18/23 5

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 ways;Wait and Watch what happens in other states prior

to considering implementationNot never, just not nowNever in it’s current iteration and format

04/18/23 6

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 based

04/18/23 7

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”

04/18/23 8

Some of the basics -

The Guides originally came from a series of articles in JAMA from 1958-1970 The First Edition of The Guides

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.

04/18/23 9

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

04/18/23 10

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 (GMFH-CDX)+(GMPE-CDX)+(GMCS- CDX)

04/18/23 11

So what’s different? Remember ease-of-application! 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) andsometimes lower extremity (amputation,

some CDX 3 and 4 injuries) (543)

04/18/23 12

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.

04/18/23 13

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

04/18/23 14

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 values

04/18/23 15

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 errata.

Tendinitis/epicondylitis handled now May be a bit more straightforward if the

strict methodology is followed, although the exceptions are significant and confusing.

04/18/23 16

The 6th Edition has issues So many issues, so little time THE PARADIGM SHIFT

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

04/18/23 17

The 6th Edition has issues THE PARADIGM SHIFT

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.

04/18/23 18

The 6th Edition has issues THE PARADIGM SHIFT

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 actuarials

04/18/23 19

The 6th Edition has issues THE PARADIGM SHIFT

“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 issues

04/18/23 20

The 6th Edition has issues THE PARADIGM SHIFT

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.

04/18/23 21

The 6th Edition has issues Changes in Ordinal Values- Untoward and

Unexpected OutcomesCervical 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

04/18/23 22

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 scoring.

04/18/23 23

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 not.

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.

04/18/23 24

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 expenses.

○ 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?

04/18/23 25

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 upIf 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?

04/18/23 26

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

Force“hidden agendas and biased allegiances which many

physicians (involved in the development of the Sixth Edition) cannot say”

○ Dr. Brigham issues

04/18/23 27

The 6th Edition has issues Bias? Unattributed statements in the

text, unrelated to impairment issues per seMental 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)

04/18/23 28

The 6th Edition has issues Bias? Unattributed statements in the

text, unrelated to impairment issues per seUnreferenced 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)

04/18/23 29

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” who

• 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?

04/18/23 30

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

04/18/23 31

The 6th Edition has issues Interrater Reliability

Problem is accuracy in ratings not interrater reliability which comes back to the consensus.

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 number

04/18/23 32

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 scenario.

Remember that you can have objective physical findings that can DECREASE the rating.

04/18/23 33

Summary

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.

04/18/23 34

04/18/23 36

04/18/23 37

04/18/23 38

04/18/23 39

04/18/23 40

04/18/23 41

04/18/23 42

04/18/23 43