Impairment rating ambiguity in the United States: the Utah Impairment Guides for calculating workers' compensation impairments.

Since the implementation of workers' compensation, accurately and consistently rating impairment has been a concern for the employee and employer, as well as rating physicians. In an attempt to standardize and classify impairments, the American Medical Association (AMA) publishes the AMA Guides ("Guides"), and recently published its 6th edition of the AMA Guides. Common critiques of the AMA Guides 6th edition are that they are too complex, lacking in evidence-based methods, and rarely yield consistent ratings. Many states mandate use of some edition of the AMA Guides, but few states are adopting the current edition due to the increasing difficulty and frustration with their implementation. A clearer, simpler approach is needed. Some states have begun to develop their own supplemental guides to combat problems in complexity and validity. Likewise studies in Korea show that past methods for rating impairment are outdated and inconsistent, and call for measures to adapt current methods to Korea's specific needs. The Utah Supplemental Guides to the AMA Guides have been effective in increasing consistency in rating impairment. It is estimated that litigation of permanent impairment has fallen below 1% and Utah is now one of the least costly states for obtaining workers' compensation insurance, while maintaining a medical fee schedule above the national average. Utah's guides serve as a model for national or international impairment guides.

Chronic pain: second, do no harm.

Pain may be undertreated--contributing to anguish, as reported by the World Health Organization. Pain may be overtreated--inadvertently contributing to drug addiction, drug diversion, and even death. Pain may be misunderstood-contributing to illness propagation, as reported in somatization literature. Pain words may even be presented as a tool of manipulation, where report of pain is verbiage in pursuit of utilitarian social consequence. Thus, primum non nocere--first, do no harm--is not easily achieved in the pharmacological treatment of pain, particularly in pain reported chronically. Herein, we examine the pharmacological treatment of chronic pain, and we suggest strategies for improved management that are based on solid principles derived from extensive experience which may protect against the problems derived from the vague and subjective nature of pain symptoms. Optimal treatment of chronic pain may be assisted by three paradigms: (1) an adequate model of appraisal, (2) treatment focused on pathophysiology (whether physical, psychosocial, or some combination of these), and (3) frequent reassessment of total social function. By these approaches, contribution to drug abuse, diversion, and life deterioration can be largely avoided. Whereas the emphasis here is pharmacological management, the principles may be more widely applied to other therapies of chronic pain.

Associations of body mass index with meniscal tears.

BACKGROUND: Meniscal tears are common knee injuries, with limited reported data on associated factors, let alone risk factors. The objective of this study was to determine whether associations exist between increasing obesity and meniscal tears leading to surgery. METHODS: We performed frequency-matched case-control studies using surgical case data for years 1996 to 2000 from administrative databases of two large Utah hospitals; each case was matched with three controls from a large cancer screening trial. Meniscal tear cases (262 male and 282 female) were determined by surgical procedures. Inclusion criteria were age (50 to 79) and body mass index (BMI) (17.00 to 54.99 kg/m(2)). Gender-specific, age-adjusted odds ratios with 95% confidence intervals (CIs) were calculated for BMI categories from <20.00 to >/=40.00. The referent BMI category was 20.00 to 22.49. RESULTS: Age-adjusted odds ratios for likelihood of meniscal surgery among those with a BMI of >/=40.00 were 15.0 (95% CI=3.8-59.0) for men, and 25.1 (95% CI=10.3-60.8) for women. All odds ratios for men and women with BMIs of >/=27.50 and >/=25.00, respectively, were statistically significantly elevated. CONCLUSIONS: Significant associations were demonstrated between increasing BMI and meniscal surgeries in both genders, including obese and overweight adults.

Presurgical biopsychosocial variables predict medical and compensation costs of lumbar fusion in Utah workers' compensation patients.

BACKGROUND CONTEXT: Elective lumbar fusion surgery is a prevalent and costly procedure that requires a lengthy rehabilitation. It is important to identify presurgical biopsychosocial predictors of medical and compensation costs in such patients. PURPOSE: To determine if presurgical biopsychosocial variables are predictive of compensation and medical costs in a cohort of Utah lumbar fusion patients receiving workers' compensation. STUDY DESIGN/SETTING: A retrospective-cohort study consisting of a review of presurgical medical records and accrued medical and compensations costs. PATIENT SAMPLE: A consecutive sample of 203 compensated workers from Utah who underwent lumbar fusion from 1990 to 1995. Patients were at least 2 years postsurgery. OUTCOME MEASURES: Total accrued medical and compensations costs. METHODS: A retrospective review of presurgical biopsychosocial variables and total accrued medical and compensation costs was conducted. RESULTS: Presurgical variables from each of the biopsychosocial domains were statistically significantly correlated with medical and compensation costs. Social and biological variables were the best predictors of total compensation costs, whereas psychological variables were better predictors of total medical costs. CONCLUSIONS: Compensation and medical costs associated with posterolateral lumbar fusion can be predicted by preintervention biopsychosocial variables. Cost reduction programs might benefit from identifying biopsychosocial factors related to increased costs.