My Thoughts on the New MTUS Treatment Guidelines

| | Evidence Based Medicine

Dr Cortes February 2017 Article on the Rise of ODG
On November 1, 2017, California Department of Workers’ Compensation (DWC) ordered evidenced based updates to Medical Treatment Utilization Schedule (MTUS) for services rendered on or after December 1, 2017. MTUS adopted and incorporated the American College of Occupational and Environmental Medicine’s Occupational Medicine Practice Guidelines (ACOEM).

The clinical topics incorporated are Cervical & Thoracic Spine Disorders (May 27, 2016), Shoulder Disorders (August 1, 2016), Elbow disorders (2013), Hand, Wrist & Forearm Disorders (June 30, 2016), Low Back Disorders (April 24, 2016), Knee Disorders (October 28, 2015), Ankle & Foot Disorders (September 2015), Stress Related Conditions (May 2017), Eye Disorders (April 1, 2017), Hip & Groin (May 1, 2011), Occupational/Work-Related Asthma (January 4, 2016), Occupational Interstitial Lung Disease (January 4, 2016), Chronic Pain (May 15, 2017), Opioids (April 20, 2017).

The Acupuncture, and Post Operative Rehabilitation guidelines were not changed and remain as part of the Clinical Topics Guideline, Chronic Pain Guidelines and/or Opioid Guideline. The previously adopted Chronic Pain Medical Treatment Guidelines based on ODG on July 28, 2016 are no longer part of MTUS.

While incorporation of these guidelines is a step forward for CA DWC, as its previous guidelines were mostly outdated, some of these newly adopted guidelines are also older. For example, the elbow disorders guideline is from 2013, and hip & groin disorder guideline is from 2011. The infrequent updating of the ACOEM guidelines makes it less relevant compared to other guidelines when it comes to addressing newer treatments and technologies.

ODG is the default guideline used by many jurisdictions for the latest up-to-date treatments. In fact, ODG is the preferred guideline by many not only because its recommendations are very current, as its constantly being updated, but also because it has a very user friendly search engine and clearly outlines treatment criteria for most treatments. Therefore, ODG leaves little room for improper interpretation.

The CA DWC website states “for all conditions or injuries not addressed in MTUS, the authorized treatment and diagnostic services are to be in accordance with other scientifically and evidenced-based medical treatment guidelines that are nationally recognized.” In a recent MTUS training webinar, the recommended search sequence for evidence based medicine was listed as MTUS, ODG, EBM, and scientifically based peer reviewed and nationally published evidence. Once again, this leaves the door open for ODG to be used for treatments that are not addressed or have no recommendations in ACOEM.

While there are a lot of strong points to MTUS and the newly adopted ACOEM guidelines, there are several deficiencies. It does not adequately address post operative rehabilitation. There are numerous treatments in which there are no recommendations, either for or against. Fortunately, many of these deficiencies are generally addressed by ODG. Also, some recommendations in ACOEM are not comprehensive. An example of this is for total hip and total knee replacements. ACOEM makes no mention of age or weight (BMI index) limitations in its recommendation for surgery, factors that are crucial due to possible adverse outcomes.

Another concern is that multiple treatments recommended in ACOEM are not FDA approved. Voltaren gel is FDA approved for osteoarthritis of the elbow, wrist, hand, knee, ankle and foot. But ACOEM recommends Voltaren for several soft tissue conditions, including tendinopathies, tenosynovitis, chronic pain, neuropathic pain and CRPS. Hyaluronate injection is recommended by ACOEM for hand osteoarthritis and hip osteoarthritis but not for the knee, which is the only use that is FDA approved.

The CA MTUS change to the current ACOEM guidelines is definitely an improvement from the outdated 2004 ACOEM guidelines previously used. Despite the fact that the change to these guidelines occurred on December 1, 2017, some providers and reviewers have not embraced the changes and need reminders of the change. Implementation of the CA drug formulary on January 1, 2018 will further add a layer of complexity. While ACOEM is the first guideline to be used to address treatment requests, having the alternate options including ODG help to fill the gaps not addressed by ACOEM.

Zenia Cortes, MD, Orthopedic Surgeon

Dr. Zenia Cortes brings her combined expertise in sports and orthopaedic medicine to UniMed Direct, along with insights from her experience in peer and utilization review.