Medical Overtreatment: Friend or Foe?

"Overtreatment" is a neologism coined some 15 years ago to denote medical and surgical interventions that are unnecessary. It is a topical term for an old concept. However, it has rapidly become a shibboleth for those inclined toward finger-pointing and blaming in matters of health policy. As such, it is a "foe" that heats up rather than modulates debate. But if one examines the notion in the context of the contemporary patient-physician dialogue, it is anything but a foe. Overtreatment and its fellow travelers, overutilization and overprescription, face off with contrary notions when a patient contends with the challenge of evaluating any clinical option.

Disability determination: validity with occupational low back pain.

UNLABELLED: Disability determination for occupational low back pain challenges indemnification systems because spinal pathoanatomy is weakly related to pain intensity and functional capacity, making judgments of disability vulnerable to such confounding factors as sociodemographic variables (eg, race, socioeconomic status). To assess the contribution of impairment, race, and socioeconomic status to disability ratings and post settlement functional status, the current study investigated 580 African American and 892 white workers' compensation claimants with occupational low back pain who were surveyed an average of 21 months after claim settlement. Results indicated that diagnosis, surgery, and medical costs (indicators of impairment) were associated with disability ratings at the time of case settlement. African American race was negatively associated with disability ratings and also with diagnosis/surgery and medical costs. Disability ratings, however, correlated only weakly with post settlement status at 21-month follow-up. The association between race and disability ratings suggests that inequities operate in disability determination. Furthermore, the relative lack of association between disability ratings and postsettlement status raises questions about the validity of disability determination for workers' compensation claimants with low back pain. PERSPECTIVE: Results demonstrated apparent racial/ethnic disparities in treatment and little association between disability ratings and post settlement status. Together, these results raise questions about social justice in the management of occupational back pain, as well as the validity of associated disability determination processes.

Clinical and social predictors of application for social security disability insurance by workers' compensation claimants with low back pain.

OBJECTIVE: The objective of this study was to identify clinical and social predictors of application for Social Security Disability Insurance (SSDI) in workers' compensation claimants with low back pain. METHODS: Archival and interview data were analyzed for 1372 Missouri claimants who were, on average, nearly 42 months postinjury. RESULTS: Two hundred sixty-five (19.3%) claimants were receiving SSDI (8.0%) or had applied for SSDI (11.3%). Logistic regression indicated that black race, older age, herniated disc diagnosis, surgery, and longer time since injury were associated with increased odds of SSDI. Higher preinjury wage, more education, and higher satisfaction with medical treatment and/or treatment by employer were associated with decreased odds of SSDI. CONCLUSIONS: Application for SSDI among claimants with occupational low back pain is associated with social factors like race, satisfaction, and socioeconomics as well as clinical factors like diagnosis and surgery.

Race and socioeconomic differences in post-settlement outcomes for African American and Caucasian Workers' Compensation claimants with low back injuries.

The purpose of this study was to predict post-settlement pain intensity, psychological distress, disability, and financial struggle among African American (n=580) and non-Hispanic Caucasian (n=892) Workers' Compensation claimants with single incident low back injury. The study was a population-based telephone survey conducted in three population centers in Missouri. Post-settlement outcomes were predicted from claimant demographics (race, age, gender); socioeconomic status (SES); diagnosis and legal representation; and Workers' Compensation resolution variables (treatment costs, temporary disability status, disability rating, settlement costs). Simultaneous-entry, hierarchical multiple linear regression analyses indicated that African American race and lower SES predicted higher levels of post-settlement pain intensity, psychological distress (general mental health, pain-related catastrophizing), disability (pain-related role interference), and financial struggle, independent of age, gender, diagnosis, legal representation, and Workers' Compensation resolution variables. The results suggest that African American race and lower SES-relative to Caucasian race and higher SES-are risk factors for poor outcomes after occupational low back injury. Mechanisms to explain these associations are discussed, including patient-level, provider-level, legal, and Workers' Compensation system-level factors.

Management of occupational back injuries: differences among African Americans and Caucasians.

This study examined differences in the case management of occupational low back injuries in a large, racially diverse population of Workers' Compensation claimants in Missouri. Participants were African Americans (N=580) and non-Hispanic whites (N=892) who had filed occupational injury claims that were settled over an 18-month period. Telephone interview data were gathered regarding diagnoses, legal representation, demographics, and socioeconomic status. The Missouri Division of Workers' Compensation also provided information on medical and temporary disability expenditures, claim duration, final disability ratings, and settlement awards. Simultaneous-entry, hierarchical multiple and logistic regression analyses showed significant and substantial effects for injury-related variables, socioeconomic status, and race across all Workers' Compensation variables. Differences remained for both injury and African Americans and lower socioeconomic status workers after controlling for injury, and for African Americans after controlling for both injury and socioeconomic status. Because Workers' Compensation mandates equal access to treatment and disability reimbursement for all injured workers, the differences observed in this study may reflect sociocultural biases in disability management among healthcare providers.

Choosing among employer-sponsored health plans: what drives employee choices?

OBJECTIVE: To probe employee basis for choosing health plans. METHODS: In a Web study, 337 employees from large private and public employers were asked to choose among health plans varying on several common dimensions. RESULTS: On per-dollar basis, respondents were more willing to spend $3 to $4 on out-of-pocket copayments than $1 on premiums. Nevertheless, sensitivity to monthly premium is greatest among those who are younger and cover only themselves, whereas sensitivity to the annual deductible is greatest among nonwhite families. CONCLUSION: Employees are facing a complicated choice and might be well-served by more information about the value of options under different likelihood scenarios.

Race differences in diagnosis and surgery for occupational low back injuries.

STUDY DESIGN: Population-based telephone survey in Missouri. OBJECTIVE: To examine the unique contribution of race to diagnosis and surgery rates in workers' compensation claimants. SUMMARY OF BACKGROUND DATA: Race differences in diagnostic specificity and rates of surgery may mediate documented differences in workers' compensation case management outcomes (treatment expenditures, disability ratings, and settlement awards) between African Americans and whites with low back injuries. PARTICIPANTS AND METHODS: African American (n = 580) and white (n = 892) workers' compensation claimants with single-incident low back injuries were interviewed regarding diagnoses and treatments received for their injury. Participants were, on average, 21 months after settlement. Analyses examined the association of race (controlling for clinical findings, legal representation, age, gender, and socioeconomic status) with diagnosis (herniated disc vs. regional backache) and surgery. Risk ratios for race were calculated. RESULTS: Whites were 40% more likely than African Americans to receive a herniated disc diagnosis. Of claimants with the latter diagnosis, whites were 110% more likely than African Americans to undergo surgery. CONCLUSIONS: Race differences in diagnosis and surgery may help to explain why African Americans, relative to whites, receive lower workers' compensation medical expenditures, disability ratings, and settlement awards.