Adoption and use of guidelines for whiplash: an audit of insurer and health professional practice in New South Wales, Australia.

BACKGROUND: In Australia, the New South Wales (NSW) State Insurance Regulatory Authority has been continuously developing and implementing clinical practice guidelines to address the health and economic burden from whiplash associated disorders (WAD). Despite this, it is uncertain the extent to which the guidelines are followed. This study aimed to determine insurer and health professional compliance with recommendations of the 2014 NSW clinical practice guidelines for the management of acute WAD; and explore factors related to adherence. METHODS: This was an observational study involving an audit of 288 randomly-selected claimant files from 4 insurance providers in NSW, Australia between March and October 2016. Data extracted included demographic, claim and injury details, use of health services, and insurer and health professional practices related to the guidelines. Analyses involved descriptive statistics and correlation analysis. RESULTS: Median time for general practitioner medical consultation was 4 days post-injury and 25 days for physical treatment (e.g. physiotherapy). Rates of x-ray investigations were low (21.5%) and most patients (90%) were given active treatments in line with the guideline recommendations. The frequency of other practices recommended by the guidelines suggested lower guideline adherence in some areas such as; using the Quebec Task Force classification (19.9%); not using specialised imaging for WAD grades I and II (e.g. MRI, 45.8%); not using routine passive treatments (e.g. manual therapy, 94.0%); and assessing risk of non-recovery using relevant prognostic tools (e.g. Neck Disability Index, 12.8%). Over half of the claimants (59.0%) were referred to other professionals at 9-12 weeks post-injury, among which 31.2% were to psychologists and 68.8% to specialists (surgical specialists, 43.6%; WAD specialists, 20.5%). Legal representation and lodgment of full claim were associated with increased number of medical visits and imaging (ρ 0.23 to 0.3; p < 0.01). CONCLUSION: There is evidence of positive uptake of some guideline recommendations by insurers and health professionals; however, there are practices that are not compliant and might lead to poor health outcomes and greater treatment cost. Organisational, regulatory and professional implementation strategies may be considered to change practice, improve scheme performance and ultimately improve outcomes for people with WAD.

Modeling Intermittent Cycling Performance in Hypoxia Using the Critical Power Concept.

PURPOSE: This study investigated the efficacy of an intermittent critical power (CP) model, termed the "work-balance" (W'BAL) model, during high-intensity exercise in hypoxia (HYPO). METHODS: Eleven trained male cyclists (mean ± SD age, 27 ± 6.6 yr; V˙O2peak, 4.79 ± 0.56 L·min(-1)) completed a maximal ramp test and a 3-min "all-out" test to determine CP and work performed above CP (W'). On another day, an intermittent exercise test to task failure was performed. All procedures were performed in normoxia (NORM) and HYPO (FiO2 ≈ 0.155) in a single-blind, randomized, and counter-balanced experimental design. The W'BAL model was used to calculate the minimum W' (W'BALmin) achieved during the intermittent test. The W'BALmin in HYPO was also calculated using CP + W' derived in NORM (N + H). RESULTS: In HYPO, there was an 18% decrease in V˙O2peak (4.79 ± 0.56 vs 3.93 ± 0.47 L·min(-1); P < 0.001) and a 9% decrease in CP (347 ± 45 vs 316 ± 46 W; P < 0.001). No significant change for W' occurred (13.4 ± 3.9 vs 13.7 ± 4.9 kJ; P = 0.69; NORM vs HYPO). The change in V˙O2peak was significantly correlated with the change in CP (r = 0.72; P = 0.01). There was no difference between NORM and HYPO for W'BALmin (1.1 ± 0.9 kJ vs 1.2 ± 0.6 kJ). The N + H analysis grossly overestimated W'BALmin (7.8 ± 3.4 kJ) compared with HYPO (P < 0.001). CONCLUSION: The W'BAL model produced similar results in HYPO and NORM, but only when model parameters were determined under the same environmental conditions as the performance task. Application of the W'BAL model at altitude requires a modification of the model or that CP and W' are measured at altitude.