California workers’ compensation reforms enacted in 2003 and 2004 introduced a new process for approving medical services for injured workers, including the adoption of mandatory utilization review (UR) using evidence-based medicine guidelines.

Nearly a decade later, state lawmakers included reforms in SB 863 that added a new element to the medical service approval process, mandating the use of independent medical review (IMR) to resolve disputes over medical necessity.

The California Workers’ Compensation Institute’s latest study of California’s medical benefit delivery process expands on earlier analyses to determine the proportion of requested and/or delivered care that is approved versus denied after UR and IMR by service category.

Results show that 94.1 percent of services performed or requested from January 1, 2018 to October 31, 2018 were either approved (92.5 percent) or approved with modifications (1.6 percent), and 5.9 percent were denied, though outcomes varied by service category.

Evaluation and management services (e.g., office and emergency department visits, consultations) represented 29 .1 percent of the medical services in the 2018 data set and had an approval rate of 99.7 percent.

Surgery services were approved with or without modifications 94.9 percent of the time, while 89.4 percent of physical medicine services (physical therapy, chiropractic manipulation, and acupuncture) were approved with or without modifications.

The study also examines the impact of the UR provisions of 2016 legislation (SB 1160), which effective Janua1y 1, 2018, exempted certain services from prospective UR.

One goal of SB 1160 was to speed delivery of medical care, and while the study does find that the proportion of physical medicine services performed in the first 30 days increased from 2017 to 2018, there was no meaningful change in the delivery of other services. At the same time, the total volume of services performed in the first 60 days from injury did not increase and the denial rate for these services remained very low in both periods, ranging from 0.0 to 4.8 percent.

For the first time, the authors were able to estimate the proportion of UR denials and modifications that underwent IMR and found that an estimated 29 percent of UR modification and denial decisions were appealed and reviewed by an IMR physician.

However, an examination of the top law firms identified in the UR data reveals that the IMR referral rates by applicant attorneys varied greatly. Some attorneys submitted nearly all of their clients’ treatment modifications and denials to IMR, while others sent none.

The last section of the study continues the Institute’s monitoring of IMR volumes and results. After a 7 percent increase in volume from 2017 to 2018, IMR volume for the first half of 2019 appears to be dropping back toward 2017 levels.

As in 2018, IMR reviewers have upheld UR decisions 88 percent of the time through the first half of 2019. In addition, a small number of physicians continue to drive a disproportionate share of the IMR volume, with the top 1 percent associated with 44 percent of the IMR decisions.

Evidence is weak for whether medicinal cannabis treatments can relieve mental illnesses such as anxiety, depression and psychosis, and doctors should prescribe them with great caution, researchers said on Monday.

Reuters Health published a review of scientific studies that analyzed the impact of medicinal cannabinoids on six mental health disorders, the researchers found “a lack of evidence for their effectiveness.”

Their findings have important implications for countries such as the United States, Australia, Britain and Canada, where medical cannabis is being made available for patients with certain illness, said Louisa Degenhardt, a drug and alcohol expert at Australia’s University of New South Wales in Sydney.

“There is a notable absence of high-quality evidence to properly assess the effectiveness and safety of medicinal cannabinoids … and until evidence from randomized controlled trials is available, clinical guidelines cannot be drawn up around their use in mental health disorders,” she said as her results were published in The Lancet Psychiatry journal.

Despite a lack of clinical trial evidence, anecdotally some military veterans and others who suffer post-traumatic stress disorder (PTSD), depression and anxiety say they have found cannabis helpful in easing some of their symptoms. Other conditions cannabis is used for include nausea, epilepsy, and traumatic brain injury, but this study did not examine its impact on those.

Medicinal cannabinoids include medicinal cannabis and pharmaceutical cannabinoids, as well as their synthetic derivatives, THC, or delta-9-tetrahydrocannabinol – the main psychoactive ingredient of cannabis – and cannabidiol, or CBD.

“Cannabinoids are often advocated as a treatment for various mental health conditions,” Degenhardt said. “(But) clinicians and consumers need to be aware of the low quality and quantity of evidence … and the potential risk of adverse events.”

Degenhardt’s team sought to look at all available evidence for all types of medicinal cannabinoids. They included all study designs and investigated the impact on remission from and symptoms of depression, anxiety, attention-deficit hyperactivity disorder (ADHD), Tourette syndrome, PTSD and psychosis. They analyzed 83 published and unpublished studies covering around 3,000 people between 1980 and 2018.

They found that pharmaceutical THC – either with or without CBD – made psychosis worse, and did not significantly affect any other primary outcomes for the mental illnesses analyzed.

It also increased the number of people who reported side effects, and the number who decided to withdraw from a study due to side effects.

Tom Freeman, an addiction and mental health expert at Britain’s Bath University who was not involved with the study, said the findings highlighted an urgent need for high-quality trials of medical cannabis to strengthen the evidence – particularly given what he said was “significant demand” from patients.

Labor Code 3208.3 supposedly set a standard for evaluating psychiatric injuries in California workers’ compensation claims.

The code requires that the worker be diagnosed using the terminology and criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised, or the terminology and diagnostic criteria of other psychiatric diagnostic manuals generally approved and accepted nationally by practitioners in the field of psychiatric medicine. We are currently on the Fifth Edition.

But, no two people are exactly alike. Therefore, attempting to classify each unique individual’s mental health issues into neat categories just doesn’t work. That’s the claim coming out of a new study published in the scientific journal Psychiatry Research, that is sure to ruffle some psychologists’ feathers.

More people are being diagnosed with mental illnesses than ever before. Multiple factors can be attributed to this rise; many people blame the popularity of social media and increased screen time, but it is also worth considering that in today’s day and age more people may be willing to admit they are having mental health issues in the first place.

That’s why a new study conducted at the University of Liverpool has raised eyebrows by concluding that psychiatric diagnoses are “scientifically meaningless,” and worthless as tools to accurately identify and address mental distress at an individual level.

Researchers performed a detailed analysis on five of the most important chapters in the Diagnostic and Statistical Manual of Mental Heath Disorders (DSM). The DSM is considered the definitive guide for mental health professionals, and provides descriptions for all mental health problems and their symptoms. The five chapters analyzed were: bipolar disorder, schizophrenia, depressive disorders, anxiety disorders, and trauma-related disorders.

Researchers came to a number of troubling conclusions. First, the study’s authors assert that there is a significant amount of overlap in symptoms between disorder diagnoses, despite the fact that each diagnosis utilizes different decision rules. Additionally, these diagnoses completely ignore the role of trauma or other unique adverse events a person may encounter in their life.

Perhaps most concerning of all, researchers say that these diagnoses tell us little to nothing about the individual patient and what type of treatments they will need. The authors ultimately conclude that this diagnostic labeling approach is “a disingenuous categorical system.”

“Although diagnostic labels create the illusion of an explanation they are scientifically meaningless and can create stigma and prejudice. I hope these findings will encourage mental health professionals to think beyond diagnoses and consider other explanations of mental distress, such as trauma and other adverse life experiences.” Lead researcher Dr. Kate Allsopp explains in a release.

According to the study’s authors, the traditional diagnostic system being used today wrongly assumes that any and all mental distress is caused by a disorder, and relies far too heavily on subjective ideas about what is considered “normal.”

A new research review reported by Reuters Health suggests that people with chronic back and neck pain who receive chiropractic care may be less likely to use opioid painkillers.

Researchers examined data from six previously-published smaller studies with a total of more than 62,000 participants with spinal pain. Across all of the studies, 11% to 51% of the patients used chiropractic care.

People who saw a chiropractor were 64% less likely to use opioids than people who didn’t, researchers report in the journal Pain Medicine.

“Patients with spinal pain who visit a chiropractor may receive treatments such as spinal manipulation, massage, acupuncture, exercises and education as appropriate,’ said lead author Kelsey Corcoran of Yale School of Medicine in New Haven, Connecticut.

“These therapies may lead to decreased pain, improved range of motion and increased function,” Corcoran said by email. “If a patient’s pain is well controlled by the treatment they received from a chiropractor, they may subsequently need less pain medications or even none at all.”

Chiropractors don’t prescribe opioids. However, all of the studies in the analysis examined whether receipt of chiropractic care was associated with whether patients also received opioid prescriptions from other clinicians.

It’s not clear from this analysis whether people already using opioids to manage pain might be able to cut back or eliminate opioid use after getting chiropractic care.

“In general, I think that patients wishing to avoid Rx (especially opioid) would do well to seek care from providers who can provide potentially helpful alternatives to opioid treatments – this could include chiropractors, physical therapists, massage therapists, pain psychologists, yoga instructors, and mindfulness-based stress reduction classes, etc.,” said Dan Cherkin, an emeritus senior scientific investigator at Kaiser Permanente Health Research Institute in Seattle, Washington, who wasn’t involved in the study.

The challenge is that some of these options aren’t always available or covered by insurance, Cherkin added.

Still, organizations such as the Veterans Health Administration and the American College of Physicians currently recommend that patients try conservative treatments commonly delivered by doctors of chiropractic instead of opioids, said Christine Goertz, a researcher at Duke University in Durham, North Carolina, who wasn’t involved in the study.

“The current study indicates that patients who follow these recommendations are, in fact, less likely to receive an opioid prescription,” Goertz said by email.

Two Home Depot warehouse workers had an accident while driving vehicles called electric pallet jacks at Home Depot’s Mira Loma distribution warehouse.

After a workplace accident and inspection, the Division of Occupational Safety and Health cited Home Depot for several violations of workplace safety standards. The investigator found that the industrial truck operators wore tennis-type shoes while they were operating industrial trucks.

The Division determined Home Depot had violated regulations which requires “appropriate foot protection” for employees exposed to foot injuries, and which sets standards for the safe operation of industrial trucks and requires employers to make sure their employees comply. The Division said that in this case “appropriate” would be steel toed shoes.

Home Depot challenged the citations. Ultimately, the respondent, California Occupational Safety and Health Appeals Board, affirmed the footwear citation because Home Depot employees were exposed to foot injuries when they manually lift heavy loads and when they worked on foot or walked in close proximity to industrial trucks. They found Home Depot’s safety policies and prohibition on open-toed or open-heeled shoes didn’t adequately protect those employees.

The Board affirmed the truck-operation citation because Home Depot did not establish the employee caused the infraction despite knowing her conduct was contrary to the employer’s safety requirements.

Home Depot filed a petition for writ of mandate, asking the trial court to relieve them of the footwear citation on the ground the findings weren’t supported. The trial court declined, and Home Depot asked the court of appeal to make the same determination. However, the court of appeal affirmed in the unpublished case of Home Depot USA v California Occupational Safety and Health Appeals Board.

Home Depot did not require their employees to wear protective shoes when they worked in the warehouse. Their policy required only that they wear “closed-toed and closed-heeled shoes.” Home Depot’s policy said “Flip-Flops, sandals, open-toed shoes, or open heeled shoes” are unacceptable.

Home Depot says they don’t require their warehouse employees to wear steel-toed boots or similar footwear because such footwear can cause ergonomic problems, tripping hazards, and fatigue, and they can be “cumbersome,” “uncomfortable” and “bulky.”

Amicus curiae, Retail Litigation Center, Inc. and National Federation of Independent Business, who support Home Depot, object that the Board’s opinion articulates an “uncertain standard [that] will have far-reaching consequences for employees in a wide range of businesses, including large retailers and small independent businesses that may have industrial trucks or pallet jacks in the facility even though the majority of employees encounter them only rarely.”

However, the court of appeal concluded that there was substantial evidence supporting the Board’s determination that Home Depot employees were both actually exposed and realistically likely to be exposed to foot injuries. A violation of the safety order is not based on previous history of accidents or injuries resulting from the exposure but rather on the existence of the danger which may cause injury.

The court did however “agree the language in the Board’s opinion can be read to sweep too broadly, so we emphasize our holding is limited to the facts and evidence of the case.”