Coming of Age

FSCO's recent report to the Ontario finance ministry suggest that evidenced-based health care has taken centre stage in the province's auto insurance system.

by Dr. Pierre Cote and Willie Handler

August 2012 issue of Canadian Underwriter

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Evidenced-based health care has existed in Ontario for years, but only until recently has the concept been introduced into Ontario’s auto insurance system. The recent recommendations made by FSCO’s Superintendent regarding changes to the definition of “catastrophic impairment” as well as the soon to be announced review of minor injury protocols are examples of how evidenced-based health care is slowly gaining acceptance.

Evidence-based health care aims to apply the best scientific evidence to clinical decision-making. This helps clinicians understand whether treatment will benefit their patient or as in some cases do them harm.

Professor Archie Cochrane, a Scottish epidemiologist, through his book Effectiveness and Efficiency: Random Reflections on Health Services (1972) introduced growing acceptance of the concepts behind evidence-based health care. The explicit methodologies used to determine "best evidence" were largely established by a McMaster University research group in 1990.

Changing practices and incorporating the best available scientific evidence into one’s practice is often challenging for clinicians, insurers and policy makers alike. Barriers to the adoption of new evidence are grounded in one’s own preferences, beliefs, experiences, expertise and education. Improving the use of evidence-based recommendations requires that stakeholders develop a better understanding of the benefits of evidence-based practice for patients and society.

In Ontario, the evidence-based management of injuries is gaining acceptance. The WSIB developed a number of Programs of Care over the last 15 years which are evidence-based health care delivery plans that describes treatments shown to be effective for workers diagnosed with specific types of injuries (eg., acute low back injuries, upper extremity injuries). FSCO adopted the Program of Care concept when it released two Pre-Approved Frameworks for WAD Injuries in 2003 and the Minor Injury Guideline in 2010.

The Catastrophic Impairment Expert Panel

The Government’s 2010 auto insurance reforms included a recommendation that the Superintendent appoint a panel of medical experts to review the definition of “catastrophic impairment.” A panel was appointed by the Superintendent in December 2010 and asked to identify the ambiguities and gaps in the current SABS definition in order to reflect emerging scientific knowledge and judgment. The panel submitted two reports to the Superintendent during 2011 and in December of the same year the Superintendent reported back to the Minister of Finance. The Superintendent’s report was made public on June 12, 2012.

The Superintendent’s report

The Superintendent has accepted the panel’s recommendations regarding the use of clinical measurement tools to improve the accuracy, relevance, clarity, validity, reliability and predictive ability of catastrophic impairment determinations. The use of these tools will introduce more fairness into the system because catastrophic impairment determinations will be based on tools that will limit the amount of errors. Moreover, accident victims will not have to rely on the persuasiveness of their representatives that they are deserving of the designation.

The following chart outlines the new proposed measurement tools and the evidence provided by the panel for adopting those tools.

Impairment	Current Test	Proposed Test	Evidence
paraplegia and tetraplegia (quadriplegia)	None	American Spinal Injury Association classification of spinal cord injuries	standard in medical practices literature suggests classification system is valid and reliable
amputations	none	None	clinical and scientific judgment of Expert Panel members
burn and crush injuries to limbs	not covered in SABS	Spinal Cord Independence Measure	clinical and scientific judgment of Expert Panel members The scientific evidence supports the validity and reliability of the SCIM
blindness	None	Legal blindness
traumatic brain injuries in adults	Glasgow Coma Scale Glasgow Outcome Scale	Extended Glasgow Outcome Scale	strong psychometric properties and reliable when used with a structured interview and standard scoring algorithm
other physical impairments	whole body impairment rating using American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th Edition	whole body impairment rating using American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th Edition, Chapters 3-13	very little scientific literature supporting use for determining catastrophic impairment but Expert Panel found no alternative rating system
psychiatric impairments	class of mental or behavioural disorder using American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th Edition, Chapter 14	Global Assessment of Functioning Scale	literature suggests scale has adequate reliability and validity
combining physical and non-physical impairments	none but the courts have assigning whole body impairment scores to impairments under Chapter 14 of AMA Guides to allow combining with scores under Chapters 3-13	no combining	no scientific literature to support combining physical and non-physical impairment ratings The physical and mental/behavioural impairment rating chapters were not developed to be combined
traumatic brain injuries in children	None	King’s Outcome Scale for Children Head Injury	little scientific evidence to support so Expert Panel recommended a study be conducted

The panel identified a number of areas where there was little scientific evidence to support a recommendation. In these cases they relied on their collective clinical judgment. Their goal was to eliminate or reduce the inconsistencies that have existed in the process for determining catastrophic impairments.

In addition to new measurement tools the Superintendent recommends some further changes to the definition and the process for determining catastrophic impairments. Children (claimants under age 18) with serious brain injuries that have been admitted to a major trauma centre will be automatically designated as catastrophic. No assessment will be necessary.

As well, the Superintendent recommends interim benefits be made available to certain claimants where due to their injury types, making an early catastrophic impairment determination would not be possible until much later. He recommends a $50,000 monetary cap which maximizes the chances of achieving the fullest possible recovery. The Superintendent recommends that the interim benefits be available to claimants with serious brain injuries and those awaiting a final determination using the AMA Guides following a traumatic physical injury.

Although the Superintendent indicated that catastrophic impairment evaluators need specialized training, in particular in the use of the proposed measurement tools, he did not accept the panel’s recommendation that evaluators be required to complete university-based training.

Stakeholder Consultations

The Superintendent conducted stakeholder consultations in the spring of 2011 following the release of the panel’s first report. FSCO received 33 submissions which are posted on the FSCO website. As is common when initially presented with evidence-based recommendations, not all stakeholders were supportive of the panel’s report. Again, this emphasizes the need for education about the merit of the recommendations.

In his report, the Superintendent has made it clear that moving ahead with changes to how catastrophic impairment is determined introduces evidence-based health care to the Ontario auto insurance system.

Conclusion

Should the government make regulatory changes based on the Superintendent’s report it will usher in the adoption of evidence-based methodology to not only the evaluation and treatment of minor auto accident injuries but also when evaluating the most serious ones. It will also be important that the definition be examined periodically to ensure it still reflects emerging scientific knowledge and judgment.