In the modern day environment, workers’ compensation costs continue to be a challenge, with a
need to balance costs, benefits, and quality of medical care. The cost of workers’ compensation care
affects all stakeholders including workers, employers, providers, regulators, legislators, and insurers.
Consequently, a continued commitment to quality, accessibility to care, and cost containment will
help ensure that workers are afforded accessible, high quality, and cost-effective care.
In 2004, workers’ compensation programs in all 50 states, the District of Columbia, and federal programs in the United States combined received an income of $87.4 billion while paying out only $56
billion in medical and cash benefits with $31.4 billion or 37% in administrative expenses and profit.
Occupational diseases represented only 8% of the workers’ compensation claims and 29% of the
cost. The American College of Occupational and Environmental Medicine (ACOEM) has published
several guidelines; though widely adopted by WCPs, these guidelines evaluate the practice of medicine of multiple specialties without adequate expertise and expert input from the concerned specialties, including interventional pain management.
An assessment of the ACOEM guidelines utilizing Appraisal of Guidelines for Research and Evaluation (AGREE) criteria, the criteria developed by the American Medical Association (AMA), the Institute of Medicine (IOM), and other significantly accepted criteria, consistently showed very low
scores (< 30%) in most aspects of the these guidelines.
The ACOEM recommendations do not appear to have been based on a careful review of the literature, overall quality of evidence, standard of care, or expert consensus. Based on the evaluation
utilizing appropriate and current evidence-based medicine (EBM) principles, the evidence ratings
for diagnostic techniques of lumbar discography; cervical, thoracic, and lumbar facet joint nerve
blocks and sacroiliac joint nerve blocks; therapeutic cervical and lumbar medial branch blocks and
radiofrequency neurolysis; cervical interlaminar epidural steroid injections, caudal epidural steroid injections, and lumbar transforaminal epidural injections; caudal percutaneous adhesiolysis; abd spinal cord stimulation were found to be moderate with strong recommendation applying for most patients in most circumstances. The evidence ratings for intradiscal electrothermal
therapy (IDET), an automated percutaneous disc decompression and also deserve further scrutiny and analysis.
In conclusion, these ACOEM guidelines for interventional pain management have no applicability in
modern patient care due to lack of expertise by the developing organization (ACOEM), lack of utilization of appropriate and current EBM principles, and lack of significant involvement of experts in
these techniques resulting in a lack of clinical relevance. Thus, they may result in reduced medical
quality of care; may severely hinder access to appropriate, medically needed and essential medical
care; and finally, they may increase costs for injured workers, third party payors, and the government
by transferring the injured worker into a non-productive disability system.
Key words: Guidelines, ACOEM, ASIPP, interventional pain management, interventional techniques, evidence-based medicine, systematic reviews, guideline development, AHCPR, AHRQ,
IOM, AMA, AGREE, workers’ compensation, chronic pain guidelines, low back pain guidelines
Reassessment of Evidence Synthesis of
Occupational Medicine Practice Guidelines for
Interventional Pain Management
