Coming of Age

Evidence-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 the superintendent of the Financial Services Commission of Ontario (FSCO) regarding changes to the definition of “catastrophic impairment,” in addition to the soon-to-be-announced review of minor injury protocols, are examples of how evidence-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 patients or, as in some cases, do them harm.

Professor Archie Cochrane, a Scottish epidemiologist, in his book Effectiveness and Efficiency: Random Reflections on Health Services (1972), helped develop a 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 policymakers 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 Workplace Safety and Insurance Board developed a number of Programs of Care over the last 15 years; these evidence-based health care delivery plans describe treatments shown to be effective for workers diagnosed with specific types of injuries (eg., acute lower-back injuries, upper-extremity injuries). FSCO adopted the Program of Care concept when it released two Pre-Approved Framework Guidelines for Whiplash-Associated Disorders in 2003 and the Minor Injury Guideline in 2010.

Catastrophic Impairment Expert Panel

Ontario’s 2010 auto insurance reforms included a recommendation that the superintendent appoint a panel of medical experts to review the definition of “catastrophic impairment.”

The superintendent appointed a panel in December 2010, asking it to identify ambiguities and gaps in the current Statutory Accident Benefits Schedule (SABS) definition in order to reflect emerging scientific knowledge and judgment. The panel submitted two reports to the superintendent in 2011, and the superintendent reported back to the Ontario minister of finance in December 2011. The superintendent’s report was made public on June 12, 2012.

FSCO Superintendent’s Report

The superintendent 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.

Figure 1 outlines the new proposed measurement tools and the evidence provided by the panel for adopting those tools.

Panel members identified areas in which little scientific evidence supported a recommendation. In these instances, they relied on their collective clinical judgment. Their goal was to eliminate or reduce inconsistencies in the process for determining catastrophic impairments.

In addition to calling for new measurement tools, the superintendent has recommended some further changes to the definition and the process for determining catastrophic impairments. Children – claimants under age 18 – with serious brain injuries who 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 under circumstances in which, due to the nature of the injuries, it would not be possible to make an early catastrophic impairment determination. He proposes a $50,000 monetary cap so as to maximize the chances of achieving the fullest possible recovery. The superintendent recommends that interim benefits be made available to claimants with serious brain injuries and those awaiting a final determination using the American Medical Association’s Guides to the Evaluation of Permanent Impairment following a traumatic physical injury.

Although the superintendent indicated that catastrophic impairment evaluators need specialized training – particularly 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 its 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 made it clear that moving ahead with changes concerning how catastrophic impairment is determined introduces evidence-based health care to the Ontario auto insurance system.

Conclusion 

If the government makes regulatory changes based on the superintendent’s report, it will usher in the adoption of evidence-based methodology – not only for the evaluation and treatment of minor auto accident injuries, but also in the evaluation of the most serious ones. It will be important to re-examine the definition periodically to ensure that it still reflects emerging scientific knowledge and judgment.