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Each incident has a range of medical, vocational, legal and financial stories. On an ecological scale of diversity, our field is in the same league as the Amazonian rain forest.

But now two studies have come my way of elegant solutions to managing injuries and their simplicity makes me want to whistle a little tune. They are solutions to two puzzles: where should an injured worker go for care right after injury and what kind of care is assured to work for back pain?

I found a managed care executive, Paul Binsfeld, who runs a program to optimize the medical triaging of fresh injuries. His firm, Company Nurse, is hired by employers to have registered nurses talk by phone with injured workers at the moment of injury. The nurses record key facts and advise on where and how the injury should be treated. They can at that moment assess the availability of nearby occupational medical clinics and hospitals.

Over time, the company has developed a refined sense of the share of injuries that typically should be seen by an occupational clinic or an emergency department. And there is a third option: self-care.

At my asking, Binsfeld did a study of how a large sample of injuries in the last quarter of 2008 were triaged. He restricted the sample to injuries sustained by urban public sector employees, occurring between 8 a.m. and 8 p.m., where a choice exists among care facilities. Company Nurse kept track of how the injuries were resolved so they could give the right advice.

Among the injuries for which a nurse advised on care, 5 percent were sent to emergency departments and 62 percent were asked to go to occupational medicine clinics. In 32 percent of the injuries, nurses recommended self-care or first aid at the worksite.

Not surprisingly, this being a pretty entitled workforce, many workers did not call into a nurse and 15 percent of them went to emergency departments. There is no evidence that these self-referrers were more seriously injured.

Here is the simple formula when planning for initial care: 33 percent self care or first aid, 60 percent occupational medical clinics, and about 5 percent emergency departments.

What kind of care is indicated for back pain? The only uniformly correct answer to this question is exercise. A research team scoured published studies and found that exercise is the only type of treatment that high quality studies recommend consistently. The research team published their findings in the February 2009 issue of Spine.

When I told him about this study, one clinic executive told me that several sessions with an exercise coach is an economic way to bring the worker back on the job. But he despaired of getting adjuster approval.

Can it be more simple than that? Adjusters and employers, do you copy?

PETER ROUSMANIERE is an expert on the workers' compensation industry.

April 1, 2009

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