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AMA 4 Guides Impairment Assessment Training E-Newsletter
Issue date: Friday 3 October 2008
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Chairman's Report


Proposed Review of Impairment Assessment system


Jurisdictional Requirements


Use of Warfarin in Cardiac Patients


Upper Extremity Vascular Impairments


Quick Tips


Transport Accident Act:Gazetting of the GEPIC for psychiatric impairment assessment


There is an AMA 4 Guides Management Committee which meets on a regular basis and reviews the feedback from the various modules and presentations. A number of problems have arisen of recent times and need clarification.

Some higher court decisions are binding in terms of interpretation of the Guides. An example is the Supreme Court case of Elworthy which clarified the use of the Guides for the Assessment of Lower Extremity Impairment.

The government may also enact amendments to the Transport Accident Act, Accident Compensation Act and Wrongs Act. An example would be amendments made to the Transport Accident Act and Accident Compensation Act (but not the Wrongs Act) after the Mountain Pine v Taylor case, which effectively excise the text from the third paragraph down in the left column of page 100 (Chapter 3) of the 4th Edition Guides.

A particular problem which has been highlighted recently is the fact that some areas have references in more than one chapter. For example, neurology has references in chapter 3, The Musculoskeletal System, as well as The Nervous System chapter. A similar problem is that anticoagulation is covered in the Haematology chapter, albeit it is usually practiced by cardiovascular physicians. The Management Committee is now attempting a program of identification of these crossover areas. We want to arrange the teaching of the modules to cover specialty areas rather than to adhere to a specific chapter.

We are also attempting to index the various articles which appear in this and previous newsletters so that they can be more readily accessed by doctors carrying out impairment assessments.

We again invite interested people to write articles for this newsletter or to invite the editorial committee of the newsletter to comment on specific problems.

Dr Tony Buzzard
Impairment Assessment Training Management Committee

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  AMA 4 NEWS  

Proposed Review of the Impairment Assessment System A recently-completed review of the Accident Compensation Act, undertaken by Peter Hanks QC, has recommended that the impairment assessment system used in Victoria be reviewed. The Review Report proposes that the system remain consistent for the Accident Compensation Act , the Transport Accident Act and the Wro ngs Act , but that alternatives to the AMA4 Guide be considered, whether later guides or an alternative system. AMA Victoria has already advised Mr Hanks that a change in the system would require a long lead time, to enable doctors to be trained. If the proposed review takes place it is expected to be a lengthy process, and relevant stakeholders would be involved.

The Review Report may be found by clicking here

Jurisdictional Requirements
Impairment assessors need to be aware of the differing requirements when conducting assessments having regard to the three jurisdictions for which impairment assessments are required-:

  • Accident Compensation Act 1985,
  • Transport Accident Act 1986
  • Wrongs Act 1958
Injuries to be assessed
For purposes of the Accident Compensation Act the impairment assessor is required to assess the accepted injury.

The referring agent will advise the assessor which injuries liability has been accepted for and therefore are required to be assessed. There are circumstances where a dual purpose examination is requested and in these cases the assessor makes a determination regarding liability before proceeding to the impairment assessment.

For the Transport Accident Act the assessor is required to assess the degree of impairment of a person who is injured as a result of the transport accident. This may also involve establishing that the impairment has arisen from the transport accident injuries.

Assessments for the Wrongs Act require an assessment of the alleged injuries without regard to determination of liability or fault. If the alleged injury is a current medical condition that the assessor determines is present and if that condition is possible as an alleged injury then that is assessed. The purpose of the assessment is to determine whether the alleged injury meets the legally defined threshold.

Currently the most significant difference between the three statutes is in regard to the assessment of surgically treated spinal injuries. In this regard amendments have been made to the Accident Compensation Act and the Transport Accident Act but to date no amendment has been made to the Wrongs Act.

An explanation of the process of the assessment of spinal injuries that have been surgically treated for the Wrongs Act as prepared by the spinal reference group is available on line click here

Dr John Malios

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Use of Warfarin in Cardiac Patients
The American Medical Association Guides to the Evaluation of Permanent Impairment Fourth Edition was first published in June 1993. Since then there have been many changes to the practice of cardiovascular medicine, in particular, the common use of warfarin to prevent thrombo-embolism in patients with atrial fibrillation. The use of warfarin is not covered in chapter 6, The Cardiovascular System.

Warfarin use is discussed in Chapter 7, The Hematopoietic System in the context of Inherited Thrombotic Disorders where “Lifelong Warfarin sodium prophylaxis may be needed and would constitute a slight impairment of 5% to 10%”.

The 4th Edition AMA guides regard the prescription of Warfarin as an additional impairment. That is the use of warfarin is “an alteration in the individual’s health status”. Atrial fibrillation imposes risks of under-anticoagulation due to thrombo-embolism and bleeding risks from over-anti-coagulation. Therefore it is proposed to add the use of warfarin as an additional impairment to the other common causes of impairment such as valvular heart disease, coronary heart disease, cardiomyopathy, arrhythmias, and chronic venous disease.

An assessor who has successfully completed the cardiovascular training module is also accredited to provide an impairment rating, if warranted, from Section 7.7 of the Guides to account for lifelong warfarin prescription.

It is then suggested that appropriate impairment would be:

  • 5% for patients taking warfarin in the usual manner for embolism prophylaxis.
  • 7% for a patient with fluctuating clinical status such as heart failure and frequent changes of warfarin dosage.
  • 10% for a patient with an ongoing continuous need for warfarin who is forced to cease the therapy for temporary periods as a result of procedures or investigation for gastro intestinal bleeding.
Cardiovascular Reference Group

Upper Extremity Vascular Impairments
Upper extremity vascular impairment can be assessed in accordance with chapter 3, table 17 and chapter 6, table 13 of the AMA Guides 4th edition. There is a difference between the format of tables 17 and 13 however the four differentiators used to determine each class of impairment are consistent.

Difficulty arises with table 17 in chapter 3 due to the lack of guidance in respect of whether or not all the differentiators are required to place a vascular disorder into an appropriate class. On the other hand table 13, chapter 6 provides instruction on which of the differentiators are required to be used in conjunction with one another.

For the purpose of applying impairment assessments consistently it is suggested that reference be made to chapter 6, table 13 to arrive at the appropriate percentage value.

A further factor requiring consideration in evaluating an upper extremity vascular impairment which applies to WorkSafe injuries incurred after 3 December 2003 arises from the S98C adjustment to the value of chapter 3 injuries. To ensure that this adjustment is applied to musculo skeletal upper extremity injuries of this nature it is suggested that the value derived from chapter 6, table 13 be attributed to chapter 3, table 17 for the purpose of calculating the impairment benefit.

The Upper Extremity Reference Group

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“Definitions related to Impairment assume importance, because terms associated with impairment evaluations may have special meanings in a legal context beyond the usual meanings in medical communications.” This opening sentence in the glossary underlines the importance of practitioners who undertake impairment assessment having a comprehensive understanding of the directions, definitions and expressions in the various chapters of the Guides.

The glossary provides some useful definitions eg:-

The Definition of Permanency
“A permanent impairment is considered to be unlikely to change substantially and by more than 3% in the next year with or without medical treatment”

Explanation of the Parameters of Activities of Daily Living
The activities of daily living are detailed in a table on page 317. This needs to be considered when conducting assessments that refer to activities of daily living for example for determination of skin impairment pursuant to table 2 of chapter 13 or assessment of cardiovascular impairment pursuant to chapter 6

Description of Intensity and Frequency
The terms that describe intensity (minimal, slight, moderate and marked) and the terms describing frequency (intermittent, occasional, frequent and constant) are defined in item 5 of the glossary. When assessments are conducted utilising tables that refer to these terms the descriptions are useful parameters.

Dr John Malios

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Transport Accident Act: Gazetting of the GEPIC for psychiatric impairment assessment

The Guide to the Evaluation of Psychiatric Impairment for Clinicians (GEPIC) was published in the Victorian Government Gazette on 8 May 2008 for impairment assessments pursuant to the Transport Accident Act 1986.  This had the effect of formalising the use of the GEPIC for the evaluation of psychiatric impairment for all transport accidents occurring on or after 26 July 2006. (The GEPIC comes into effect on the day after the day on which the guidelines are published in the Government Gazette).

The Clinical Guidelines to the Rating of Psychiatric Impairment remain the prescribed method of assessment for accidents from 19 May 1998 to 25 July 2006.

Most accredited psychiatric examiners should have a copy of the GEPIC from when they attended either the AMA or WorkSafe/TAC Impairment Assessment Training - Psychiatric Module. A copy of the relevant government gazette (which includes a copy of the GEPIC) can be accessed at www.gazette.vic.gov.au. The Relevant Gazette is No G19 Thursday 8 May 2008.

In summary, for psychiatric impairment assessments conducted on or after 9 May 2008, the following methods now apply:

  • for accidents occurring on or after 26 July 2006, the GEPIC should be used.
  • for accidents occurring on or after 19 May 1998 up to and including 25 July 2006, the Clinical Guidelines to the Rating of Psychiatric Impairment still apply.

The 2009 program will be available soon. Register your interest by email to iat@amavic.com.au

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