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Thank you for joining the Optum CE webinar:Comorbid conditions

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• CE credits are only available for those who qualify during the LIVE version of this webinar held from 2:00-3:00 p.m. ET on 11/13/2019.

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continuing education activity. Optum does not receive any commercial advantage nor financial

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Medical disclaimer

Medicine is an ever-changing science. As new research and clinical experience broaden our

knowledge, new treatment options and approaches are developed. The authors have checked

with sources believed to be reliable in their efforts to provide information that is complete and

generally in accord with the standards accepted at time of publication.

However, in view of the possibility of human error or changes in medical sciences, neither Optum

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contained herein is in every respect accurate or complete, and are not responsible for errors or

omissions or for the results obtained from the use of such information. Readers are encouraged

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agents that are not approved by the Food and Drug Administration (FDA). We do not promote the

use of any agent outside of approved labeling. Statements made in this presentation have not

been evaluated by the FDA.


Presenter

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Deborah Conlon, PharmD Clinical Pharmacist Liaison


Learning objectives

• Define the term comorbidity and discuss its impact upon the claimant.

• Identify comorbidity in injured parties and how they may impact a claim

• Identify management strategies to support an injured parties with comorbidity

• Holistic approach to returning the injured party to the workforce

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What is a comorbidity?

• Defined as the coexistence of two or more disease processes

• In other words, a co-morbidity is the presence of two or more medical conditions or disease states. They can exist simultaneously, but independently or they could be related medical conditions.

• Within the workers’ compensation population, this can be especially concerning because a minor injury could escalate to a chronic condition due to a comorbidity

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Medilexicon. https://www.medilexicon.com/dictionary. Accessed Feb 26, 2019

https://www.medilexicon.com/dictionary


There are multiple factors that contribute to health within populations

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Valderas JM, Starfield B, Sibbald B, et al. Defining comorbidity:Implications for understanding health and health services. Ann Fam Med. 2009;7(4):357-363.

Understanding influencers may help provide a more holistic view of the injured worker and assist with recovery and return to work.

Genetic and biologic characteristics may

Genetic factors have been linked to chronic conditions such as diabetes and osteoarthritis

Economic conditions may influence ability to manage care play a key role in an individual

Ability to purchase medications and healthy foods may beimpacted by financial factors

Social influences may share a common pattern in managing care

Religious beliefs may influence healthcare decisionsCultural influence and family traditions can influence dietary choices


Comorbid conditions-why they matter?

• Conditions unrelated to the workplace injury are generally not covered under the claim but may still have a large influence on a claimants return to work

• Comorbid conditions in workers’ compensation can create negative outcomes and aggravate an already difficult situation for an injured worker.

• Comorbidity can make a bad situation worse:

－ Impact disability duration

－ Medications can worsen comorbidity

－ Injuries can lead to comorbidity

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Comorbidities in workers’ compensation

2012 NCCI Research Brief –Nationwide medical data on comorbidities impacting injured workers from 1996-2010

Source: Comorbidities in Workers Compensation, NCCI Research Brief, 2012. Retrieved from: http://www.workcompprofessionals.com/advisory/2013L5/february/NCCI%20Comorbidities-in-Workers-Compensation-2012-1.pdf

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Comorbidities have approximately twicethe medical costs of comparable claims without comorbidities

Percentage of claims with a comorbidity diagnosis (diabetes, hypertension, obesity) tripled from 2000 to 2009, from 2.4% to 6.6%

Drug abuse (including drug and alcohol abuse) as a comorbid diagnosis quadrupled in the same time span



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Why comorbidity is on the rise?


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Aging population The average age of U.S. population has risen from 30.0 years in 1980 to 38.2 years in 2018

Aging workforce The median age of workforce population has risen from 34.6 years in 1980 to 40.5 years in 2015

Increasing rates of obesity • Obesity rates climbed 3% from 2008 to 2016, leading to an estimated seven million adults in the United States classified as obese in 2016

• More than 90% of Type 2 diabetics are classified as overweight or obese

Sedentary lifestyle • Sitting has been linked to a nearly doubled risk of developing type 2 diabetes

• Associated with increased risk of cardiovascular mortality by 10-20%

• Increased risk of depression


Obesity

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Causes of obesity Consequences of obesity

• Energy imbalance (too many calories, limited physical activity)

• Metabolism

• External factors: culture and environment

• Coronary heart disease

• Type 2 diabetes

• Hypertension

• Dyslipidemia (high triglycerides or total cholesterol)

• Stroke

• Liver and gallbladder disease

• Sleep apnea and respiratory problems (obesity hypoventilation syndrome)

• Osteoarthritis

• Lower back pain

• Carpel tunnel syndrome


The consequences of obesity on a claim

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Medical concerns Medication concerns• Higher overall medical costs

• Increased time away from work

• Closely associated with musculoskeletal (lower back) and sprain/strain injuries

• Risk for developing other comorbid conditions

• Long-term effect on claim costs and duration (healing time)

• Risks of treatment

• Selection of medications for the indexed, or underlying condition

• Side effects

• Addition of medications used for treatment of obesity and other comorbid conditions

• Medication concerns for post gastric bypass claimants or weight loss surgery


Managing obesity on a claim

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Medical Non-medical

• Coordination of physicians

• Consider adding case management

• Physical therapy if appropriate for injury

• Encourage ongoing activity if appropriate

• Identify support unit for claimant and encourage regular

• Maintain primary care physician appointments

• Accommodate limitation to allow return to work


Diabetes statistics 2018

Medical costs associated with diabetes may be direct or indirect

• Direct costs include preventative, diagnostic, and treatment services

• Indirect costs include lost workdays due to diabetes-related health reasons

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Estimated medial costs in the U.S. in 2017

$327 billionEstimated Americans

with diabetes

30 millionU.S.population with

diabetes

9.4%Estimated US

population with pre-diabetes

84%

Source: American Diabetes Association. Statistics about diabetes. 2018. https://www.diabetes.org/resources/statistics/statistics-about-diabetes

https://www.diabetes.org/resources/statistics/statistics-about-diabetes


Diabetes

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Causes of diabetes Consequences of diabetes

• Obesity

• Inactivity

• Genetics

• Coronary heart disease

• Dyslipidemia (high triglycerides or total cholesterol)

• Kidney disease

• Increased risk of infection

• Prolonged wound healing

• Increased fall risk

• Increased sensitivity to heat/hyperthermia


The consequences of diabetes on a claim

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Medical concerns Medication concerns

• Higher overall medical costs

• Increased time away from work


• Long-term effect on claim costs and duration (healing time)

• Medications prescribed for injury may worsen diabetes

• Side effects may mimic those of high or low blood sugar

• Addition of medications used for treatment diabetes


Managing diabetes on a claim

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Medical Non-medical

• Coordination of physicians

• Consider adding case management

• Physical therapy if appropriate for injury

• Maintain routine primary care appointments

• Blood glucose monitoring

• Encourage ongoing activity if appropriate

• Identify support unit for claimant and encourage regular activity



• James is a 55-year-old male that sustained a burn injury to hands and arms

• History of diabetes, obesity, hypertension and sleep apnea

• He was prescribed several doses of a steroid dose pack and silver sulfadiazine cream

Case study 1 – James

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Comorbidity can make a bad situation worse:Impact disability duration

• Underlying diabetes may slow or hinder wound healing

• Hypertension may impede wound healing

Medications can worsen comorbidity

• Prescribed medications (high dose steroids) worsened blood glucose control

• Steroids can worsen hypertension

Injuries can lead to comorbidity

• Severity of injury and pain limit ability to exercise further hindering diabetes and hypertension management

• Obesity may hinder ability to exercise

Case study 1 – James

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In 2018, an estimated 16 million adults (6.9% of all U.S. adults) have at least one episode of major depressive disorder

Anxiety disorders include: panic disorder, obsessive-compulsive, post-traumatic stress disorder, generalized anxiety disorder, and phobias)

Mental health facts and statistics

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Source: https://www.samhsa.gov/data/report/2018-nsduh-annual-national-reporthttps://www.nami.org/learn-more/mental-health-by-the-numbers

Mental illness costs nearly $193 billion in lost earnings per year in the U.S.

In 2018, an estimated 47.6 million adults have had a diagnosis of mental illness

An estimated 19.3 million adults in US have had a substance abuse disorder

Only 40% of adults diagnosed with a mental disorder received treatment in 2018

An estimated 43 million (18.1% of U.S adults) with anxiety disorder

An estimated 9.2 million adults have mental illness and substance use disorder in the past year

https://www.samhsa.gov/data/report/2018-nsduh-annual-national-report

https://www.nami.org/learn-more/mental-health-by-the-numbers


Substance misuse and abuse

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Source: https://www.samhsa.gov/data/report/2017-nsduh-annual-national-report

30.5 million

26 million

3.2 million

SUBSTANCE ABUSE

~19.7 million

140.6 million

66.6 million

ALCOHOL USE

11.4 million

48.7 million

27.8 million

TOBACCO USE


Depression and other psychological disorders

• Major depression is one of the top psychological conditions in the United StatesCriteria for diagnosis include a minimum of two weeks of feelings of depression and/or lack of interest in daily activities or pleasurable events. Symptoms may include sleep disruption, eating concerns, low energy and feelings of worthlessness.

• Other mental health conditions include: － Anxiety disorder

－ Insomnia

－ Post-traumatic stress disorder

－ Bipolar disease

－ Attention-deficit/hyperactivity disorder

－ Schizophrenia

－ Substance abuse disorder

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Sources1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4570484/ - Incidence & Cost of Depression after Occupational injury2. https://pdfs.semanticscholar.org/4841/5b85657440be8695c39c088a493441afc8c8.pdf


Causes of mental health comorbidity

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Causes of mental health conditions Consequences of mental health condition

• Hereditary

• Environmental

• Traumatic event

• Ongoing Stress

• Change in familial, financial and or social situation

• Suicide

• Catastrophizing

• Absenteeism

• Hypertension

• Increased risk for substance abuse

• Delayed recovery


Impact of mental health conditions

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Sources1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4570484/ - Incidence & Cost of Depression after Occupational injury2. https://pdfs.semanticscholar.org/4841/5b85657440be8695c39c088a493441afc8c8.pdf

Condition Potential Impact

• Anxiety disorder

• Insomnia

• Post-traumatic stress

• Substance abuse disorder

• Difficulty concentrating, difficulty sleeping, social avoidance

• Increased irritability, decreased focus, weight gain, daytime sedation, decreased function

• Difficulty sleeping, poor concentration, socialwithdrawal

• Decreased functionality, difficulty sleeping, financial and relationship stress, poor concentration


Managing mental health on a claim

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Medical Non-medical

• Case management

• Counseling

• Review of medical records and claimant history for other comorbidities

• Cognitive behavior and/or biofeedback

• Consider using medications that can manage both the injury and the comorbid depression or anxiety for improved return to work

• Physical therapy if appropriate for injury as physical activity improves mood

• Encourage ongoing physical activity as appropriate

• Identify support unit for claimant

• Group support



• Mary is a 35-year-old female that sustained back injury in 2017

• History of depression with worsening of symptoms since injury, currently a smoker

• Prescribed sertraline to treat depression, back pain continues despite use of ibuprofen and skeletal muscle relaxants

Case study 2 – Mary

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Case study 2 – Mary

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Comorbidity can make a bad situation worse:Impact disability duration• Underlying depression make Mary higher risk for prolonged

recovery• Smoking may indicate potential for addiction

Medications and comorbidity • While prescribed medications for depression, options for

treatment of both back pain and depression may provide improvement

• Skeletal muscle relaxants can act as CNS depressants; short term use is recommended

Injuries can lead to comorbidity• Severity of injury and pain limit ability to exercise further

worsening depression• Working provides social interaction and feeling of value and

worth, can improve symptoms of depression


Smoking

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480,000 deaths

38 million

16 million

TOBACCO BY THE NUMBERSTOBACCO USE

• Linked to many major health conditions and remains the leading preventable cause of premature disease and death in the U.S.

• Approximately one-third of all cancer deaths are contributed to smoking

• Smoking can contribute to diabetes, erective dysfunction, inflammation and impaired immune function among other diseases

• Approximately 77-93% of people in treatment for substance use disorders use tobacco

• Tobacco use may impact healing time of surgery


Smoking

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Recognize high-risk groups• Men• Adults 25-64 years old• Lower education level• Lower socio-economic class• Midwest and South• Uninsured or Medicaid assistance• Disabled• Psychological disorders• Certain ethnicities: American Indians, Alaska Natives, and multiracial



Vaping and the younger workforce

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Source: https://www.collinsdictionary.com/us/dictionary/english/aerosolization

https://medical-dictionary.thefreedictionary.com/aerosolization

https://www.collinsdictionary.com/us/dictionary/english/aerosolization


Tobacco products and the injured worker

• Increased risk for smoking related disorders• Increased risk of infection• Delayed wound healing• Increased risk of osteoarthritis• Increased risk for hypertension and cardiac diseases• Higher absenteeism• Increased medical costs• Increased indirect costs related to decreased productivity

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Source: Halpern MT, Shikiar R, Rentz AM et al. Impact of smoking status on workplace absenteeism and productivity. BMJ. 2001;10:233-238.


Respiratory conditions

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22.5 million

33.2 million

CHRONIC RESPIRATORY CONDITIONS

16.3 million

• Smoking most recognized cause of respiratory diseases and lung cancer, it is not the only cause.

• Jobs such as mining, working in machine shops, firefighting, farming, cleaning and construction may expose workers to respiratory irritation from aerosolized particulates.

• Working in the presence of respiratory irritants can cause reactive airway disease and worsen pre-existing respiratory conditions.

• Comorbid respiratory disorders increase the risk of developing an exposure-related condition and can result in long-term disability and increased costs.


Causes of respiratory conditions

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Causes of respiratory conditions Consequences of respiratory conditions

• Smoking

• Inhalants/vaping

• Second-hand smoke

• Environmental exposure

• Occupational exposure

• Exercise tolerance

• Shortness of breath

• Hypertension

• Stroke

• Delayed healing from smoking

• Absenteeism

• Decreased life expectancy


Respiratory comorbidities

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• Risk for injury

• Time away from work

• Higher overall treatment costs


• Selection of medications for pain control and/or inflammation

• Drug-drug interactions

• Side effects

• Contraindications

• Addition of medications used for treatment of comorbidity


Managing respiratory comorbidity on a claim

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Medical Non-medical

• Case management

• Coordination of care with all prescribers

• Medication management and education

• Physical therapy if appropriate for injury as physical activity maintain respiratory health

• Encourage ongoing exercise as appropriate

• Smoking free environment

• Employer sponsored smoking cessation opportunities



Heart (Cardiac) Disease

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Cardiac Disease and Hypertension

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The number one cause of death for men and women in 2018

Approximately 2,300

CARDIAC CONDITIONS

$205B

92.1M U.S. adults have cardiovascular disease as pf 2018

Source:https://www.mayoclinic.org/diseases-conditions/heart-disease/symptoms-causes/syc-20353118

https://labor.mo.gov/sites/labor/files/2017_DWC_Conf_Cormorbidities_Injured_Melander.pdf

103M

TRIPLED

HIGH BLOOD PRESSURE

>130/80 mmHg:

38%

https://www.mayoclinic.org/diseases-conditions/heart-disease/symptoms-causes/syc-20353118

https://labor.mo.gov/sites/labor/files/2017_DWC_Conf_Cormorbidities_Injured_Melander.pdf


Causes of cardiac disease

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Causes of cardiac conditions Consequences of cardiac condition

• Smoking

• Lack of physical activity

• Poor nutrition

• Obesity

• High cholesterol

• Diabetes

• Hospitalization

• Increased medical costs

• Increased indirect costs

• Decreased exercise tolerance

• Increased shortness of breath

• Hypertension

• Heart attack (myocardial infarction(

• Stroke

Source: https://healthmetrics.heart.org/wp-content/uploads/2018/02/At-A-Glance-Heart-Disease-and-Stroke-Statistics-2018.pdf

https://healthmetrics.heart.org/wp-content/uploads/2018/02/At-A-Glance-Heart-Disease-and-Stroke-Statistics-2018.pdf


Cardiac comorbidities

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• Time away from work

• Higher overall treatment costs


• Permanent disability

• Selection of medications for pain control and/or inflammation

• Drug-drug interactions

• Side effects

• Contraindications

• Addition of medications used for treatment of comorbidity

• High pill burden


Managing cardiac comorbidity on a claim

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Medical Non-medical

• Case management

• Coordination of care with all prescribers

• Medication management and education

• Physical therapy if appropriate for injury as physical activity maintain cardiac health

• Nutritional counseling by primary care providers

• Encourage ongoing exercise as appropriate

• Encourage weight management

• Encourage healthy diet (include healthy options in company dining facilities)

• Smoking free environment

• Employer sponsored smoking cessation opportunities


• Albert is a 63-year-old male that works as an accountant

• History of depression, smoker, hypertension, overweight

• Coworker notices Albert is short of breath as they walk to a meeting together

• Prescriptions include blood pressure medications

Case study 3 – Albert

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Case study 3 – Albert

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Comorbidity can make a bad situation worse:Impact disability duration• Obesity, smoking and high blood pressure increase Albert’s risk

for a significant cardiac event• Smoking may indicate potential for addiction

Medications and comorbidity • High blood pressure medications may not adequately be

controlling Albert’s hypertension

Injuries can lead to comorbidity• Opportunity for employee sponsored weight loss incentives• Smoke free workplace campus and smoking cessation incentives• Encourage walking breaks during work• Coworker partner to encourage healthier choices


Putting it all together

• During the course of this presentation we explained what a comorbidity is and the impact they can have on workers’ compensation claims.

• We discussed potential causes of comorbidities and potential treatments for obesity, diabetes, and mental health disorders such as depression and substance use, smoking, respiratory and cardiac conditions.

• We discussed solutions or interventions that may improve outcomes for a workers’ compensation claim with comorbidities.

• We discussed how looking at the injured worker holistically may improve outcomes and return to work

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Managing comorbidities of the injured worker

• If the comorbidity existed prior to the industrial injury and is not impacting the treatment of the injury, the payer may not be responsible for these non-associated treatment costs.

• Although some states have enacted workers’ compensation legislation regarding the treatment of the injury based on guidelines, there is not a corresponding law or rule regarding the treatment of comorbidities.

• Recommended treatment guidelines such as Official Disability Guidelines (ODG) from the Work Loss Data Institute have begun to incorporate resources into their treatment guidelines for mental illness, stress, diabetes, hypertension, and respiratory disorders.

• Effective management of all comorbidities must be based on a partnership between a highly motivated patient and a committed team of health professionals.

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Thank you!Questions?

CE credits for this course are administered by the CEU Institute. If you have any issues or questions regarding your credits, please contact [email protected].

Register for additional Continuing Education opportunities workcompauto.optum.com/Resources/Continuing-Education

You will receive an email from the CEU Institute on our behalf approximately 24 hours after the webinar. This email will contain a link that you will use to submit for your CE credits. You must complete this task within 72 hours.

For additional information on comorbid conditions, read our blog series located on the Clinical Connections section of our website http://www.workcompauto.optum.com/insights/clinical-connection

http://www.workcompauto.optum.com/insights/clinical-connection

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Thank you for joining the Optum CE webinar: Comorbid ......• Comorbid respiratory disorders...

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