Alternative approaches for measuring duration of work disability after low back injury based on administrative workers' compensation data

The Prevalence of Mental Health Service Use in Australian Workers with Accepted Workers' Compensation Claims for Low Back Pain: A Retrospective Cohort Study

PURPOSE

Low back pain (LBP) is a leading cause of disability globally and interferes with work performance and quality of life. For work-related LBP, Australian workers can receive workers' compensation and access funded healthcare to promote recovery, including mental health services, as there are strong links between chronic LBP and mental health. The objective of this study was to determine the prevalence of funded mental health services for workers with compensated LBP.

METHODS

Claims and services data from four Australian workers' compensation jurisdictions were analysed. Prevalence of accessing at least one mental health service was reported as a percentage of all claims overall and by duration of time loss, age group, sex, financial year of claim lodgement, jurisdiction, socioeconomic status and remoteness. Odds of accessing at least one service was determined using logistic regression.

RESULTS

Almost 10% of LBP claims accessed at least one mental health service (9.7%) with prevalence increasing with time loss. Prevalence was highest in Victoria however a higher percentage of workers with LBP accessed mental health services earlier in Queensland. Odds of accessing services was highest with longest time loss duration, among females and in Queensland. Lower odds were observed in regional areas and among those aged over 56 years.

CONCLUSION

Findings suggest opportunities for workers' compensation regulators and insurers to provide greater access to appropriate mental health services alongside physical treatment as standard practice, such as those in more remote locations or earlier in a claim, to improve recovery outcomes for workers with LBP.

Injured worker outcomes after compensation system overhaul: an interrupted time series study

OBJECTIVE

In 2015, South Australia replaced its workers' compensation system with the aim of improving return to work rates. We examined whether this was achieved by focusing on the duration of time off work, as well as claim processing times and claim volumes to understand how this may have been achieved.

METHODS

The primary outcome was mean weeks of compensated disability duration. Secondary outcomes tested alternative mechanisms of a change in disability duration: (1) mean employer report and insurer decision times to evaluate whether there had been changes in claim processing and (2) claim volumes to determine whether the new system altered the cohort under investigation. Outcomes were aggregated into monthly units and analysed with an interrupted time series design. Three condition subgroups-injury, disease and mental health-were compared in separate analyses.

RESULTS

While disability duration steadily declined before the RTW Act came into effect, afterwards it flatlined. A similar effect was observed in insurer decision time. Claim volumes gradually increased. Employer report time gradually decreased. Condition subgroups mostly followed a similar pattern to overall claims, though the increase in insurer decision time appears largely driven by changes in injury claims.

CONCLUSIONS

The increase in disability duration after the RTW Act took effect may be attributable to an increase in insurer decision time, which itself could be due to the disruption of overhauling a compensation system or the elimination of provisional liability entitlements that incentivised early decision making and provided early intervention.

Simple clinical tools improve ability-to-work predictions for individuals 3-24 months after upper limb injury

BACKGROUND

Despite numerous previous studies, predicting the ability to work (ATW) after an upper limb injury (ULI) remains difficult for those still not working 3-24 months after their initial injury.

OBJECTIVES

We aimed to identify simple prognostic characteristics that were associated with the long-term ATW for individuals who remained unable to work several months after the accident that caused their ULI.

METHODS

A single-center prospective observational study in a rehabilitation center in the French-speaking part of Switzerland. We included participants who were 18-60 years old, still unable to work because of persistent pain/disability 3-24 months after an ULI, and who were referred to our rehabilitation center for a 1-month intensive interdisciplinary treatment. Data were collected on personal characteristics, body function/structure variables, activity limitations/participation restrictions, and environmental factors. Participants' evolution during rehabilitation was assessed using functional tests/questionnaires and the 7-level self-reported Patient's Global Impression of Change (PGIC) assessment at discharge. Participant outcomes after 1 year were categorized as either able (ATW>0%) or unable (ATW=0%) to work. The best prognostic characteristics were selected by logistic regression analysis.

RESULTS

Among the 317 participants, 202 (64%) had an ATW>0% at 1 year. A grip strength ≥16 kg (Jamar Hand Dynamometer score - affected side) and "(I) do not take pain medicine" were independent predictors. Overall, 96% (26/27) of participants with these 2 characteristics had an ATW>0% at 1 year. The simultaneous absence of these characteristics predicted an unfavorable prognosis in 50% (59/119) of participants. For those who also had a positive PGIC score then 100% (25/25) of participants with these 3 characteristics had an ATW>0%; for those without, only 42% (19/45) had an ATW>0%.

CONCLUSIONS

Grip strength (≥16 kg) and not taking pain medicine are favorable prognostic factors for an ATW after an ULI. Their absence is associated with a poor ATW prognosis for half of people with ULI and should alert caregivers to risk of long-term absenteeism ("red flags"). Including data from a PGIC further improves the ATW prediction. We recommend that these 3 criteria be systematically evaluated.

Work-related injuries in the Australian education sector: A retrospective cohort study

INTRODUCTION

Educators are exposed to several work-related hazards. Evidence suggests musculoskeletal pain, psychological distress, and student-inflicted violence-related injuries are common. However, there is little evidence on the burden of workplace injury among Australian educators.

AIM

To compare incidence of injury claims and duration of compensated time off work between educators and non-educators, and associated factors.

METHODS

Retrospective cohort study of 1,559,676 Australian workers' compensation claims, including 84,915 educator claims, lodged between July 2009 to June 2015, from the National Dataset for Compensation-based Statistics. Cases were included if aged 18+ years and working in the education sector less than 100 h per week. Negative binomial regression models estimated the relative risk of making a compensation claim and survival analyses calculated disability duration within educators by sex, age, injury type and mechanism, socioeconomic area, remoteness, and jurisdiction.

RESULTS

Compared to non-educators, educators had lower rates of injury claims and shorter disability durations. However, educators had a higher rate of claims for mental health conditions and assault, with the highest risk being among those in special education and education aides. Among educators, injury claim rates were highest among special educators, education aides, and secondary educators.

DISCUSSION AND CONCLUSION

Though surveys indicate Australians in the education sector have higher incidences of work-related injuries, this study found lower incidence of injury claims and shorter disability durations than others. Educators' injury-reporting and absenteeism behaviors may be constrained by ethical, social, and administrative attitudes. Educators had higher rates of claims for mental health and assault-related injury, particularly special educators, and education aides, which suggests a need for targeted prevention efforts.

The Association between Early Opioids Prescribing and the Length of Disability in Acute Lower Back Pain: A Systematic Review and Narrative Synthesis

BACKGROUND

There is conflicting evidence with respect to whether early opioid prescribing (EOP) within the first two weeks of acute Low Back Pain (LBP) onset is associated with the length of disability (LOD). The aim of this systematic review was to examine the relationship between EOP and LOD in individuals with acute LBP.

METHODS

A systematic search of Medline, EMBASE, and CINAHL was conducted. The Newcastle-Ottawa scale was used to assess the methodological quality of included studies. A narrative synthesis of findings was used owing to between-study heterogeneity.

RESULTS

Six cohort studies using workers' compensation administrative data on 178,130 adults with LBP were included. Most studies were of good methodological quality. One study reported that LBP cases with EOP had higher LOD by 4 days than cases without EOP. Two studies reported that each 100 mg morphine equivalent amount (MEA) was associated with an increase in mean LOD by 0.4 day (95% confidence interval (CI): 0.3, 0.5) and 0.4 day (95% CI: 0.3, 0.4). One study showed that LBP cases with EOP had a higher hazard of continuation of time loss benefits by 1.94 (95% CI 1.86, 2.02). One study reported a dose-response relationship between MEA of EOP and LOD ranging between 5.2 days (95% CI 14.6, 25.0) for 1-140 mg MEA and 69.1 (95% CI 49.3, 89.0) for 450+ mg MEA. One study reported that LBP cases with EOP had a higher mean LOD by 3.8 days, but there was no statistically significant relationship between EOP and LOD (Hazard ratio 1.02; 95% CI 0.91, 1.13).

CONCLUSIONS

The use of early opioid in the management of acute uncomplicated LBP is associated with prolonged disability duration. Further research on factors influencing inadequate adherence to evidence-based guidelines and optimal strategies to modify such factors may improve disability outcomes among patients presenting with acute LBP.

Regional Differences in Time Off Work After Injury: A Comparison of Australian States and Territories Within A Single Workers' Compensation System

Purpose Time off work after workplace injury varies by compensation system. While often attributed to features of the compensation system, unaccounted regional factors may drive much of the effect. In this study, we compare disability durations by state and territory of residence within a single national workers' compensation system. Large differences would indicate that factors other than compensation system settings are responsible for system effects observed in previous studies. Methods We applied crude and adjusted Cox proportional hazards models to compare disability durations by state and territory of residence. Confounders included factors known to influence disability duration. Durations were left-censored at two weeks and right-censored at 104 weeks. Results We analysed N = 31,641 claims. In both crude and adjusted models, three of the seven states and territories significantly differed from the reference group, New South Wales. However, two of the three were different between crude and adjusted models. Regional effects were relatively small compared to other factors including insurer type, age, and type of injury. Conclusions Regional factors influence disability duration, which persist with adjustment for demographic, work, insurer type, and injury confounders. However, the effects are inconsistently significant and fairly small, especially when compared to the effect of confounders and system effects found in previous studies. Regional factors likely only account for a small share of the difference in disability duration between compensation systems.

Measuring the impact and reach of informal educational videos on YouTube: The case of Scientific Animations Without Borders

Given the popularity, reach, and variable accessibility of online platforms as channels for informal education by higher-education institutions (HEIs), it becomes practically and theoretically important to better understand the factors that affect the impact and reach of any such Internet-delivered ICT informal learning. Accordingly, this study analysed viewer data from one informal, science animation educational channel on currently the most-watched online platform, YouTube, to measure characteristics affecting the videos’ impact and reach. Results from the study identified the most watched videos on the channel—including survival gardening using drip irrigation, charcoal water filtration, and tuberculosis prevention—and characteristic demand, time, location, and volume of video access. While the basic findings reaffirm prior research measuring statistically significant correlations between user-activity and YouTube engagement metrics (including watch-time, view counts, likes, and subscribers), they also demonstrate the and ability to make such content broadly applicable across demographics and globally. Offering some measure of insights for boosting HEI participation in informal educational science animation and ICT learning practices using platforms like YouTube—especially around the topics of water, agriculture, food security, and improved health outcomes—the findings also point to where improved methods for reaching the intended recipients of informal education online are needed to best leverage the potential of such platforms.

Geographic variation in work disability burden: Identifying hotspots, coldspots, and associated sociodemographic factors

OBJECTIVES

To identify geographic hotspots and coldspots of work disability burden and their associated sociodemographic factors in Australia.

METHODS

Using Australian workers' compensation and census data, we calculated weeks of compensated time off work per 1000 labor force, an indicator of work disability burden, at Statistical Area Level 4, the smallest level of labor force data produced by the Australian Bureau of Statistics. Records included all claims with at least 1 day of compensated time off work lodged between 2010 and 2015. Work disability burden was z-transformed by state and territory and mapped across Australia. Statistical Areas that were more than 1 standard deviation from the state or territory mean were considered hotspots and coldspots. We tested several sociodemographic factors as predictors of work disability burden.

RESULTS

Work disability burden hotspots were concentrated in lower socioeconomic suburbs and exurbs of state capitals, in addition to several regional areas. Coldspots were primarily in wealthy central urban and suburban areas. Factors associated with greater work disability burden include higher area socioeconomic disadvantage, rurality, lower labor force participation, higher unemployment, higher proportion of work in production industries and in blue-collar occupations, and higher numbers of those with core activity limitations, those aged 65+ years, and foreign-born residents.

CONCLUSIONS

Work disability burden is unequally distributed across Australia and strongly influenced by sociodemographic and occupational factors. The findings can guide more efficient allocation of resources for work disability prevention and rehabilitation.

Age Differences in Work-Disability Duration Across Canada: Examining Variations by Follow-Up Time and Context

Purpose This study aimed to understand age differences in wage-replacement duration by focusing on variations in the relationship across different periods of follow-up time. Methods We used administrative claims data provided by six workers' compensation systems in Canada. Included were time-loss claims for workers aged 15-80 years with a work-related injury/illness during the 2011 to 2015 period (N = 751,679 claims). Data were coded for comparability across cohorts. Survival analysis examined age-related differences in the hazard of transitioning off (versus remaining on) disability benefits, allowing for relaxed proportionality constraints on the hazard rates over time. Differences were examined on the absolute (hazard difference) and relative (hazard ratios [HR]) scales. Results Older age groups had a lower likelihood of transitioning off wage-replacement benefits compared to younger age groups in the overall models (e.g., 55-64 vs. 15-24 years: HR 0.62). However, absolute and relative differences in age-specific hazard rates varied as a function of follow-up time. The greatest age-related differences were observed at earlier event times and were attenuated towards a null difference across later follow-up event times. Conclusions Our study provides new insight into the workplace injury/illness claim and recovery processes and suggests that older age is not always strongly associated with worse disability duration outcomes. The use of data from multiple jurisdictions lends external validity to our findings and demonstrates the utility of using cross-jurisdictional data extracts. Future work should examine the social and contextual determinants that operate during various recovery phases, and how these factors interact with age.

Step-downs reduce workers' compensation payments to encourage return to work: are they effective?

OBJECTIVE

To determine whether step-downs, which cut the rate of compensation paid to injured workers after they have been on benefits for several months, are effective as a return to work incentive.

METHODS

We aggregated administrative claims data from seven Australian workers' compensation systems to calculate weekly scheme exit rates, a proxy for return to work. Jurisdictions were further subdivided into four injury subgroups: fractures, musculoskeletal, mental health and other trauma. The effect of step-downs on scheme exit was tested using a regression discontinuity design. Results were pooled into meta-analyses to calculate combined effects and the proportion of variance attributable to heterogeneity.

RESULTS

The combined effect of step-downs was a 0.86 percentage point (95% CI -1.45 to -0.27) reduction in the exit rate, with significant heterogeneity between jurisdictions (I ²=68%, p=0.003). Neither timing nor magnitude of step-downs was a significant moderator of effects. Within injury subgroups, only fractures had a significant combined effect (-0.84, 95% CI -1.61 to -0.07). Sensitivity analysis indicated potential effects within mental health and musculoskeletal conditions as well.

CONCLUSIONS

The results suggest some workers' compensation recipients anticipate step-downs and exit the system early to avoid the reduction in income. However, the effects were small and suggest step-downs have marginal practical significance. We conclude that step-downs are generally ineffective as a return to work policy initiative.Postprint link: https://www.medrxiv.org/content/10.1101/19012286.

Why does the adverse effect of inappropriate MRI for LBP vary by geographic location? An exploratory analysis

BACKGROUND

Early magnetic resonance imaging (eMRI) for nonspecific low back pain (LBP) not adherent to clinical guidelines is linked with prolonged work disability. Although the prevalence of eMRI for occupational LBP varies substantially among states, it is unknown whether the risk of prolonged disability associated with eMRI varies according to individual and area-level characteristics. The aim was to explore whether the known risk of increased length of disability (LOD) associated with eMRI scanning not adherent to guidelines for occupational LBP varies according to patient and area-level characteristics, and the potential reasons for any observed variations.

METHODS

A retrospective cohort of 59,360 LBP cases from 49 states, filed between 2002 and 2008, and examined LOD as the outcome. LBP cases with at least 1 day of work disability were identified by reviewing indemnity service records and medical bills using a comprehensive list of codes from the International Classification of Diseases, Ninth Edition (ICD-9) indicating LBP or nonspecific back pain, excluding medically complicated cases.

RESULTS

We found significant between-state variations in the negative impact of eMRI on LOD ranging from 3.4 days in Tennessee to 14.8 days in New Hampshire. Higher negative impact of eMRI on LOD was mainly associated with female gender, state workers' compensation (WC) policy not limiting initial treating provider choice, higher state orthopedic surgeon density, and lower state MRI facility density.

CONCLUSION

State WC policies regulating selection of healthcare provider and structural factors affecting quality of medical care modify the impact of eMRI not adherent to guidelines. Targeted healthcare and work disability prevention interventions may improve work disability outcomes in patients with occupational LBP.

Health Care Provider Communication and the Duration of Time Loss Among Injured Workers: A Prospective Cohort Study

BACKGROUND

In addition to providing injured workers with biomedical treatment, health care providers (HCPs) can promote return to work (RTW) through various communications.

OBJECTIVES

To test the effect of several types of HCP communications on time loss following injury.

RESEARCH DESIGN

The authors analyzed survey and administrative claims data from a total of 730 injured workers in Victoria, Australia. Survey responses were collected around 5 months postinjury and provided data on HCP communication and confounders. Administrative claim records provided data on compensated time loss postsurvey. The authors conducted multivariate zero-inflated Poisson regressions to determine both the odds of having future time loss and its duration.

MEASURES

Types of HCP communications included providing an estimated RTW date, discussing types of activities the injured worker could do or ways to prevent a recurrence, and contacting other RTW stakeholders. Each was measured in isolation as well as modified by a low-stress experience with the HCP. Time loss was the count of cumulative compensated work absence in weeks, accrued postsurvey.

RESULTS

RTW dates reduced the odds of future time loss [odds ratio, 0.26; 95% confidence interval (CI), 0.09-0.82] regardless of the stressfulness of the experience. Communications that predicted shorter durations of time loss only did so with low-stress experiences: RTW date [incidence rate ratio (IRR), 0.56; 95% CI, 0.50-0.63], stakeholder contact (IRR, 0.78; 95% CI, 0.70-0.87), and prevention discussions (IRR, 0.87; 95% CI, 0.78-0.98).

CONCLUSIONS

HCPs may reduce time loss through several types of communication, particularly when stress is minimized. RTW dates had the largest and most robust effect.

Association between workers' compensation claim processing times and work disability duration: Analysis of population level claims data

Delays in workers' compensation claim processing (CP) times have been associated with reduced recovery and delayed return-to-work. This study aimed to (1) determine the injury, worker, and workplace factors associated with CP delays and (2) investigate whether CP delays are associated with longer disability duration after adjusting for these factors. Retrospective cohort analysis of Australian workers' compensation claims was conducted from 1st July 2009 to 30th June 2016 for objective (1) and to 30th June 2014 for objective (2). CP times were derived by calculating differences in days between: injury and lodgement dates (lodgement); lodgement and decision dates (decision) and; injury and decision dates (total). All CP times were shorter for younger workers and those with fractures or traumatic injury, and longer for those with neurological or mental health conditions, and other diseases. Claims from self-insured employers had shorter decision times. With increasing lodgement, decision and total time there was significantly higher hazard of longer disability duration. Findings suggest the need for more efficient claims management to ensure fewer barriers to claim lodgement or approval. This in turn should reduce disability duration and ensure improved return-to-work outcomes.

Age, sex, and the changing disability burden of compensated work-related musculoskeletal disorders in Canada and Australia

BACKGROUND

The objectives of this study were (1) to identify age and sex trends in the disability burden of compensated work-related musculoskeletal disorders (MSDs) in Canada and Australia; and (2) to demonstrate a means of comparing workers' compensation data internationally.

METHODS

All non-fatal, work-related MSD claims with at least one day of compensated time-loss were extracted for workers aged 15-80 during a 10-year period (2004-2013) using workers' compensation data from five Canadian and eight Australian jurisdictions. Disability burden was calculated for both countries by sex, age group, and injury classification, using cumulative compensated time-loss payments of up to two years post-injury.

RESULTS

A total of 1.2 million MSD claims were compensated for time-loss in the Canadian and Australian jurisdictions during 2004-2013. This resulted in time-loss equivalent to 239,345 years in the Canadian jurisdictions and 321,488 years in the Australian jurisdictions. The number of time-loss years declined overall among male and female workers, but greater declines were observed for males and younger workers. The proportion of the disability burden grew among older workers (aged 55+), particularly males in the Canadian jurisdictions (Annual Percent Change [APC]: 7.2, 95% CI 6.7 to 7.7%) and females in the Australian jurisdictions (APC: 7.5, 95% CI 6.2 to 8.9%).

CONCLUSIONS

The compensated disability burden of work-related MSDs is shifting towards older workers and particularly older females in Australia and older males in Canada. Employers and workers' compensation boards should consider the specific needs of older workers to reduce injuries and time off work. Comparative research made possible through research-stakeholder partnerships offers a unique opportunity to use existing administrative data to identify long-term trends in disability burden. Future research can apply similar approaches for estimating long-term trends in occupational health.

Evaluation of the Effects of Physical Activity, Cardiorespiratory Condition, and Neuromuscular Fitness on Direct Healthcare Costs and Sickness-Related Absence Among Nursing Personnel With Recurrent Nonspecific Low Back Pain

STUDY DESIGN

A cross-sectional study, part of a randomized controlled trial.

OBJECTIVE

To evaluate the association of physical activity, cardiorespiratory fitness, and neuromuscular fitness with direct healthcare costs and sickness-related absence among nursing personnel with nonspecific low back pain.

SUMMARY OF BACKGROUND DATA

Low back pain creates a huge economic burden due to increased sick leave and use of healthcare services.

METHODS

Female nursing personnel with nonspecific low back pain were included (n = 219). Physical activity was assessed with accelerometry and a questionnaire. In addition, measurements of cardiorespiratory and muscular fitness were conducted. Direct costs and sickness-related absence for a 6-month period were collected retrospectively by questionnaire. Health care utilization and absence from work were analyzed with a general linear model.

RESULTS

The mean total costs were 80.5% lower among women who met physical activity recommendations than inactive women. Those with a higher mean daily intensity level of 10-minute activity sessions showed lower total costs than women in the lowest tertile (middle: 64.0% of the lowest; highest: 54.3% of the lowest). Women with good cardiorespiratory fitness (the highest tertile) as measured with the 6-minute-walk test (based on walking distance) had 77.0% lower total costs when compared with the lowest tertile. Women in the highest third for the modified push-up test had 84.0% lower total costs than those with the poorest results (the bottom tertile).

CONCLUSION

High cardiorespiratory and muscular fitness and meeting physical activity recommendations for aerobic and muscular fitness were strongly associated with lower total costs among nursing personnel with pain-related disorders of recurrent nonspecific low back pain. Actions to increase physical activity and muscle conditioning may significantly save on healthcare costs and decrease sick-leave costs due to low back pain.

Regional socioeconomic disparities in outcomes for workers with low back pain in the United States

BACKGROUND

Although regional socioeconomic (SE) factors have been associated with worse health outcomes, prior studies have not addressed important confounders or work disability.

METHODS

A national sample of 59 360 workers' compensation (WC) cases to evaluate impact of regional SE factors on medical costs and length of disability (LOD) in occupational low back pain (LBP).

RESULTS

Lower neighborhood median household incomes (MHI) and higher state unemployment rates were associated with longer LOD. Medical costs were lower in states with more workers receiving Social Security Disability, and in areas with lower MHI, but this varied in magnitude and direction among neighborhoods. Medical costs were higher in more urban, more racially diverse, and lower education neighborhoods.

CONCLUSIONS

Regional SE disparities in medical costs and LOD occur even when health insurance, health care availability, and indemnity benefits are similar. Results suggest opportunities to improve care and disability outcomes through targeted health care and disability interventions.

Does time off work after injury vary by jurisdiction? A comparative study of eight Australian workers' compensation systems

OBJECTIVES

To determine whether the jurisdiction in which a work-related injury compensation claim is made is an independent predictor of duration of time off work following work injury, and if so, the magnitude of the effect.

SETTING

Eight Australian state and territory workers' compensation systems, providing coverage for more than 90% of the Australian labour force. Administrative claims data from these systems were provided by government regulatory authorities for the study.

PARTICIPANTS

95 976 Australian workers with workers' compensation claims accepted in 2010 and with at least 2 weeks of compensated time off work.

PRIMARY OUTCOME MEASURE

Duration of time lost from work in weeks, censored at 104 weeks.

RESULTS

After controlling for demographic, worker, injury and employer factors in a Cox regression model, significant differences in duration of time loss between state and territory of claim were observed. Compared with New South Wales, workers in Victoria, South Australia and Comcare had significantly longer durations of time off work and were more likely to be receiving income benefits at 104 weeks postinjury, while workers in Tasmania and Queensland had significantly shorter durations of time off work.

CONCLUSIONS

The jurisdiction in which an injured worker makes a compensation claim has a significant and independent impact on duration of time loss. Further research is necessary to identify specific compensation system policies and practices that promote timely and appropriate return to work and reduce duration of time off work.

Return to work outcomes for workers with mental health conditions: A retrospective cohort study

OBJECTIVES

The aims of this study were to describe predictors of sustained return to work (RTW) among a cohort of workers with compensated work-related mental health conditions (MHCs); and to examine predictors of subsequent absences due to the same condition.

METHODS

This study was a retrospective analysis of compensation claims data in Victoria, Australia. We selected workers with an accepted wage replacement claim due to a work-related MHC from 1 January 2002 to 31 December 2009, with two years of follow-up data.

RESULTS

We identified 8358 workers meeting our inclusion criteria. The median age of workers was 44 years (Interquartile range (IQR): 36-51) and 56% were female. In a multivariable Cox regression analysis, older age, being from a small organisation, working in some specific industry segments, consulting a psychiatrist or psychologist, using medications, and having a previous claim were all associated with a delayed RTW. Workers experiencing work pressure, assault/workplace violence or other mental stress factors, working in the public administration and safety industry and having a medical incapacity certification between 3-4 days and 5-7 days had a higher rate of multiple RTW attempts.

CONCLUSION

This study identified a number of risk factors associated with a delayed RTW and multiple attempts at RTW. Predictors may help identify high-risk groups and facilitate the RTW process of workers with MHCs.

A cluster randomized clinical trial comparing functional capacity evaluation and functional interviewing as components of occupational rehabilitation programs

PURPOSE

Functional capacity evaluations (FCE) are used to identify work abilities and are commonly integrated into rehabilitation programs. We studied whether integrating FCE into rehabilitation leads to better outcomes for injured workers.

METHODS

A cluster randomised controlled trial was conducted at a workers' compensation rehabilitation facility (registration ISRCTN61284905). Clinicians were randomised into 2 groups: 1 group used FCE while another conducted semi-structured functional interviews. Outcomes included recommendations following assessment, rehabilitation program outcomes including functional work levels and pain intensity, as well as compensation outcomes at 1, 3, and 6 months after assessment. Analysis included Mann-Whitney U, Chi square and t tests.

RESULTS

Subjects included 225 claimants of whom 105 were tested with FCE. Subjects were predominantly employed (84 %) males (63 %) with sub-acute musculoskeletal conditions (median duration 67 days). Claimants undergoing FCE had ~15 % higher average functional work levels recommended at time of assessment (Mann-Whitney U = 4,391.0, p < 0.001) but differences at other follow-up times were smaller (0-8 %), in favour of functional interviewing, and not statistically significant. Clinically important improvement during rehabilitation in functional work level (0.9/4, SRM = 0.94), pain intensity (2.0/10, SRM = 0.88) and self-reported disability (21.8/100, SRM = 1.45) were only observed in those undergoing the functional interview.

CONCLUSIONS

Performance-based FCE integrated into occupational rehabilitation appears to lead to higher baseline functional work levels compared to a semi-structured functional interview, but not improved RTW rates or functional work levels at follow-up. Functional interviewing has potential for efficiency gains and higher likelihood of clinically important improvement following rehabilitation, however further research is needed.

Exploring the diversity of conceptualizations of work (dis)ability: a scoping review of published definitions

PURPOSE

Researchers are confronted to numerous definitions of work ability/disability, influenced by their context of emergence, discipline, purpose, underlying paradigm and relationship to time. This study provides an in-depth analysis of the concept through a systematic scoping review and the development of an integrative concept map of work (dis)ability. The research questions are: How has work (dis)ability been conceptualized from the perspectives of research, practice, policy and industry in the published scientific literature? How has the conceptualization of work (dis)ability evolved over time?

METHODS

A search strategy was designed with a library scientist to retrieve scientific publications containing explicit definition(s) of work (dis)ability in leading-edge databases. The screening and the extraction of the definitions were achieved by duplicate assessment. The definitions were subject to a comparative analysis based on the grounded theory approach.

RESULTS

In total, 423 abstracts were retrieved from the bibliographic databases. After removing duplicates, 280 unique records were screened for inclusion. A final set of 115 publications containing unique original conceptual definitions served as basis for analysis.

CONCLUSIONS

The scientific literature does not reflect a shared, integrated vision of the exact nature and dimensions of work (dis)ability. However, except for a few definitions, there seems to be a consensus that work (dis)ability is a relational concept resulting from the interaction of multiple dimensions that influence each other through different ecological levels. The conceptualization of work (dis)ability also seems to have become more dynamic over time. The way work (dis)ability is defined has important implications for research, compensation and rehabilitation.

Effects of residential location and work-commuting on long-term work disability

PURPOSE

Little is known about the independent effect of workers' residential location and work-commuting on their long-term disability due to work-related injuries. We examined 149,110 incident claims while adjusting for multiple risk factors in a large, population-based sample of Washington State workers' compensation State Fund claims during 2002-2008.

METHODS

Claimants' residential addresses were geocoded with census tract and aggregated into four category classification of the Rural Urban Commuting Area Codes (RUCAs) which takes into account for tract-level work-commuting. We used logistic regressions to assess the association between RUCAs and whether or not a person was off work for more than 180 days due to injury; Quantile regressions to predict various percentiles of cumulative lost workdays by RUCAs.

RESULTS

Compared to those who live in the Urban Core, workers in other areas experienced longer average paid time loss days due to work-related injury. The association between residential location and long-term disability was significant, odds ratio (OR) 1.19 (95 % confidence interval (CI) 1.11-1.27) for residents of Small Town and Isolated Rural and OR 1.17 (95 % CI 1.12-1.22) for those of Sub Urban, and persisted after controlling for injury nature, socio-demographic, employment-related, and claim administrative characteristics. The impact of residential location and work-commuting elevated as the duration of disability increased.

CONCLUSIONS

This study shows that residential location and work-commuting has a significant and time-varying impact on duration of work disability. Workers living in Sub Urban and Small Town and Isolated Rural areas represent a particularly vulnerable group with respect to risk of long-term work disability.

Prognostic factors for return to work in patients with sciatica

BACKGROUND CONTEXT

Little is known about the prognostic factors for work-related outcomes of sciatica caused by disc herniation.

PURPOSE

To identify the prognostic factors for return to work (RTW) during a 2-year follow-up among sciatica patients referred to secondary care.

STUDY DESIGN/SETTING

Multicenter prospective cohort study including 466 patients. Administrative data from the National Sickness Benefit Register were accessed for 227 patients.

PATIENT SAMPLE

Two samples were used. Sample A comprised patients who at the time of inclusion in the cohort reported being on partial sick leave or complete sick leave or were undergoing rehabilitation because of back pain/sciatica. Sample B comprised patients who, according to the sickness benefit register, at the time of inclusion received sickness benefits or rehabilitation allowances because of back pain/sciatica.

OUTCOME MEASURES

In Sample A, the outcome was self-reported return to full-time work at the 2-year follow-up. In Sample B, the outcome was time to first sustained RTW, defined as the first period of more than 60 days without receiving benefits from the register.

METHODS

Significant baseline predictors of self-reported RTW at 2 years (Analysis A) were identified by multivariate logistic regression. Significant predictors of time to sustained RTW (Analysis B) were identified by multivariate Cox proportional hazard modeling. Both analyses included adjustment for age and sex. To assess the effect of surgery on the probability of RTW, analyses similar to A and B were performed, including the variable surgery (yes/no).

RESULTS

One-fourth of the patients were still out of work at the 2-year follow-up. In Sample A (n=237), younger age, better general health, lower baseline sciatica bothersomeness, less fear-avoidance work, and a negative straight-leg-raising test result were significantly associated with a higher probability of RTW at the 2-year follow-up. Surgery was not significantly associated with the outcome. In Sample B (n=125), history of sciatica, duration of the current sciatica episode more than 3 months, greater sciatica bothersomeness, fear-avoidance work, and back pain were significantly associated with a longer time to sustained RTW. Surgery was significantly negatively associated with time to sustained RTW both in univariate (hazard ratio [HR] 0.60; 95% confidence interval [CI] 0.39, 0.93; p=.02) and in multivariate (HR 0.49; 95% CI 0.31, 0.79; p=.003) analyses.

CONCLUSIONS

The baseline factors associated with RTW identified in multivariate analysis were age, general health, history of sciatica, duration of the current episode, baseline sciatica bothersomeness, fear-avoidance work, back pain, and the straight-leg-raising test result. Surgical treatment was associated with slower RTW, but surgical patients were more severely affected than patients treated without surgery; so, this finding should be interpreted with caution.

Absence from work and return to work in people with back pain: a systematic review and meta-analysis

Background

A considerable proportion of work absence is attributed to back pain, however prospective studies in working populations with back pain are variable in setting and design, and a quantitative summary of current evidence is lacking.

Objective

To investigate the extent to which differences in setting, country, sampling procedures and methods for data collection are responsible for variation in estimates of work absence and return to work.

Methods

Systematic searches of seven bibliographic databases. Inclusion criteria were: adults in paid employment, with back pain, work absence or return to work during follow-up had been reported. Random effects meta-analysis and meta-regression analysis was carried out to provide summary estimates of work absence and return to work rates.

Results

45 studies were identified for inclusion in the review; 34 were included in the meta-analysis. The pooled estimate for the occurrence of work absence in workers with back pain was 15.5% (95% CI 9.8% to 23.6%, n=17 studies, I² 98.1%) in studies with follow-up periods of ≤6 months. The pooled estimate for the proportion of people with back pain returning to work was 68.2% (95% CI 54.8% to 79.1%, n=13, I² 99.2%), 85.6% (95% CI 78.2% to 90.7%, n=13, I² 98.7%) and 93.3% (95% CI 84.0% to 94.7%, n=10, I² 99%), at 1 month, 1–6 months and ≥6 months, respectively. Differences in setting, risk of participation bias and method of assessing work absence explained some of the heterogeneity.

Conclusions

Pooled estimates suggest high return to work rates, with wide variation in estimates of return to work only partly explained by a priori defined study-level variables. The estimated 32% not back at work at 1 month are at a crucial point for intervention to prevent long term work absence.

On the recurrence of occupational injuries and workers' compensation claims

This paper represents the first study to estimate counts of individual occupational injuries and claims over long spells of working life (up to 13 years) in the USA. It explores data from the National Longitudinal Survey of Youth 1979. I found that 37% of all surveyed workers who had experienced one on-the-job accident reported at least one additional injury, but only 56% of all occupational injuries and illnesses resulted in workers' compensation claims. I estimated different count models to assess the effect of different individual worker and job characteristics on individual injury counts and workers' compensation claims counts. Lower educational levels, less tenure, work in dangerous industries and unskilled occupations, and job demands are found to be important determinants of multiple on-the-job injuries. The most interesting results, however, refer to the role played by individuals' pre-injury characteristics: early exposure to dangerous jobs is among the main determinants of higher counts of occupational injuries later in life. Early health limitations are also significant predictors of recurrent workers' compensation claims. These results provide new evidence about the important role played by both the health and the socioeconomic status of young people as determinants of their future occupational injuries.

Predictors of sustained return to work after work-related injury or disease: insights from workers' compensation claims records

AIM

After work-related injury or disease, multiple spells of work absences and unsuccessful return to work (RTW) are common. The purpose of this study was to identify predictors of sustained RTW and work disability recurrences.

METHODS

Australian WorkSafe Victoria claims containing income compensation payments starting between January 1st, 2001 and December 31st, 2004 (n = 59,526) were analysed over a 2-year observation window. Time until first RTW and final RTW, and 'recurrences' (cessations of payments of >7 days), were derived from claims payments data. Regression models were used relating demographic, occupational, workplace and injury characteristics to RTW outcomes.

RESULTS

Although 94% of claimants had at least one RTW, only 79% achieved sustained RTW during follow-up. Median time until first RTW was 50 days; median time until final RTW was 91 days. Independent predictors of delayed final RTW were older age, afflictions involving the neck or multiple locations, and working in manufacturing. Of those who returned to work, 37% had at least one recurrence: risk factors were ages 35-55, female sex, working as a labourer, working in manufacturing, traumatic joint/ligament or muscle/tendon injury and musculoskeletal and connective tissue diseases, and afflictions involving the neck or multiple locations.

CONCLUSIONS

Work disability recurrences are common and have considerable impact on sustained RTW outcomes. A policy focus on education about secondary prevention may help improve long-term RTW outcomes, particularly for persons with musculoskeletal disorders and those working in manufacturing.

The impact of aging on work disability and return to work: insights from workers' compensation claim records

OBJECTIVE

To assess the impact of an aging workforce on (1) the incidence of work-related injury or disease and (2) the return-to-work (RTW) process.

METHODS

Workers' compensation claims (from 2001 to 2004) from Victoria, Australia (n = 59,525) were analyzed. Time off work was defined in terms of time until first RTW, number of workdays compensated, and work disability recurrences.

RESULTS

The incidence of lost-time claims was 7.54 per 1000 worker-years; incidence increased with age to reach a maximum at ages 50 to 54 years. Days until first return also increased with age, as did the sum of compensated days. Recurrences were common (37%) and also increased with age.

CONCLUSIONS

The aging workforce will lead to substantial increase in work disability. Besides general disease and injury preventative practices, policies could aim to provide tailored RTW programs for aging workers.

Identifying neck and back pain in administrative data: defining the right cohort

STUDY DESIGN

We reviewed existing methods for identifying patients with neck and back pain in administrative data. We compared these methods using data from the Department of Veterans Affairs.

OBJECTIVE

To answer the following questions: (1) what diagnosis codes should be used to identify patients with neck pain and back pain in administrative data; (2) because the majority of complaints are characterized as nonspecific or mechanical, what diagnosis codes should be used to identify patients with nonspecific or mechanical problems in administrative data; and (3) what procedure and surgical codes should be used to identify patients who have undergone a surgical procedure on the neck or back.

SUMMARY OF BACKGROUND DATA

Musculoskeletal neck and back pain are pervasive problems, associated with chronic pain, disability, and high rates of health care utilization. Administrative data have been widely used in formative research, which has largely relied on the original work of Volinn, Cherkin, Deyo, and Einstadter and the Back Pain Patient Outcomes Assessment Team first published in 1992. Significant variation in reports of incidence, prevalence, and morbidity associated with these problems may be due to nonstandard or conflicting methods to define study cohorts.

METHODS

A literature review produced 7 methods for identifying neck and back pain in administrative data. These code lists were used to search Veterans Health Administration data for patients with back and neck problems, and to further categorize each case by spinal segment involved, as nonspecific/mechanical and as surgical or not.

RESULTS

There is considerable overlap in most algorithms. However, gaps persist.

CONCLUSION

Gaps are evident in existing methods and a new framework to identify patients with neck pain and back pain in administrative data is proposed.

Barriers and enablers to returning to work from long-term sickness absence: Part I-A quantitative perspective

BACKGROUND

Long-term sickness absence (LTSA) in the United Kingdom labor market has become a major health issue in recent years. In contrast to short-term sickness absence, rates for LTSA have been on the increase. This paper, part 1 of a two-part paper, identifies individual domain barriers to returning to work (RTW) from LTSA across the work disability timeline in the UK labor market.

METHODS

This is a retrospective cohort study of 6,246 workers from an occupationally diverse Police Force within the UK using a large administrative database. A series of chi-squared analyses were conducted to analyze the between and within group associations. Next, multiple logistic regression analyses using the Enter method were performed to develop a predictive model for RTW and Absence Phase.

RESULTS

Findings substantiated the presence of individual domain barriers to RTW and predictors of RTW outcome and established the absence phase specificity of a number of risk factors of prolonged work disability. In particular, injury/illness especially mental ill health (MIH), physical job demands, sex, and number of episodes of LTSA are significant individual domain barriers to RTW and represent important risk factors for prolonged work disability.

CONCLUSIONS

Duration of work disability is associated with medical diagnosis, especially MIH, physical job demands, sex, and number of LTSA episodes. Findings also support the importance of using the outcome measure of absence phase of risk factors in addition to RTW outcome.

Recovery expectations predict recovery in workers with back pain but not other musculoskeletal conditions

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

We examined whether recovery expectations predict future return-to-work in workers filing injury claims for a variety of musculoskeletal conditions.

SUMMARY OF BACKGROUND DATA

Recovery expectations seem to influence recovery and return-to-work after back pain, but their role in other compensable conditions is uncertain.

METHODS

All workers' compensation claimants receiving time-loss benefits for a musculoskeletal condition and undergoing return-to-work assessment were enrolled. Claimants completed a work-related recovery expectations questionnaire. Outcomes during the 1-year follow-up included surrogate indicators of timely return-to-work (days until suspension of time-loss benefits) and recovery (claim closure). Analysis included multivariable Cox regression.

RESULTS

The sample consisted of 1040 claimants of whom 298 (29%) had back pain, 461 (44%) had sprains, strains, or pain of other body parts besides the back, 234 (23%) had specific injuries such as fracture, dislocation, or amputation, and 47 (5%) had other compensable conditions such as carpal tunnel syndrome or knee internal derangement. The majority of participants had chronic conditions (mean duration >6 mo). Negative work-related recovery expectations were consistently associated with slower suspension of time-loss benefits (Hazard Ratio 0.83) and slower claim closure (Hazard Ratio 0.84) in claimants with back pain, but associations in other diagnostic groups were inconsistent and not statistically significant. Associations were slightly larger within the group of claimants with back pain of less than 3-month duration.

CONCLUSIONS

Recovery expectations provide some information for predicting future recovery in workers filing injury claims for back pain, but do not seem to predict recovery in claimants with other musculoskeletal conditions.

How accurate are self-reports? Analysis of self-reported health care utilization and absence when compared with administrative data

OBJECTIVE

To determine the accuracy of self-reported health care utilization and absence reported on health risk assessments against administrative claims and human resource records.

METHODS

Self-reported values of health care utilization and absenteeism were analyzed for concordance to administrative claims values. Percent agreement, Pearson's correlations, and multivariate logistic regression models examined the level of agreement and characteristics of participants with concordance.

RESULTS

Self-report and administrative data showed greater concordance for monthly compared with yearly health care utilization metrics. Percent agreement ranged from 30% to 99% with annual doctor visits having the lowest percent agreement. Younger people, males, those with higher education, and healthier individuals more accurately reported their health care utilization and absenteeism.

CONCLUSIONS

Self-reported health care utilization and absenteeism may be used as a proxy when medical claims and administrative data are unavailable, particularly for shorter recall periods.

Back pain recurrence: an evaluation of existing indicators and direction for future research

STUDY DESIGN

Literature review.

OBJECTIVE

To present a framework for future analyses of back pain recurrence and explore the applicability and relevance of existing recurrence indicators.

SUMMARY OF BACKGROUND DATA

Empirical studies of back pain have included a variety of indicators of recurrence, resulting in a range of findings about recurrence rates and associated factors. Little is known about the relationships between existing indicators.

METHODS

Literature overview, expert panel, and workshop discussion at the IX International Forum on Primary Care Research on Low Back Pain.

RESULTS

Using the International Classification of Functioning, Disability, and Health (ICF), disabling back pain was conceptualized as a health condition, i.e., back pain disorder (BPD), and BPD recurrence was conceptualized as involving a return of atypical back pain and/or back-pain-related difficulty performing tasks and actions related to the initial episode. Using the ICF, 2 types of recurrence indicators were identified: those directly describing components of BPD and those indirectly doing so (e.g., recurrence of health care utilization).

CONCLUSION

In light of the difficulty in measuring BPD recurrence, transparent definitions and a clear understanding of the implications of using particular indicators is required. Future research should focus: on examining the capture BPD recurrence by various research instruments, improving understanding of the relationship between indicators, and gaining insight into how individuals experiencing BPD view recurrence.

Coordinated and tailored work rehabilitation: a randomized controlled trial with economic evaluation undertaken with workers on sick leave due to musculoskeletal disorders

INTRODUCTION

In Denmark, the magnitude and impact of work disability on the individual worker and society has prompted the development of a new "coordinated and tailored work rehabilitation" (CTWR) approach. The aim of this study was to compare the effects of CTWR with conventional case management (CCM) on return-to-work of workers on sick leave due to musculoskeletal disorders (MSDs).

METHODS

The study was a randomized controlled trial with economic evaluation undertaken with workers on sick leave for 4-12 weeks due to MSDs. CTWR consists of a work disability screening by an interdisciplinary team followed by the collaborative development of a RTW plan. The primary outcome variable was registered cumulative sickness absence hours during 12 months follow-up. Secondary outcomes were work status as well as pain intensity and functional disability, measured at baseline, 3 and 12 months follow-up. The economic evaluation (intervention costs, productivity loss, and health care utilization costs) was based on administrative data derived from national registries.

RESULTS

For the time intervals 0-6 months, 6-12 months, and the entire follow-up period, the number of sickness absence hours was significantly lower in the CTWR group as compared to the control group. The total costs saved in CTWR participants compared to controls were estimated at US $ 1,366 per person at 6 months follow-up and US $ 10,666 per person at 12 months follow-up.

CONCLUSIONS

Workers on sick leave for 4-12 weeks due to MSD who underwent "CTWR" by an interdisciplinary team had fewer sickness absence hours than controls. The economic evaluation showed that-in terms of productivity loss-CTWR seems to be cost saving for the society.

Opioid prescriptions in canadian workers' compensation claimants: prescription trends and associations between early prescription and future recovery

STUDY DESIGN

Historical cohort study.

OBJECTIVE

We investigated the prescription of opioids in injured Canadian workers to determine recent trends in use and the association between early prescription and future recovery.

SUMMARY OF BACKGROUND DATA

Opioid analgesia is effective for reducing chronic nonmalignant pain, and opioid prescriptions for musculoskeletal pain seem to have increased over the past years. However, recent evidence indicates early opioid use may be associated with delayed recovery in patients with back pain.

METHODS

Data were extracted from the Alberta Workers' Compensation Board administrative database, and information was obtained on all time loss claims for sprains, strains, fractures, dislocations, amputations, or burns between January 1, 2000 and December 31, 2005. Information on all narcotic prescriptions was obtained along with demographic data and duration of time loss benefits. Injury severity was controlled for via nature of injury coding. Analysis included multivariable logistic and Cox regression.

RESULTS

Data were obtained for 137,175 subjects. The majority were males ( approximately 70%) with back sprains (approximately 35%), and a mean age of 37 years. Between the years 2000 and 2005, all opioid prescriptions within the first year of claim decreased from 11.4% of claimants to 8.3%. Older males with fractures, dislocations, or amputations were more likely to receive narcotics. Claimants receiving early opioid prescriptions experienced delayed suspension of benefits. However, this association was also seen in claimants prescribed early non-narcotic analgesics.

DISCUSSION

Prescriptions for opioid analgesia appear to be decreasing within workers' compensation claimants in Alberta, Canada. As expected, claimants with more severe injuries were more likely to receive opioids. An association was observed between early opioid prescription and delayed recovery, however, this is likely explained by pain severity or other unmeasured confounders.

Sick leave reductions from a comprehensive manual therapy programme for low back pain: the Gotland Low Back Pain Study

OBJECTIVE

To evaluate if a comprehensive manual therapy programme reduces sick leave due low back pain and facilitates return to work more than the conventional optimized activating care.

DESIGN

A randomized controlled trial over a 10-week period with a two-year follow-up.

SETTING

Primary health care and Visby Hospital, Municipality of Gotland, Sweden.

SUBJECTS

One hundred and sixty patients (70 women, 90 men, ages 20-55 years) with acute or subacute low back pain with or without pain radiation into the legs.

INTERVENTIONS

Standardized optimized activating care (n = 71) versus a comprehensive pragmatic manual therapy programme including specific corticosteroid injections (n = 89).

MAIN MEASURES

Sick leave measured as net sick leave volume, point prevalence and return to work.

RESULTS

After 10 weeks, significantly more manual therapy patients than reference patients had returned to work (hazards ratio 1.62, 95% confidence interval (CI) 1.006-2.60, P<0.05), and among those on sick leave at baseline, significantly fewer were still on sick leave (8/58 versus 13/40, ratio 0.35, 95% CI 0.13-0.97, P<0.05). For all other measures there were inconclusive differences in favour of the manual therapy group. No significant differences remained after two years.

CONCLUSIONS

The manual therapy programme used in this study decreased sick leave and increased return to work more than the standardized optimized activating care only up to 10 weeks but not up to two years.

Including injured workers without compensated time loss in Cox regression models: analyzing time loss using all available data

INTRODUCTION

Cox proportional hazards regression is commonly used to analyze time loss duration, but statistical packages conventionally exclude cases with no recorded follow-up time. For this and other substantive reasons, many researchers limit time loss analyses to the subset of workers who received time loss compensation. This can exclude both injured workers who missed no work days and those missing up to a week of work. For some research questions, excluding cases where injury is reported but no time loss is recorded may result in significant ascertainment bias. We present a novel technique based on standard survival analysis methods to allow for the inclusion of all cases when appropriate.

METHODS

A simple technique to allow standard statistical software to include both medical-only and time loss claims in Cox regression is illustrated by example and compared with a two-part model using a time-varying step function to allow regression effects to change over time.

RESULTS

We showed that a pooled analysis is obtained by simply adding a small constant to the time loss duration variable. This technique produced appropriate estimates while accounting for censoring when a suitable method was used for tied event times. Using a formal statistical framework, the combined model was justified as a special case of the more standard two-part model approach.

CONCLUSIONS

When it is desirable to have a single pooled outcome estimate for injured workers with both medical-only and time loss claims, all claims can be combined into one statistical model. This may have particular utility for research questions where the risk factor or intervention of interest would be expected to affect time loss duration beginning upstream of claim filing or statutory compensation waiting periods. This novel alternative modeling strategy expands the tool kit available for analyzing time loss data.

Delayed return-to-work in workers after non-severe occupational upper extremity fracture in Taiwan

BACKGROUND/PURPOSE

Occupational injury of the upper extremities account for 24% of occupational injuries in Taiwan. However, studies on the timing and factors influencing return-to-work are lacking.

METHODS

A total of 102 hospitalized workers with non-severe upper extremity fractures, defined as without avulsion, amputation and nerve damage, were interviewed over the telephone using a structured questionnaire at 45, 90 and 180 days after injury.

RESULTS

After controlling other factors, cases with other-than-digit fracture presented three-fold more difficulty than those with digit fracture on returning to work (OR, 0.32; 95% CI, 0.17-0.63). Male workers (OR, 2.70; 95% CI, 1.16-6.25) and those with financial help from their employer (OR, 2.32; 95% CI, 1.17-4.60) found it easier to return to work 90 days after injury. There were 32% who were still unable to return to work 180 days after injury.

CONCLUSION

Women workers and workers without financial help from employers are at a disadvantage with regard to early return-to-work. Other assistance besides medical treatment could be of significant help but should be cautiously exercised in extrapolating to workers who are not the main breadwinner in their household.

The influence of a continuum of care model on the rehabilitation of compensation claimants with soft tissue disorders

STUDY DESIGN

Population-based before-and-after design with concurrent control group.

OBJECTIVE

As continuums of care have been little studied, we evaluated the impact of the Workers' Compensation Board of Alberta (WCB-Alberta) model on sustained return to work, satisfaction with care, and cost.

SUMMARY OF BACKGROUND DATA

Musculoskeletal conditions, such as back pain, continue to be leading causes of disability and work loss. From 1996 through 1997, the WCB-Alberta implemented a continuum of care model to guide rehabilitation service delivery for claimants with soft tissue injury. The model was designed as a decision-making tool to promote a consistent, evidence-based approach to care within the jurisdiction.

METHODS

The model was implemented province-wide so the entire population of workers insured by the WCB-Alberta was studied. Data were extracted from the WCB-Alberta administrative database from 2 years before implementation (1994-1995) to 5 years after (1996-2000). An intervention group was created from patients filing soft tissue injury claims for the low back, ankle, knee, elbow, and shoulder. The comparison group was formed of workers experiencing fractures or other traumatic non-soft tissue injuries. Satisfaction was measured through surveys. Primary outcome was cumulative days receiving wage replacement benefits. Multivariable Cox regression was used to determine the model's effect.

RESULTS

Over the entire study period, 70,116 claimants filed soft tissue injury claims while 101,620 claimants experienced non-soft tissue injuries. Significant improvement was observed in intervention group return-to-work outcomes after model implementation (hazard ratio = 1.54). Median duration of benefits decreased from 13 to 8 days. Little change was seen in the control group's disability duration (median duration, consistently 10 days). The majority of claimants were satisfied with care received. Cost savings over a 2-year full implementation period was $21.5 million (Canadian).

CONCLUSION

Implementation of a soft tissue injury continuum of care involving staged application of various types of rehabilitation services appears to have resulted in more rapid and sustained recovery.

Evaluation of a short-form functional capacity evaluation: less may be best

PURPOSE

Functional Capacity Evaluation (FCE) contributes to clinical decisions regarding fitness-for-work and may improve return-to-work outcomes. However, FCE is a burdensome clinical tool in terms of time and cost. We evaluated the effectiveness of a short-form FCE protocol.

METHODS

A cluster randomized controlled trial was conducted. Data were collected on all claimants undergoing FCE at Alberta's workers' compensation rehabilitation facility. Twenty-three clinicians who were trained and experienced with FCE were randomized to either an intervention or control group. The intervention group was trained to conduct short-form FCE and used this protocol through the trial's duration, while the control group continued standard FCE procedures. Data on subject characteristics, administrative outcomes (days to suspension of time loss benefits, days to claim closure, and future recurrence) and claimant satisfaction were extracted from the WCB-Alberta computer databases. Clinicians logged time taken to complete assessments. Analysis included examining differences between groups using independent samples t tests, Cox and logistic regression.

RESULTS

Subjects included 372 claimants of whom 173 were tested with short-form FCE. Subjects were predominantly employed (64%) males (69%) with chronic musculoskeletal conditions (median duration 252 days). Administrative recovery outcomes were similar between groups as were claimant satisfaction ratings. No statistically significant or clinically relevant differences were observed on these outcomes between groups. A 43% reduction in functional assessment time was seen.

CONCLUSION

A short-form FCE appears to reduce time of assessment while not affecting recovery outcomes when compared to standard FCE administration. Such a protocol may be an efficient option for therapists performing fitness-for-work assessments.

Duration Dependence in Sickness Absence: How Can We Optimize Disability Management Intervention Strategies?

OBJECTIVE

The optimal timing of interventions during sickness absence remains difficult to determine, because we do not have a clear picture of the presence and type of duration dependence that exists. This study investigates the impact of an intervention by the occupational physician as well as of socioeconomic and work-related factors on duration dependence during sickness absence.

METHODS

Analyses were performed at the population level using data from a major longitudinal survey on work incapacity and return to work in The Netherlands. Several models of duration dependence are estimated.

RESULTS

Evidence is found for the presence of variable-duration dependence. Characteristics that influence duration dependence of the return-to-work (RTW) rate are identified.

CONCLUSIONS

The findings imply that RTW intervention strategies should vary according to differences in workers' susceptibility to positive or negative duration-dependence effects.

Duration of work disability: a comparison of self-report and administrative data

BACKGROUND

Studies have used insurer-reported compensable days absent as an outcome measure when studying work-related injury or illness. Compared to self-reported days absent, insurer data are less expensive to collect. Previous work has identified that insurer-claims data consistently underestimate the duration of days absent when compared to self-report. The objective of this study was to examine the agreement between the number of self-reported days absent from work following a compensable work-related injury and the number of insurer-reported compensation days paid, and to examine factors associated with the magnitude of the discrepancy between the number of self-reported days absent and the number of insurer-reported compensated days paid.

METHODS

One hundred sixty six respondents who experienced a work-related injury were interviewed approximately 200 days post-injury to assess the number of days absent from work. The number of days compensated by the insurer was compared to self-report using descriptive statistics and linear regression.

RESULTS

Respondents who had yet to experience a return-to-work (RTW) had the largest median discrepancy followed by respondents with an unsustained RTW and finally sustained RTW. Respondents with upper extremity injuries, lower education, and lower RTW self-efficacy showed greater discrepancy between self-reported and compensated days absent. Among respondents who self-reported fewer days absent than insurer-compensated days absent an inverse relationship between firm size and discrepancy was noted.

CONCLUSIONS

Researchers should be aware of the discrepancies between self-reported and compensated days absent. Future studies planning to incorporate days absent as an outcome variable should carefully consider what measure would be more appropriate and potentially collect both self-report and administrative data to assess the discrepancy.

Does functional capacity evaluation predict recovery in workers' compensation claimants with upper extremity disorders?

OBJECTIVES

Functional capacity evaluations (FCEs) are commonly used to determine return-to-work readiness and guide decision making following work related injury, yet little is known of their validity. The authors examined performance on the Isernhagen Work Systems' FCE as a predictor of timely and sustained recovery in workers' compensation claimants with upper extremity disorders. A secondary objective was to determine whether FCE is more predictive in claimants with specific injuries (that is, fracture) as compared to less specific, pain mediated disorders (that is, myofascial pain).

METHODS

The authors performed a longitudinal study of 336 claimants with upper extremity disorders undergoing FCE. FCE indicators were maximum performance during handgrip and lift testing, and the number of tasks where performance was rated below required job demands. Outcomes investigated were days receiving time-loss benefits (a surrogate of return to work or work readiness) in the year following FCE, days until claim closure, and future recurrence defined as whether benefits restarted, the claim reopened, or a new upper extremity claim was filed. Cox and logistic regression were used to determine the prognostic effect of FCE crudely and after controlling for potential confounders. Analysis was performed separately on claimants with specific and pain mediated disorders.

RESULTS

Most subjects (95%) experienced time-loss benefit suspension within one year following FCE. The one year recurrence rate was 39%. Higher lifting performance was associated with faster benefit suspension and claim closure, but explained little variation in these outcomes (r2 = 1.2-11%). No FCE indicators were associated with future recurrence after controlling for confounders. Results were similar between specific injury and less specific groups.

CONCLUSIONS

Better FCE performance was a weak predictor of faster benefit suspension, and was unrelated to sustained recovery. FCE was no more predictive in claimants with specific pathology and injury than in those with more ambiguous, pain mediated conditions.

Length of disability prognosis in acute occupational low back pain: development and testing of a practical approach

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Practical evaluation of a rapid prognostic screening method to predict length of disability after acute occupational low back pain (OLBP).

SUMMARY OF BACKGROUND DATA

Few studies have evaluated the prognostic value of administrative data and selected clinical variables in typical practice settings.

METHODS

Nurse case manager (NCM) input for 16 variables and 7 administrative data variables were collected for 494 OLBP cases with at least 30 days of disability. Length of disability (LOD) was ascertained by individual indemnity payment analysis. Cases were censored after accumulating 365 days of temporary total disability or if they received a lump sum settlement. Prognostic variables were evaluated by Cox proportional hazards modeling.

RESULTS

In a multivariate model, prolonged LOD was associated with older age, shorter job tenure, female gender, presence of language barriers, comorbidity, prior work absence, delayed referral, attorney involvement nonsupportive of return to work (RTW), and low RTW motivation. Although only 12% of overall variance in LOD was explained by the model, high-risk and low-risk terciles were readily distinguished.

CONCLUSIONS

In a typical setting, data collection and risk prediction by nurses or case managers are feasible and provide specific information that can be used to identify who should receive intervention, as well as some guidance on factors that should be addressed.

Development and validation of a short-form functional capacity evaluation for use in claimants with low back disorders

OBJECTIVES

Functional Capacity Evaluations (FCE) are used for making return-to-work decisions, yet FCE's modest predictive ability is currently outweighed by the administrative burden of testing. We attempted to develop a short-form FCE while maintaining comparable predictive ability.

METHODS

Three databases previously created for evaluating FCE predictive validity were used. Subjects were compensation claimants with low back disorders. FCE measures included items in the Isernhagen Work Systems' FCE. Days until benefit suspension served as an indicator of return-to-work. Analysis included Cox regression.

RESULTS

Three items, floor-to-waist lift, crouching, and standing, were maintained in the short-form FCE. The short-form FCE was found to predict comparably to the entire FCE protocol in two validation cohorts (R (2) difference<3%). Subjects meeting job demands on all three items consistently experienced faster benefit suspension.

CONCLUSION

A short-form FCE for determining future work status in claimants with low back disorders was developed. A substantially abbreviated FCE may offer an efficient alternative.

Work disability and costs caused by recurrence of low back pain: longer and more costly than in first episodes

STUDY DESIGN

Retrospective analysis of workers' compensation (WC) claims data for nonspecific low back injuries (LBI) in a single jurisdiction.

OBJECTIVE

To examine whether recurrences, defined as post-initial episodes of work disability or medical care, substantially contribute to total medical and indemnity costs, and total duration of work disability.

SUMMARY OF BACKGROUND DATA

Previous studies have not measured the proportion of care seeking and work disability that are associated with recurrences in claims for work-related LBI.

METHODS

All persons with new lost-time claims for nonspecific LBI reported in New Hampshire to a large WC provider from 1996 to 1999 were selected (N = 1867). Three years of follow-up data, starting at the beginning of the first episode, were collected. Previously validated definitions of recurrence were used identify new episodes of care and new episodes of lost work time (work disability). Total duration of work disability, total medical costs, and total indemnity costs were investigated. For individuals with recurrences, these variables were separated into first-episode and recurrent period duration and costs.

RESULTS

The rate of recurrent work disability was 17.2%, and the rate of recurrent care seeking was 33.9%. Individuals with recurrence had significantly higher total length of work disability, and higher medical and indemnity costs. For those with recurrent work disability, 69% of total lost time from work, 71% of associated indemnity costs, and 84% of total medical costs occurred during the recurrent period. For those with recurrence of care, the respective values were 48%, 47%, and 42%.

CONCLUSIONS

Recurrences contributed disproportionately to the total burden of work-related nonspecific LBI, through both additional care seeking and work disability. Results imply that those who have recurrences may be an especially important target for secondary prevention efforts.

Prognosis and the identification of workers risking disability: research issues and directions for future research

INTRODUCTION

Screening procedures based on prognostic data are an important prerequisite for prevention of disability due to low-back pain. This paper reviews the research on prognosis to delineate the most pertinent research challenges, and outlines directions for future research to improve the scientific quality and screening accuracy of prognostic efforts.

METHODS

Reviews of prognosis research were examined to identify key methodological and research issues.

RESULTS

Certain issues such as sampling procedures, research designs, data analyses, prognostic indicators, and follow-up procedures limit the value of prior studies. Absence of a clear conceptual framework hampers interpretation of findings and moving research questions forward. The recurrent nature of back pain and the need to effectively include the impact of employer actions and the job market were also identified as significant issues.

CONCLUSIONS

Future research will be enhanced by addressing conceptual and definitional issues, applying tested and sensible measures, and careful follow-up of the study population.