Doctor proactive communication, return-to-work recommendation, and duration of disability after a workers' compensation low back injury

The Needs and Experiences of Patients Returning to Work After Total Knee Arthroplasty and Total Hip Arthroplasty: A Systematic Review and Meta-Synthesis

OBJECTIVE

The objective of this study was to conduct a systematic and comprehensive review of qualitative research to examine the physical and psychological needs, as well as work experiences, of patients undergoing total knee replacement and total hip replacement surgeries during their process of returning to work.

METHODS

A systematic review and meta-synthesis of qualitative literature was conducted. A systematic search was conducted across 8 databases to identify qualitative or mixed-methods research on the needs and experiences of individuals with total knee replacement and total hip replacement who have returned to work. The search period extended from the inception of each database to March 2023. Two researchers independently utilized a predetermined search strategy to retrieve relevant English-language studies published in any year. The included studies were assessed for quality using the Critical Appraisal Skills Program appraisal tool. Findings from the studies were then summarized and integrated using the pooled integration method.

RESULTS

There were 10 studies in total. Three key themes were identified from the original research: needs during the return to work process and rehabilitation training, faith and support to return to work, and constraints and challenges at work.

CONCLUSION

Health care professionals and employers should conscientiously consider the physical and psychological requirements of patients who have undergone total knee replacement and total hip replacement when they are resuming work, taking into account the specific constraints and challenges that may arise in the workplace. To ensure a seamless transition back to work, it is essential to develop tailored occupational interventions, implement comprehensive return to work programs, and offer patients sufficient understanding and support.

IMPACT

The findings of this study offer valuable insights into the physical and psychological needs, as well as the work experiences, of patients who have undergone total knee replacement and total hip replacement during their reintegration into the workforce. These findings have the potential to assist health care professionals and employers in providing enhanced support to facilitate successful return-to-work outcomes for patients.

Recovery expectations can be assessed with single-item measures: findings of a systematic review and meta-analysis on the role of recovery expectations on return-to-work outcomes after musculoskeletal pain conditions

ABSTRACT

The objective of this systematic review is to quantify the association between recovery expectations and return-to-work outcomes in adults with musculoskeletal pain conditions. In addition, this review has the second objective to compare the predictive utility of single-item and multi-item recovery expectation scales on return-to-work outcomes. Relevant articles were selected from Embase, PsycINFO, PubMed, Cochrane, and manual searches. Studies that assessed recovery expectations as predictors of return-to-work outcomes in adults with musculoskeletal pain conditions were eligible. Data were extracted on study characteristics, recovery expectations, return-to-work outcomes, and the quantitative association between recovery expectations and return-to-work outcomes. Risk of bias was assessed using the Effective Public Health Practice Project. Odds ratios were pooled to examine the effects of recovery expectations on return-to-work outcomes. Chi-square analyses compared the predictive utility of single-item and multi-item recovery expectation scales on return-to-work outcomes. Thirty studies on a total of 28,741 individuals with musculoskeletal pain conditions were included in this review. The odds of being work disabled at follow-up were twice as high in individuals with low recovery expectations (OR = 2.06 [95% CI 1.20-2.92] P < 0.001). Analyses also revealed no significant differences in the predictive value of validated and nonvalidated single-item measures of recovery expectations on work disability (χ 2 = 1.68, P = 0.19). There is strong evidence that recovery expectations are associated with return-to-work outcomes. The results suggest that single-item measures of recovery expectations can validly be used to predict return-to-work outcomes in individuals with musculoskeletal pain conditions.

Influence of social support on return to work after total hip or total knee arthroplasty: a prospective multicentre cohort study

OBJECTIVES

There is strong evidence that social support is an important determinant of return to work (RTW). Little is known about the role of social support in RTW after total hip or knee arthroplasty (THA/TKA). Objective was to examine the influence of preoperative and postoperative perceived social support on RTW status 6 months postoperatively.

DESIGN

A prospective multicentre cohort study was conducted.

SETTING

Orthopaedic departments of four Dutch medical centres; a tertiary university hospital, two large teaching hospitals and a general hospital.

PARTICIPANTS

Patients planned to undergo THA/TKA, aged 18-63 and employed preoperatively were included.

MAIN OUTCOME MEASURES

Questionnaires were filled out preoperatively and 3 and 6 months postoperatively and included questions to assess patients' perceived social support targeting three sources of social support: from home (friends, family), from work (coworkers, supervisors) and from healthcare (occupational physician, general practitioner, other caregivers). Control variables included age, gender, education, type of arthroplasty and comorbidities. RTW was defined as having fully returned to work 6 months postoperatively. Univariate and multivariate logistic regression analyses were conducted.

RESULTS

Enrolled were 190 patients (n=77 THA, n=113 TKA, median age was 56 years, 56% women). The majority returned to work (64%). Preoperatively, social support from the occupational physician was associated with RTW (OR 2.53, 95% CI 1.15 to 5.54). Postoperatively, social support from the occupational physician (OR 3.04, 95% CI 1.43 to 6.47) and the supervisor (OR 2.56, 95% CI 1.08 to 6.06) was associated with RTW.

CONCLUSIONS

This study underscores the importance of work-related social support originating from the occupational physician and supervisor in facilitating RTW after primary THA/TKA, both preoperatively and postoperatively. Further research is needed to confirm our results and to understand the facilitating role of social support in RTW, as arthroplasty is being performed on a younger population for whom work participation is critical.

Identification of the return-to-work mode in unemployed workers with mental health issues: A focus group study among occupational health professionals

BACKGROUND: Return-to-work (RTW) perceptions and attitudes are predictive for future work participation in workers with mental health issues. OBJECTIVE: To identify what RTW perceptions and attitudes occupational health professionals recognize in sick-listed unemployed workers with mental health issues and how these perceptions and attitudes can be systematically assessed. METHODS: Four focus group sessions, each involving five-six different occupational health professionals, were held. The audio records were transcribed verbatim and coded by two researchers independently. A thematic analysis was conducted. RESULTS: Professionals recognized RTW perceptions and attitudes in sick-listed unemployed workers with mental health issues. These perceptions and attitudes were described as characteristics of three modes in a process regarding RTW: the passive, ambivalent and active RTW mode. A passive RTW mode includes perceptions about not being able to work and an expectant attitude. The ambivalent RTW mode is characterized by uncertainty and ambivalence regarding RTW with a desire for occupational support. Workers in an active RTW mode have positive RTW perceptions and show job search behavior. A main theme was the flexible nature of RTW attitudes and perceptions, with workers switching between the passive, ambivalent and active RTW modes. For the assessment of the RTW mode, the professionals preferred personal contact, possibly with support of a tool. This enables them to ask specific questions and to observe non-verbal signs. CONCLUSIONS: Recurring assessments of the RTW mode can be helpful in identifying unemployed workers with mental health issues at risk of long-term sickness absence and for starting targeted RTW interventions.

The Value of the Patient-Centered Medical Home in Getting Adults Suffering From Acute Conditions Back to Work: An Integrative Literature Review

Acute conditions are the leading cause of work restrictions and missed workdays, contributing to over $27 billion in lost productivity each year and negatively impacting workers' health and quality of life. Primary care services, specifically patient-centered medical homes (PCMHs), play an essential role in supporting timely acute illness or injury recovery for working adults. The purpose of this review is to synthesize the evidence on the relationship between PCMH implementation, care processes, and outcomes. In addition, we discuss the empirical connection between this evidence and return-to-work outcomes, as well as the need for further research.

Patient Vs. Soldier-Centered Medical Home: Comparing Access, Continuity, and Communication in the U.S. Army

INTRODUCTION

Over the last 40 years, patient-centered medical home (PCMH) has evolved as the leading primary care practice model, replacing traditional primary care models in the United States and internationally. The goal of PCMH is to improve chronic condition management. In the U.S. Army, the scope of the medical home, which encompasses various care delivery platforms, including PCMH and soldier-centered medical home (SCMH), extends beyond the management of chronic illnesses. These medical home platforms are designed to support the unique health care needs of the U.S. Army's most vital asset-the soldier. The PCMHs and SCMHs within the U.S. Army employ patient-centered care principles while incorporating nationally recognized structural attributes and care processes that work together in a complex adaptive system to improve organizational and patient outcomes. However, U.S. Army policies dictate differences in the structures of PCMHs and SCMHs. Researchers suggest that differences in medical home structures can impact how organizations operationalize care processes, leading to unwanted variance in organizational and patient outcomes. This study aimed to compare 3 care processes (access to care, primary care manager continuity, and patient-centered communication) between PCMHs and SCMHs.

MATERIALS AND METHODS

This was a retrospective, cross-sectional, and correlational study. We used a subset of data from the Military Data Repository collected between January 1, 2018, and December 31, 2018. The sample included 266 medical home teams providing care for active duty soldiers. Only active duty soldiers were included in the sample. We reviewed current U.S. Army Medical Department policies to describe the structures and operational functioning of PCMHs and SCMHs. General linear mixed regressions were used to evaluate the associations between medical home type and outcome measures. The U.S. Army Medical Department Center and School Institutional Review Board approved this study.

RESULTS

There was no significant difference in access to 24-hour and future appointments or soldiers' perception of access between PCMHs and SCMHs. There was no significant difference in primary care manager continuity. There was a significant difference in medical home team continuity (P < .001), with SCMHs performing better. There was no significant difference in patient-centered communication scores. Our analysis showed that while the PCMH and SCMH models were designed to improve primary care manager continuity, access to care, and communication, medical home teams within the U.S. Army are not consistently meeting the Military Health System standard of care benchmarks for these care processes.

CONCLUSIONS

Our findings comparing 3 critical medical home care processes suggest that structural differences may impact continuity but not access to care or communication. There is an opportunity to further explore and improve access to appointments within 24 hours, primary care manager and medical home team continuity, perception of access to care, and the quality of patient-centered communication among soldiers. Knowledge gained from this study is essential to soldier medical readiness.

A primary care team approach to secondary prevention of work-related musculoskeletal disorders: Physical therapy perspectives

BACKGROUND

Among work-related conditions in the United States, musculoskeletal disorders (MSDs) account for about thirty-four percent of work absences. Primary care physicians (PCPs) play an essential role in the management of work-related MSDs. For conditions diagnosed as work-related, up to seventeen percent of cases are PCP managed; within these conditions, up to fifty-nine percent are diagnosed as musculoskeletal. Negative factors in treatment success confronting PCPs include time constraints and unfamiliarity with work-related MSDs. A multidimensional team approach to secondary prevention, where PCPs can leverage the expertise of allied health professionals, might provide a useful alternative to current PCP practices for the treatment of work-related MSDs.

OBJECTIVE

Provide the structure of and rationale for an "extended care team" within primary care for the management of work-related MSDs.

METHODS

A systematic literature search, combining medical subject headings and keywords, were used to examine eight peer-reviewed literature databases. Gray literature, such as government documents, were also used.

RESULTS

An extended care team would likely consist of at least nine stakeholders within primary care. Among these stakeholders, advanced practice orthopedic physical therapists can offer particularly focused guidance to PCPs on the evaluation and treatment of work-related MSDs.

CONCLUSIONS

A multidimensional approach has the potential to accelerate access and improve quality of work-related outcomes, while maintaining patient safety.

A Systematic Review of Educational Interventions and Their Impact on Empathy and Compassion of Undergraduate Medical Students

Introduction: A compassionate and patient-centered care leads to improved clinical outcomes. Promoting empathy and compassion of medical students is a forerunner of their well-being, emotional stability, and a patient-centered care. However, there is slender evidence about best educational interventions that can inculcate empathy and compassion skills. Our objective was to conduct a systematic review of research evaluating the associations between spectrum, effectiveness, frequency of teaching modalities and their outcomes on compassion and empathy to highlight best practices.

Methods: We searched the Web of Science, PubMed, Scopus, and EBSCO Host on 22nd July 2020. We adapted our search strategy from a previously published systematic review on education for compassion and empathy. Selected studies were required to have used unique educational interventions for promoting empathy and compassion of medical students. The research questions were based on Participants (medical students), Intervention (empathy and/or compassion related teaching), Comparison, and Outcome.

Results: We analyzed 24 articles from the initial yield of 2,861. Twenty-two were quantitative studies with a mean of 12.8 on MERSQI. Twelve were randomized controlled trials while 5 measured outcomes with single group pre- and post-tests. There was no association found between duration, frequency and complexity of an educational intervention and its effectiveness. Twenty used multimodality curricula, and of those 18 reported statistically significant positive improvement in empathy, while 3 of 4 single modality were effective. Only three studies looked for long-term effects of educational interventions. Fourteen studies evaluated Kirkpatrick's level one (self-reported knowledge), 2 level three (behavior), and 6 level four (patient outcomes). We identified six major educational constructs of teaching empathy and compassion; communication, mindfulness, early clinical exposure, technology-enhanced learning, comics and arts and culture.

Discussion: Our review couldn't identify a standard teaching construct in place and highlighted that different teaching tools carry similar impact in promoting compassion and empathy and a sustainable program rather than a single training activity is essential.

Ineffective Communication: The Uninformed Injured Worker

BACKGROUND

Effective communication has been demonstrated to impact patient health outcomes, specifically in improving symptom resolution, safety, function, and emotional well-being, and to lower malpractice claims. I hypothesized that the communication process with patients with Workers' Compensation is inadequate.

METHODS

Prospectively, claimants presenting for an independent medical evaluation or an impairment rating were assessed concerning the education that they received with regard to their claim. Basic principles were based on the Utah Labor Commission Employee's Guide to Workers' Compensation and an employee information sheet.

RESULTS

There were 556 consecutive claimants assessed. None of the participants expressed any familiarity with the employee information sheet. Although there was a mean of 12 months since the date of claim to the evaluation, 536 participants (96.4%) were effectively unaware of the principles surrounding their claim; of these participants, 6 had attorneys and 23 had prior industrial claims. Of the 3.6% of participants who had received the State Employee Guide, 5 had a prior evaluation with the medical director of the Labor Commission, 6 had located the information online, and 9 had been provided information by their nurse-case manager. Even with this information, the context or importance of the information was not well understood. There were 16.4% of participants who were aware of the mileage compensation. Two claimants were aware that the insurer, not the employer, was responsible for managing the claim, 2 claimants were aware that their claim was open for life, and 1 claimant was aware that claimants could change physicians.

CONCLUSIONS

Workers' Compensation programs were designed to expedite care and treatment while decreasing the adversarial environment for workplace injuries. Yet delays and confrontational events continue to be experienced by the injured worker. This often results in the impression that workplace injuries have worse outcomes for the same diagnosis. The lack of effective education with regard to the rights and responsibilities of the claimant may also lead to this poorer outcome. Given studies showing the benefits of patient education in preventing malpractice claims and improving health-care outcomes, it is suggested that improved patient education for the injured worker is warranted and may lead to improved outcomes with diminished adversarial events.

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.

Perceived Role and Expectations of Health Care Providers in Return to Work

Purpose Health care providers (HCPs) play an important role in return to work (RTW) and in the workers' compensation system. However, HCPs may feel unsure about their responsibilities in the RTW process and experience difficulty making recommendations about RTW readiness and limitations. This study examines the ways in which HCPs and case managers (CMs) perceive HCPs role in the RTW process, and how similarities and differences between these views, in turn, inform expectations of HCPs. Methods In-depth interviews were conducted with 69 HCPs and 34 CMs from 4 provinces. Data were double coded and a thematic, inductive analysis was carried out to develop key themes. Findings The main role of HCPs was to diagnose injury and provide patients with appropriate treatment. In addition, the majority of HCPs and CMs viewed providing medical information to workers' compensation board (WCB) and the general encouragement of RTW as important roles played by HCPs. There was less clarity, and at times disagreement, about the scope of HCPs' role in providing medical information to WCB and encouraging RTW, such as the type of information they should provide and the timelines for RTW. Conclusion Interviews suggest that different role expectations may stem from differing perspectives of HCPs and the CMs had regarding RTW. A comprehensive discussion between WCB decision-makers and HCPs is needed, with an end goal of reaching consensus regarding roles and responsibilities in the RTW process. The findings highlight the importance of establishing clearer role expectations.

Patients' return-to-work expectancy relates to their beliefs about their physician's opinion regarding return to work volition and ability

Purpose

This study investigates the relationship between sick-listed patients’ return to work (RTW) expectancy and how they perceive that their physicians evaluate their ability and volition for RTW.

Methods

Hierarchical logistic regression controlling for sociodemographic factors and pain characteristics was carried out on cross-sectional data from 205 participants (mean age= 47.24±9.66 years, 83.9% women). They were currently on full-time sick leave with a total duration of 10 years or less and represented various diagnosed and undiagnosed pain conditions.

Results

A positive expectation for RTW within a year was significantly associated with the belief that the physician favorably evaluated one’s ability (OR= 1.44, 95% CI= 1.13–1.83) and volition (OR= 1.42, 95% CI= 1.11–1.83) to RTW. This held even when other variables significantly associated with RTW expectancy were accounted for. Beyond beliefs, only age made a significant contribution in our final model (OR= 0.94, 95% CI= 0.90–0.98).

Conclusion

The results indicate that patients’ beliefs regarding their physician’s opinion about their ability and volition for RTW influence their own RTW expectancy. Rehabilitation might be facilitated if health care professionals address and affirm patients’ ability and volition for RTW, regardless of patients’ pain characteristics or if the total duration of their sick leave is <10 years. As other studies have found that RTW expectancy is one of the strongest predictors for actual RTW, future research should test the effect of beliefs about physicians’ opinions on actual RTW rates.

Image and perception of physicians as barriers to inter-disciplinary cooperation? - the example of German occupational health physicians in the rehabilitation process: a qualitative study

BACKGROUND

In the German rehabilitation system, primary care physicians (PCPs), occupational health physicians (OPs), and rehabilitation physicians (RPs) fulfill different distinct functions and roles. While effective cooperation can improve outcomes of rehabilitation, the cooperation between these groups of stakeholders has been criticized as lacking or insufficient. This article proposes an approach to understand the low levels of cooperation by examining the role of group perception and group identity in intra-professional cooperation as a barrier to cooperation between physicians in different roles. Group perception was evaluated in terms of (1) negative views about another group of medical specialists and (2) differences between the perception of members and non-members of a medical specialty group. To examine this issue, we focused on the role of OPs in the German rehabilitation process.

METHODS

We implemented a qualitative study design with eight focus group discussions with PCPs, OPs, RPs, and patients (two focus group discussions per stakeholder group; 4-10 participants) and qualitative content analysis. We used the Social Identity Approach by Tajfel and Turner as a theoretical underpinning.

RESULTS

While all protagonists reported a positive perception of their own professional group, we found numerous negative perceptions about other groups, especially regarding OPs. Negative perceptions of OPs included 1) apparent conflict of interest between employer and employee, 2) lack of commitment to patient outcomes, 3) lack of useful specialized knowledge which could have a bearing on rehabilitation outcomes, and 4) distrust on the part of their patients. We also found divergent perceptions regarding roles, responsibilities, and capabilities among the specialist groups. Both negative and conflicting perceptions about roles were characterized as barriers to cooperation by study participants.

CONCLUSION

This example of cooperation between RPs, OPs, and PCPs suggests that negative and diverging perceptions about an out-group could create barriers in intra-professional and inter-disciplinary cooperation between physicians. These perspectives might also be useful in explaining problems at intersections between different specialties. We suggest examining the inter-group dimension of perception-based barriers to cooperation in future interventions to overcome problems caused by intra-professional and inter-disciplinary conflicts in addition to other barriers (i.e. organizational hurdles).

Cohort profile: workers' compensation in a changing Australian labour market: the return to work (RTW) study

PURPOSE

Workers' compensation claims for older workers and workers who have suffered psychological injury are increasing as a proportion of total claims in many jurisdictions. In the Australian state of Victoria, claims from both these groups are associated with higher than average wage replacement and healthcare expenditures. This cohort profile describes a longitudinal study which aims to investigate differences in the return to work (RTW) process for older workers compared with younger workers and claimants with musculoskeletal injuries compared with those with psychological injuries.

PARTICIPANTS

This prospective cohort study involved interviewing workers' compensation claimants at three time points. The cohort was restricted to psychological and musculoskeletal claims. Only claimants aged 18 and over were recruited, with no upper age limit. A total of 869 claimants completed the baseline interview, representing 36% of the eligible claimant population. Ninety-one per cent of participants agreed at baseline to have their survey responses linked to administrative workers' compensation data. Of the 869 claimants who participated at baseline, 632 (73%) took part in the 6-month follow-up interview, and 572 (66%) participated in the 12-month follow-up interview.

FINDINGS TO DATE

Information on different aspects of the RTW process and important factors that may impact the RTW process was collected at the three survey periods. At baseline, participants and non-participants did not differ by injury type or age group, but were more likely to be female and from the healthcare and social assistance industry. The probability of non-participation at follow-up interviews showed younger age was a statistically significant predictor of non-participation.

FUTURE PLANS

Analysis of the longitudinal cohort will identify important factors in the RTW process and explore differences across age and injury type groups. Ongoing linkage to administrative workers' compensation data will provide information on wage replacement and healthcare service use into the future.

Optimizing cooperation between general practitioners, occupational health and rehabilitation physicians in Germany: a qualitative study

PURPOSE

To achieve successful medical rehabilitation and timely return to work, general practitioners, occupational health and rehabilitation physicians need to cooperate effectively. This cooperation, however, can be hampered by organizational, interpersonal, and structural barriers. In this article, we present and discuss suggestions proposed by physicians and patients on how these barriers can be overcome.

METHODS

We conducted eight qualitative focus group discussions with general practitioners (GPs), occupational health physicians (OPs), rehabilitation physicians (RPs) and rehabilitation patients, which we analyzed with qualitative content analysis methods.

RESULTS

Room for improvement exists with regard to (1) regulation (e.g. formalized role and obligatory input of occupational physicians), (2) finance (e.g. financial incentives for physicians based on the quality of the application), (3) technology (e.g. communication by email), (4) organizational procedures (e.g. provision of workplace descriptions to RPs on a routine basis), (5) education and information (e.g. joint educational programs, measures to improve the image of OPs), and (6) promotion of cooperation (e.g. between OPs and GPs in regards to the application process).

CONCLUSIONS

Many suggestions are practical and could be implemented into the daily routine of physicians, while others demand multi-level, multi-stakeholder approaches. Our findings are supported by numerous international studies (especially from Western Europe). Future quantitative research could assess the relative weight of these findings. Feasibility and effectiveness of the proposed suggestions should be tested in controlled interventional studies.

Cooperation between general practitioners, occupational health physicians, and rehabilitation physicians in Germany: what are problems and barriers to cooperation? A qualitative study

Purpose

General practitioners (GPs), occupational health physicians (OPs), and rehabilitation physicians (RPs) fulfill different functions in the rehabilitation process, which need to be interlinked effectively to achieve a successful medical and occupational rehabilitation. In Germany, this cooperation at the interfaces is often suboptimal. The aim of this study was to identify and discuss perceived barriers to cooperation between GPs, OPs, and RPs.

Methods

We used a qualitative study design with eight focus group discussions (FGD) with GPs, OPs, RPs, and rehabilitants. Two FGDs per expert group with 4–10 participants were conducted. The transcripts were analyzed using qualitative content analysis.

Results

A number of obstacles to cooperation were reported by the participants, including (1) organizational (e.g., missing contact details, low reachability, schedule restrictions), (2) interpersonal (e.g., rehabilitants level of trust in OPs, low perceived need to cooperate with OPs, low motivation to cooperate), and (3) structural barriers (e.g., data privacy regulations, regulations concerning rehabilitation reports).

Conclusion

The present data agree with study results from other countries, which addressed interfaces in the rehabilitation process. While some barriers could be overcome by the participants themselves, a multi-level stakeholder approach might be necessary. Future quantitative research is required to assess the relative weight of the findings.

The structure and process of workers' compensation systems and the role of doctors: A comparison of Ontario and Québec

BACKGROUND

This study sought to identify impacts of compensation system characteristics on doctors in Québec and Ontario.

METHODS

(i) Legal analysis; (ii) Qualitative methods applied to documentation and individual and group interviews with doctors (34) and other system participants (31); and (iii) Inter-jurisdictional transdisciplinary analysis involving cross-disciplinary comparative and integrative analysis of policy contexts, qualitative data, and the relationship between the two.

RESULTS

In both jurisdictions the compensation board controlled decisions on work-relatedness and doctors perceived the bureaucratic process negatively. Gatekeeping roles differed between jurisdictions both in initial adjudication and in dispute processes. Québec legislation gives greater weight to the opinion of the treating physician. These differences affected doctors' experiences.

CONCLUSIONS

Policy-makers should contextualize the sources of the "evidence" they rely on from intervention research because findings may reflect a system rather than an intervention effect. Researchers should consider policy contexts to both adequately design a study and interpret their results. Am. J. Ind. Med. 59:1070-1086, 2016. © 2016 Wiley Periodicals, Inc.

Does medical certification of workers with injuries influence patterns of health service use?

BACKGROUND

Among workers with injuries who seek compensation, a general practitioner (GP) usually plays an important role in a person's return to work (RTW) by advising if the worker is unfit for work (UFW), is able to work on alternate (ALT) duties or is fit for work and also providing referrals to other health service providers.

OBJECTIVE

To examine patterns of health service utilization (HSU) in workers with injuries by condition and type of certificate issued by GP.

METHODS

Zero-inflated negative binomial and logistic regressions were conducted for major healthcare services accessed over the 12-month period post-initial medical examination. Services included GP consultations, pharmacy, physiotherapy, occupational rehabilitation and psychology.

RESULTS

The average number of physiotherapy services was greater in workers with musculoskeletal disorders, back pain and fractures. In contrast, the median number of psychological services was greater in mental health conditions (MHC). Workers with ALT certificates were more likely to use GPs, pharmacy and physiotherapy services.

CONCLUSION

HSU in the 12 months post-initial medical certification varied substantially according to the worker's condition, certificate type, age, gender and residential location. Understanding these factors can facilitate more appropriate resource allocation; strategic thinking on optimal use of particular health services and enables better targeting of particular provider groups for more education on the health benefits of RTW.

A modified Delphi method toward multidisciplinary consensus on functional convalescence recommendations after abdominal surgery

Background

Evidence-based information on the resumption of daily activities following uncomplicated abdominal surgery is scarce and not yet standardized in medical guidelines. As a consequence, convalescence recommendations are generally not provided after surgery, leading to patients’ insecurity, needlessly delayed recovery and prolonged sick leave. The aim of this study was to generate consensus-based multidisciplinary convalescence recommendations, including advice on return to work, applicable for both patients and physicians.

Method

Using a modified Delphi method among a multidisciplinary panel of 13 experts consisting of surgeons, occupational physicians and general practitioners, detailed recommendations were developed for graded resumption of 34 activities after uncomplicated laparoscopic cholecystectomy, laparoscopic and open appendectomy, laparoscopic and open colectomy and laparoscopic and open inguinal hernia repair. A sample of occupational physicians, general practitioners and surgeons assessed the recommendations on feasibility in daily practice. The response of this group of care providers was discussed with the experts in the final Delphi questionnaire round.

Results

Out of initially 56 activities, the expert panel selected 34 relevant activities for which convalescence recommendations were developed. After four Delphi rounds, consensus was reached for all of the 34 activities for all the surgical procedures. A sample of occupational physicians, general practitioners and surgeons regarded the recommendations as feasible in daily practice.

Conclusion

Multidisciplinary convalescence recommendations regarding uncomplicated laparoscopic cholecystectomy, appendectomy (laparoscopic, open), colectomy (laparoscopic, open) and inguinal hernia repair (laparoscopic, open) were developed by a modified Delphi procedure. Further research is required to evaluate whether these recommendations are realistic and effective in daily practice.

Return to work after knee replacement: a qualitative study of patient experiences

OBJECTIVE

An increasing number of patients in the working population are undergoing total knee replacement (TKR) for end-stage osteoarthritis. The timing and success of return to work is becoming increasingly important for this group of patients with social and economic implications for patients, employers and society. There is limited understanding of the patient variables that determine the ability to return to work. Our objective was (from the patient's perspective) to gain an insight into the factors influencing return to work following knee replacement.

SETTING AND PARTICIPANTS

This qualitative study was undertaken in a secondary-care setting in a large teaching hospital in the north of England. Semistructured interviews were carried out with 10 patients regarding their experiences of returning to work following TKR.

OUTCOMES

Interviews were transcribed and analysed using a qualitative thematic approach to identify the factors influencing return to work from the patient's perspective.

RESULTS

Three themes were identified that influenced the process of return to work, from the patient's perspective. These were delays in surgical intervention, limited and often inconsistent advice from healthcare professionals regarding return to work, and finally the absence of rehabilitation to optimise patient's recovery and facilitate return to work.

CONCLUSIONS

There is currently no consistent process to optimise return to work for patients of working age after TKR. The impact of delayed surgical intervention, limited advice regarding return to work, and a lack of work-focused rehabilitation, all contribute to potential delays in successful return to work. There is a need to change the focus of healthcare provision for this cohort of patients, and provide a tailored healthcare intervention to optimise patient outcomes.

Patient-reported factors influencing return to work after joint replacement

BACKGROUND

An increasing number of patients in the working population are undergoing total hip and knee replacement for osteoarthritis and the timing and success of return to work (RTW) is becoming increasingly important as a measure of success for these patients. There is limited understanding of the patient variables that determine the ability to RTW.

AIMS

To explore the factors influencing RTW following hip and knee replacement from the patient's perspective.

METHODS

A cross-sectional population-based postal survey carried out with patients of working age after hip and knee replacement surgery in a UK teaching hospital. Free text comments were collected regarding the experiences of patients returning to work following hip and knee replacement. Qualitative thematic analysis was undertaken to identify the factors influencing RTW from the patient's perspective.

RESULTS

From the patients' perspective three key factors were identified that influenced RTW. Patients reported an improved physical and psychological performance at work after surgery in comparison to pre-operative functioning, although there was a lack of informed advice regarding RTW after surgery. Workplace support and adaptation of the job role enhanced the experience of RTW.

CONCLUSIONS

Return to work is influenced by a combination of patient, clinician and occupational factors. The relationship between each of these needs to be explored in greater depth through further qualitative work to gain a wider understanding of the variables influencing patients' RTW following hip and knee replacement.

Trends in sickness certification of injured workers by general practitioners in Victoria, Australia

BACKGROUND

General practitioners (GPs) play a critical role in facilitating injured workers return to work via their ability to certify capacity to return to employment. However, little is known about the sickness certification patterns of GPs in the context of workers' compensation claims.

AIM

To determine if GPs' sickness certification behaviour has changed between 2003 and 2010 in Victoria, Australia.

METHOD

Retrospective population-based cohort study of all injured workers with an accepted compensation claim. Sickness certification rates per 1,000 working population per annum were calculated. General regression models adjusted for workers' age and annual claim number were fitted to summarize changes in count and duration (expressed as incidence rate ratios or IRRs) of unfit for work (UFW) versus alternate duties (ALT) certificates within six categories of work-related injury and disease.

RESULTS

92,134 UFW and 28,293 ALT certificates were identified. A significant decrease in the unadjusted annual certification rates per 1,000 working population was observed. However, after adjusting for the annual number of claims and age, the IRRs of certificates increased over time. The rate of injuries and IRRs of certificates varied across affliction categories, IRRs being higher in mental health conditions in women than in men (IRR: 0.40, 95 % CI 0.38-0.41 vs. IRR: 0.17, 95 % CI 0.16-0.18). The duration of certificates remained stable, with the ALT being longer than UFW certificates in all claimants.

CONCLUSION

Our findings indicate that GPs in Victoria issue an increasing number of UFW sickness certificates each year. Further research is required to investigate the reasons for such practises.

Topics and trends in research on non-clinical interventions aimed at preventing prolonged work disability in workers compensated for work-related musculoskeletal disorders (WRMSDs): a systematic, comprehensive literature review

PURPOSE

This study sought to provide an overview of the main topics and trends in contemporary research on successful non-clinical interventions for preventing prolonged work disability in workers compensated for work-related musculoskeletal disorders (WRMSDs).

METHODS

A systematic electronic search (English and French) was performed in ten scientific databases using keywords and descriptors. After screening the identified titles and abstracts using specific sets of criteria, categorical and thematic analyses were performed on the retained articles.

RESULTS

Five main topics appear to dominate the research: (1) risk factors and determinants; (2) effectiveness of interventions (programmes, specific components, strategies and policies); (3) viewpoints, experiences and perceptions of specific actors involved in the intervention process; (4) compensation issues; and (5) measurement issues. A currently widespread trend is early screening to identify risks factors for appropriate intervention and multidisciplinary, multimodal approaches. Morover, workplace-related psychosocial and ergonomic factors are considered vital to the success and sustainability of return-to-work (RTW) interventions. Finally, involving workplace actors, and more specifically, affected workers, in the RTW process appears to be a powerful force in improving the chances of moving workers away from disabled status.

CONCLUSIONS

The findings of this literature review provide with information about the main topics and trends in research on rehabilitation interventions, revealing some successful modalities of intervention aimed at preventing prolonged work disability.

IMPLICATIONS FOR REHABILITATION

Successful intervention for preventing prolonged work disability in workers compensated for WRMSDs address workplace issues: physical and psychosocial demands at work, ability of the workers to fill these demands, work organization and support of the worker, and worker' beliefs and attitudes related to work. Successful intervention promotes collaboration, coordination between all actors and stakeholders involved in the process of rehabilitation. Strategies able to mobilize the employees, employers, insurers and health care providers are still needed to be implemented.

Effective doctor-patient communication: an updated examination

This article examines, in detail, the quality of doctor-patient interaction. Doctor-patient communication is such a powerful indicator of health care quality that it can determine patients' self-management behavior and health outcomes. The medical visit (i.e., the medical encounter) plays a pivotal role in the health care process. In fact, doctor-patient communication is one of the most essential dynamics in health care, affecting the course of patient care and patient compliance with recommendations for care. Unlike many other analyses (that often look at only one or two specific aspects of doctor-patient relationships), this analysis is more encompassing; it looks at doctor-patient communication from multiple perspectives.

What circumstances prompt a workplace discussion in medical evaluations for back pain?

PURPOSE

To determine how frequently workplace topics emerge in the interactions between patients and providers in an evaluation for low back pain (LBP) and to determine its association with patient and provider characteristics.

METHODS

Adults with work-related LBP (N = 97; 64 % male; median age = 38) completed a demographic questionnaire and a survey of disability risk factors, then agreed to audio-taping of their visits with a participating occupational healthcare provider (n = 14). Utterance-level verbal exchanges were categorized by trained coders using the Roter interaction analysis system. In addition, coders flagged any instance of workplace discussion between patients and providers.

RESULTS

Workplace discussions occurred in 51 % of visits, and the most frequent topic was physical job demands. Workplace discussions were more frequent among the oldest and youngest patients and when patients were seen by providers who were more patient-centered and made more efforts to establish patient rapport and engagement. However, patients reporting numerous disability risk factors and workplace concerns in the pre-visit questionnaire were no more likely to discuss workplace topics with their providers (p > 0.05). Only the patient-centered orientations of providers and patients remained statistically significant predictors in multivariate modeling (p < 0.05).

CONCLUSIONS

Workplace discussions are facilitated by a patient-centered orientation and by efforts to establish patient engagement and rapport, but workplace discussions are no more frequent among patients with the most significant workplace concerns. Screening questionnaires and other assessment tools may be helpful to foster workplace discussions to overcome possible barriers for returning to work.

eHealth program to empower patients in returning to normal activities and work after gynecological surgery: intervention mapping as a useful method for development

BACKGROUND

Full recovery after gynecological surgery takes much longer than expected regardless of surgical technique or the level of invasiveness. After discharge, detailed convalescence recommendations are not provided to patients typically, and postoperative care is fragmented, poorly coordinated, and given only on demand. For patients, this contributes to irrational beliefs and avoidance of resumption of activities and can result in a prolonged sick leave.

OBJECTIVE

To develop an eHealth intervention that empowers gynecological patients during the perioperative period to obtain timely return to work (RTW) and prevent work disability.

METHODS

The intervention mapping (IM) protocol was used to develop the eHealth intervention. A literature search about behavioral and environmental conditions of prolonged sick leave and delayed RTW in patients was performed. Patients' needs, attitudes, and beliefs regarding postoperative recovery and resumption of work were identified through focus group discussions. Additionally, a literature search was performed to obtain determinants, methods, and strategies for the development of a suitable interactive eHealth intervention to empower patients to return to normal activities after gynecological surgery, including work. Finally, the eHealth intervention was evaluated by focus group participants, medical doctors, and eHealth specialists through questionnaires.

RESULTS

Twenty-one patients participated in the focus group discussions. Sufficient, uniform, and tailored information regarding surgical procedures, complications, and resumption of activities and work were considered most essential. Knowing who to contact in case of mental or physical complaints, and counseling and tools for work reintegration were also considered important. Finally, opportunities to exchange experiences with other patients were a major issue. Considering the determinants of the Attitude-Social influence-self-Efficacy (ASE) model, various strategies based on a combination of theory and evidence were used, resulting in an eHealth intervention with different interactive functionalities including tailored convalescence recommendations and a video to communicate the most common pitfalls during the perioperative period to patients and employers. Fifteen patients in the focus groups, 11 physicians, and 3 eHealth specialists suggested points for improvement to optimize the usability of the eHealth intervention and judged it an approachable, appropriate, and attractive eHealth intervention to empower gynecological patients.

CONCLUSIONS

The IM protocol was a useful method to develop an eHealth intervention based on both theory and evidence. All patients and stakeholders judged the eHealth intervention to be a promising tool to empower gynecological patients during the perioperative period and to help them to return to normal activities and work.

Guiding low back claimants to work: a randomized controlled trial

STUDY DESIGN

A single-blinded, randomized controlled trial.

OBJECTIVE

To determine the impact of information and advice during a disability evaluation by medical advisers on the return to work (RTW) rate and recurrence of sick leave of claimants with low back pain (LBP).

SUMMARY OF BACKGROUND DATA

There is evidence on the importance of advice during the course of subacute LBP. The effect of informative interventions on RTW rates in workers receiving sickness benefit is not clear.

METHODS

A total of 506 claimants with LBP were randomly assigned to the control group (disability evaluation) or the intervention group (combined counseling and disability evaluation). RTW, sick leave recurrence, subsequent surgery, and sick leave duration were measured during a 12-month follow-up.

RESULTS

Patients who were provided information and advice showed a higher RTW rate, which was statistically significant at 1 year. That result is mainly attributable to the lower relapse rate in the intervention group (38%) than in the control group (60%). There were no differences between the 2 groups regarding subsequent surgery for LBP and duration of sick leave.

CONCLUSION

Claimants should be routinely reassured and advised about LBP to allow early and safe RTW during a disability evaluation before any side effects of being sick-listed have settled.

Preserving workers' dignity in workers' compensation systems: an international perspective

BACKGROUND

Workers' compensation systems are among the most generous disability insurance systems in North America, although they are also known to be potentially adversarial and may have iatrogenic effects on claimants. This article examines issues to be considered to ensure fair compensation provided in a way that respects the dignity of workers.

METHODS

An overview of the literature on characteristics and effects of workers' compensation systems is followed by an analysis based on classic legal methods, including those of comparative law, complemented with interview data to examine three models of disability compensation.

RESULTS

The first part of the article identifies cross cutting issues to be considered in the examination of the equity of compensation systems and the protection of the dignity of claimants. These include three underpinnings of workers' compensation: the links between a "no-fault" system and the adversarial process, the appropriate use of medical and scientific evidence in the determination of compensability and the application of appropriate measures for promoting return to work. The second part looks at accident compensation in New Zealand, where compensation is available regardless of the cause of the accident, and disability insurance in the Netherlands, where compensation is available regardless of the cause of the disability. It then describes a composite of characteristics favorable to equity drawn from the thirteen workers' compensation systems in Canada.

CONCLUSION

Systems that succeed in reducing opportunities for adversarial interactions and that provide substantive protection could better promote the dignity of claimants.

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.

Creating Successful Rehabilitation Partnerships Between Health Professionals and Employers

Successful rehabilitation outcomes rest on the quality of the links among multiple stakeholders. However, the literature has increasingly recognised the challenges in creating effective partnerships between stakeholders such as external health professionals, employers and injured workers. This study presents findings from an industry-directed project aimed at investigating the links between external health professionals and the employer in relation to return-to-work rehabilitation. Semistructured interviews were conducted with general practitioners (GPs), psychologists, and organisation-based rehabilitation personnel. Findings indicated several major points of consideration to facilitate health professional and employer partnerships, including educating stakeholders about organisational rehabilitation services and key contact personnel within the organisation, establishing standard communication protocols, understanding organisational culture and providing explicit organisational support for the rehabilitation process. To ensure appropriate and timely outcomes for injured workers, the current findings highlight the proactive and educative role that employers must assume when acting in partnership for rehabilitation.

Factors in client-clinician interaction that influence hearing aid adoption

The influence of client-clinician interactions has not been emphasized in hearing health care, despite the extensive evidence of the impact of the provider-patient interaction on health outcomes. The purpose of this study was to identify factors in the client-clinician interaction that may influence hearing aid adoption. Thirteen adults who had received a hearing aid recommendation within the previous 3 months and 10 audiologists participated in a study to generate, sort, and rate the importance of factors in client-clinician interaction that may influence the hearing aid purchase decision. A concept mapping approach was used to define meaningful clusters of factors. Quantitative analysis and qualitative interpretation of the statements resulted in eight concepts. The concepts in order of their importance are (a) Ensuring client comfort, (b) Understanding and meeting client needs, (c) Client-centered traits and actions, (d) Acknowledging client as an individual, (e) Imposing undue pressure and discomfort, (f) Conveying device information by clinician, (g) Supporting choices and shared decision making, and (h) Factors in client readiness. Two overarching themes of client-centered interaction and client empowerment were identified. Results highlight the influence of the client-clinician interaction in hearing aid adoption and suggest the possibility of improving hearing aid adoption by empowering clients through a client-centered interaction.

The role of health care providers in long term and complicated workers' compensation claims

INTRODUCTION

Health care providers (HCPs) play a central role in workers' compensation systems. In most systems, they are involved in the legitimization of work-related injury, are required to provide information to workers' compensation boards about the nature and extent of the injury, give recommendations about return-to-work capability and provide treatment for injury or illness. This study identifies problems that occur at the interface between the health care system, injured workers, and workers' compensation boards (WCBs) that may complicate and extend workers' compensation claims and the mechanisms that underlie the development of these problems.

METHODS

Interviews were sought with injured workers, peer helpers and service providers from a variety of geographic locations in order to get a broad picture of return to work problems and concerns. This analysis includes data from total of 34 interviews with injured workers who had long term and complicated claims. Interviews were also conducted with 14 peer helpers and 21 service providers.

RESULTS

We identified four domains related to injured workers' interface with the health care system that played a key role in complicating and prolonging compensation claims. These problems, related to health care access, conflicting or imperfect medical knowledge, limited understanding of compensation system requirements and confusion about decision-making authority, resulted in frustration, financial difficulties and mental health problems for injured workers.

CONCLUSION

Recommendations are made about how compensation system parties can find better ways to serve injured worker health care needs and facilitate a smooth relationship between the compensation board and HCPs.

Factors that affect the occurrence and chronicity of occupation-related musculoskeletal disorders

The components that affect the occurrence and chronicity of musculoskeletal disease are multifactorial. The return to work process and prevention of future chronic disability commences at the time of the initial assessment. The clinician can identify, at an early stage, patients with negative expectations of return to work and adopt a care plan oriented to functional adaptation. Medical and psychosocial treatment plans taking account of coping preferences, beliefs and practices are more likely to help prevent chronic disability. Other factors that can influence the long-term disability rate include medically discretionary or unnecessary time off work and litigation itself. Workplace factors can result in unnecessary absenteeism and poorly managed presenteeism.

Health maintenance care in work-related low back pain and its association with disability recurrence

OBJECTIVES

To compare occurrence of repeated disability episodes across types of health care providers who treat claimants with new episodes of work-related low back pain (LBP).

METHOD

A total of 894 cases followed 1 year using workers' compensation claims data. Provider types were defined for the initial episode of disability and subsequent episode of health maintenance care.

RESULTS

Controlling for demographics and severity, the hazard ratio [HR] of disability recurrence for patients of physical therapists (HR = 2.0; 95% confidence interval [CI] = 1.0 to 3.9) or physicians (HR = 1.6; 95% CI = 0.9 to 6.2) was higher than that of chiropractor (referent, HR = 1.0), which was similar to that of the patients non-treated after return to work (HR = 1.2; 95% CI = 0.4 to 3.8).

CONCLUSIONS

In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services or no treatment.

Determinants of physicians' communication behaviour in disability assessments

PURPOSE

Knowledge about the determinants of communication behaviour of physicians during face-to-face consultations with patients might increase our understanding of communication behaviour, and provide insight into how training might be able to change their communication behaviour. For physicians who conduct work disability assessment interviews, referred to as 'social insurance physicians', communication with patients is their most important instrument. Therefore, the aim of this study was to understand the determinants of communication behaviour of social insurance physicians, by modelling the following constructs of the Theory of Planned Behaviour: attitudes, social influence, self-efficacy, skills, barriers and intentions concerning their communication with claimants in medical disability assessments.

METHOD

Cross-sectional data were collected by means of questionnaires. Analyses were performed with the LISREL maximum likelihood estimation procedure.

RESULTS

The results showed a well-fitting model in which attitudes had a significant and substantial direct effect on two intentions. Self-efficacy had a significant, but smaller direct effect on one intention.

CONCLUSIONS

Empirical support was found for a model that describes intentions of social insurance physicians, especially intentions to give information and to consider personal aspects. Attitudes were the main determinants of physicians' intentions and therefore these may be a promising focus of communication skills training.

Disparities by ethnicity, language, and immigrant status in occupational health experiences among Las Vegas hotel room cleaners

OBJECTIVE

We examined disparities in workers' occupational health experiences.

METHODS

We surveyed 941 unionized Las Vegas hotel room cleaners about their experiences with work-related pain and with employers, physicians, and workers' compensation. Data were analyzed for all workers and by ethnicity, language, and immigrant status.

RESULTS

Hispanic and English as second language (ESL) workers were more likely than their counterparts to report work-related pain and, along with immigrant workers, to miss work because of this pain. Hispanic, ESL, and immigrant workers were not consistently at a disadvantage with regard to their own responses to work-related pain but were so with respect to reported responses by workers' compensation, physicians, and employers.

CONCLUSIONS

There are indications of disparities in occupational health experiences within this job title. The use of different group classifications, while implying different mechanisms, produced similar results.