Medical Care Spending and Labor Market Outcomes: Evidence from Workers' Compensation Reforms

Medical care represents an important component of workers' compensation benefits with the potential to improve health and post-injury labor outcomes, but little is known about the relationship between medical care spending and the labor outcomes of injured workers. We exploit the 2003--2004 California workers' compensation reforms which reduced medical spending disproportionately for workers incurring low back injuries. We link administrative claims data to earnings records for injured workers and their uninjured coworkers. We find that workers with low back injuries experienced a 7.6 percent post-reform decline in medical care, and an 8.1 percent drop in post-injury earnings relative to other injured workers.

Zero Lift Programs in Small Rural Hospitals in Washington State

In Washington State, health care workers have the highest rate of compensable back injuries. Washington Hospital Services, a self-insured workers' compensation program, implemented a zero lift program in 31 of its 38 hospitals. Zero lift was defined as replacing manual lifting, transferring, and re-positioning of patients with mechanical lifting or use of other patient assist devices. This program included two trusts, two pools of hospitals that self-insure workers' compensation. The pools are governed by elected boards of trustees from the pool memberships and regulated by the State Department of Labor and Industries. This pretest–posttest descriptive study compared patient-handling injury data prior to program implementation with those after program implementation. Patient-handling injury claims decreased by 43% in the participating hospitals from 2000 to 2004 (i.e., from 3.51 to 2.23). The time lost frequency rate decreased by 50% (i.e., from 1.91 to 1.03).

Recruitment for Occupational Research: Using Injured Workers as the Point of Entry into Workplaces

OBJECTIVE

To investigate the feasibility, costs and sample representativeness of a recruitment method that used workers with back injuries as the point of entry into diverse working environments.

METHODS

Workers' compensation claims were used to randomly sample workers from five heavy industries and to recruit their employers for ergonomic assessments of the injured worker and up to 2 co-workers.

RESULTS

The final study sample included 54 workers from the workers' compensation registry and 72 co-workers. This sample of 126 workers was based on an initial random sample of 822 workers with a compensation claim, or a ratio of 1 recruited worker to approximately 7 sampled workers. The average recruitment cost was CND$262/injured worker and CND$240/participating worksite including co-workers. The sample was representative of the heavy industry workforce, and was successful in recruiting the self-employed (8.2%), workers from small employers (<20 workers, 38.7%), and workers from diverse working environments (49 worksites, 29 worksite types, and 51 occupations).

CONCLUSIONS

The recruitment rate was low but the cost per participant reasonable and the sample representative of workers in small worksites. Small worksites represent a significant portion of the workforce but are typically underrepresented in occupational research despite having distinct working conditions, exposures and health risks worthy of investigation.

[Direct cost of spinal cord injuries]

BACKGROUND

High prevalence and high costs in the treatment of spine injuries make a cost study necessary. The objective of this paper is to analyze, from the economic point of view, the behavior of traumatic and non-traumatic spinal pathologies in relation to hospital stay.

METHODS

Analysis of economic cost per hospital stay (January 2000 to May 2010).

RESULTS

4,173 cases studied, 45% women and 55% men, predominantly elderly and a mean age of 48.9, standard deviation 16.8 years, with a notable increase in hospital expenses in prevalence and peak months: January, February and April; and a decrease in July, October and December. Total expenses for hospital stay were estimated as $85,565,288.00. Traumatic entities consumed $40,404,477.00, and degenerative $21,866,815.00. The months of highest spending were: April, $11,072,683.00, December, $8,423,773.00 and February $8,154,152.00; whereas July showed the lowest spending: $4,874,261.00. Inflation up to July 2011 remained at 3.55% on average, down 2.98 percentage points from 2008 figures.

DISCUSSION

there is a clear increase in spending connected with spine condition treatment at hospitals, in particular those resulting from traumatic events. The definition of risk groups for preventive measures is also reflected in the spending records. Spending on hospital treatment of spinal conditions of the elderly reflects an increment in degenerative conditions.

CONCLUSION

It is necessary to plan a timely resource distribution by month and year in order to achieve a better and more efficient scheme for health services. The epidemiological basis for the reorientation of the current models is now clear.

ACC and back injuries: the relevance of pre-existing asymptomatic conditions revisited

The application of the New Zealand Accident Compensation Corporation (ACC) legislation in the management of patients who sustain back injuries requires a detailed knowledge of the pathogenesis of tissue injury, and the natural history of ageing and related conditions, so that the application of the ACC Act(s) is appropriate. We have reviewed the new information published in the last decade, and updated the previous knowledge basis in these fields, so as to assist the interpretation of the Act(s).

Saving costs, saving health care providers' backs, and creating a safe patient environment

Back injuries are increasing among health care providers and are related to a multitude of factors, including repetitive tasks related to patient handling, the aging of the nursing workforce, higher patient acuity levels, and an increased prevalence of obesity in patients, as well as limited workspaces in patient rooms. An estimated 12% of nurses leave the profession annually because of back injuries, and more than 52% complain of chronic back pain and injuries. Implemented in response to rising costs of health care providers' injuries, a safe patient handling program resulted in decreased injuries from staff performing work-related duties, and decreased workers' compensation claims, which resulted in significant cost savings and improved patient satisfaction.

Predictors of delayed return to work after back injury: A case-control analysis of union carpenters in Washington State

METHODS

Union administrative records identified 20,642 union carpenters who worked in Washington State from 1989 to 2003. The Department of Labor and Industries provided records of workers' compensation claims and associated medical care. Work-related back claims (n = 4,241) were identified by ANSI codes (back, trunk, or neck/back) or ICD-9 codes relevant to medical care consistent with a back injury. Cases (n = 738) were defined as back injury claims with >90 days of paid lost time; controls (n = 699) resulted in return to work within 30 days. Logistic regression models estimated odds ratios and 95% confidence intervals (OR, 95% CI) of delayed return to work (DRTW).

RESULTS

Thirty percent of case claims and 8% of control claims were identified by an ICD-9 code. DRTW after back injury was associated with being female (2.7, 95% CI: 1.3-5.5), age 30-44 (1.2, 95% CI: 0.9-1.7) and age over 45 (1.6, 95% CI: 1.1-2.3), four or more years union experience (1.4, 95% CI: 1.1-1.8), previous paid time loss back claim (1.8, 95% CI: 1.3-2.5), and >or=30-day delay to medical care (3.6, 95% CI: 2.1, 6.1). Evidence of more acute trauma was also associated with DRTW.

CONCLUSIONS

Use of ICD-9 codes identified claims with multiple injuries that would otherwise not be captured by ANSI codes alone. Though carpenters of younger age and inexperience were at increased risk for a paid lost time back injury claim, older carpenters and more experienced workers, once injured, were more likely to have DRTW as were those who experienced acute events.

Impact of publicly sponsored interventions on musculoskeletal injury claims in nursing homes

BACKGROUND

The rate of lost-time sprains and strains in private nursing homes is over three times the national average, and for back injuries, almost four times the national average. The Ohio Bureau of Workers' Compensation (BWC) has sponsored interventions that were preferentially promoted to nursing homes in 2000-2001, including training, consultation, and grants up to $40,000 for equipment purchases.

METHODS

This study evaluated the impact of BWC interventions on back injury claim rates using BWC data on claims, interventions, and employer payroll for all Ohio nursing homes during 1995-2004 using Poisson regression. A subset of nursing homes was analyzed with more detailed data that allowed estimation of the impact of staffing levels and resident acuity on claim rates. Costs of interventions were compared to the associated savings in claim costs.

RESULTS

A $500 equipment purchase per nursing home worker was associated with a 21% reduction in back injury rate. Assuming an equipment life of 10 years, this translates to an estimated $768 reduction in claim costs per worker, a present value of $495 with a 5% discount rate applied. Results for training courses were equivocal. Only those receiving below-median hours had a significant 19% reduction in claim rates. Injury rates did not generally decline with consultation independent of equipment purchases, although possible confounding, misclassification, and bias due to non-random management participation clouds interpretation. In nursing homes with available data, resident acuity was modestly associated with back injury risk, and the injury rate increased with resident-to-staff ratio (acting through three terms: RR = 1.50 for each additional resident per staff member; for the ratio alone, RR = 1.32, 95% CI = 1.18-1.48). In these NHs, an expenditure of $908 per resident care worker (equivalent to $500 per employee in the other model) was also associated with a 21% reduction in injury rate. However, with a resident-to-staff ratio greater than 2.0, the same expenditure was associated with a $1,643 reduction in back claim costs over 10 years per employee, a present value of $1,062 with 5% discount rate.

CONCLUSIONS

Expenditures for ergonomic equipment in nursing homes by the Ohio BWC were associated with fewer worker injuries and reductions in claim costs that were similar in magnitude to expenditures. Un-estimated benefits and costs also need to be considered in assessing full health and financial impacts.

Compensation costs of work-related back disorders among union carpenters, Washington State 1989-2003

BACKGROUND

We measured resources used to provide medical care and to estimate lost productivity represented by payments for lost work time or impairment for work-related back injuries among a large cohort of union carpenters over 15 years.

METHODS

Using administrative data we identified a cohort of carpenters, their hours worked, their workers' compensation claims and associated costs. After adjustment for inflation and discounting to 2006 dollars, yearly costs for injuries and payment rates based on hours worked were calculated. Using negative binomial regression, dollars paid per claim were modeled based on age, gender, union tenure, and predominant type of work of the carpenter and whether the injury resulted from overexertion or acute trauma.

RESULTS

Workers' compensation costs for back injuries exceeded $128 million dollars between 1998 and 2003, representing payments of $0.97 for each hour of work. Costs per hour of work declined substantively over time due largely to declining overexertion injury rates. Traumatic injuries, though less common than overexertion injuries, were more expensive. Costs increased with the number of prior back injuries and with increasing age, beginning as early as age 30.

CONCLUSIONS

Increasing costs even among relatively young carpenters likely reflect the heavy nature of their work rather than simply the effects of biological aging. Musculoskeletal back problems remain a common, and consequently costly, source of injury among these carpenters that needs to be addressed through engineering modifications; there are also clearly needs for prevention of the often more costly back injuries associated with acute trauma.

Ergonomic and socioeconomic risk factors for hospital workers' compensation injury claims

BACKGROUND

Hospital workers are a diverse population with high rates of musculoskeletal disorders (MSDs). The risk of MSD leading to workers' compensation (WC) claims is likely to show a gradient by socioeconomic status (SES) that may be partly explained by working conditions.

METHODS

A single community hospital provided workforce demographics and WC claim records for 2003-2005. An ergonomic job exposure matrix (JEM) was developed for these healthcare jobs from direct observation of physical workload and extraction of physical and psychosocial job requirements from the O*NET online database. Occupational exposures and SES categories were assigned to workers through their O*NET job titles. Univariate and multivariate Poisson regression analyses were performed to estimate the propensity to file an injury claim in relation to individual factors, occupational exposures, and SES.

RESULTS

The jobs with the highest injury rates were nurses, semi-professionals, and semi-skilled. Increased physical work and psychological demands along with low job tenure were associated with an increase in risk, while risk decreased with psychosocial rewards and supervisor support. Both occupational and individual factors mediated the relationship between SES and rate of injury claims.

CONCLUSIONS

Physical and organizational features of these hospital jobs along with low job tenure predicted WC injury claim risk and explained a substantial proportion of the effects of SES. Further studies that include lifestyle risk factors and control for prior injuries and co-morbidities are warranted to strengthen the current study findings.

Effect of a nurse back injury prevention intervention on the rate of injury compensation claims

PROBLEM

This study evaluated the effect of introducing a No Lifting policy on back injuries to nurses, across an entire health care system.

METHODS

Methods included: analysis of the data for all public health agencies in the Australian state of Victoria; compensation data from the Victorian Workcover Authority; data about workforce and program implementation from a retrospective survey of agencies; longitudinal analysis of standardized workers compensation claim rates for back injuries before, during and after the intervention.

RESULTS

A statistically significant decline in back injury claim rates during implementation contrasted with no statistically significant trends within the periods before and after the intervention. A statistically significant reduction occurred in mean quarterly standard back injury claim incidence rates per 1,000 equivalent fulltime nursing staff (EFTNS), representing a 24% reduction in standard back injury claims/1000 EFTNS.

DISCUSSION

Ergonomics principles encourage changing the work environment to suit the worker. This approach delivered a significant improvement in the immediate term.

IMPACT OF INDUSTRY

The substantial decline in back injury rates signifies a major improvement in the safety of a critical aspect of the work environment for nurses.

The economic impact of implementing an ergonomic plan

It is of paramount importance for executives to be well aware of registered nurse (RN) hidden replacement costs related to musculoskeletal injuries. Developing and implementing an ergonomic plan that includes procurement of appropriate lifting equipment at the point of care makes sense. Armed with an ergonomic plan, proactive case management, and a return to work program, the organization is positioned for fiscal success. The ANA's Handle With Care campaign addressed the fact that 12% of RN turnover and 38% of RN workers' compensation pay are related to back strains. Using the benchmarks reported in the Handle With Care campaign, the average cost of replacing an RN who leaves nursing due to a back injury ranged from $25,450 to $38,280 per nurse. Health care worker injury prevention should be valued as a retention strategy, as well as a fiscal responsibility where all stakeholders benefit.

The recovery patterns of back pain among workers with compensated occupational back injuries

OBJECTIVES

To investigate the longitudinal patterns of recovery among workers with compensated occupational back injuries.

METHODS

A longitudinal cohort study, with one-year follow-up via structured telephone interviews, among respondents off work because of "new" back injuries. Self-reported pain intensity was recorded at baseline and at four follow-up time points over the course of one year. Workers who answered the questionnaire on at least three occasions (n = 678) were classified into clusters according to their patterns of pain intensity over time using a two-step cluster analysis.

RESULTS

Four pain recovery patterns were identified: workers with high levels of pain intensity showing no improvement over time (43%); those experiencing recovery in the first four months with no further improvement or possibly even some deterioration, in the second half year (33%); those experiencing a slow consistent recovery but still with considerable back pain at the end of the follow-up (12%); and those quickly progressing to low level of pain or resolution (12%). Trajectories of average Roland-Morris Disability scores and SF-36 Role of Physical scores for above clusters mapped consistently with the corresponding patterns in pain. However, individuals with fluctuating, recurrent pain patterns showed the shortest cumulative duration on 100% benefit and the earliest return-to-work among other clusters.

CONCLUSIONS

Four clinically sensible patterns were identified in this cohort of injured workers, suggesting inter-individual differences in back pain recovery. The results confirm that recurrent or chronic back pain is a typical condition in respondents with new back injuries. Pain intensity and disability scores are good measures of recovery of back pain at the individual level. After initial return-to-work, or cessation of benefits, administrative measures of percentage of respondents back at work, or no longer on benefits, may not accurately reflect an individual's condition of back pain.

Utilization and costs of chiropractic care for work-related low back injuries: do payment policies make a difference?

BACKGROUND

Chiropractic care is frequently used in the treatment of work-related low back pain. Chiropractors have been shown to be more sensitive to cost-sharing than other providers.

PURPOSE

This study examined the differences in utilization and costs of chiropractic care for work-related low back injuries in seven jurisdictions and whether these differences can be associated with workers' compensation (WC) payment policies.

STUDY DESIGN

A retrospective analysis of WC data from a single insurer.

METHODS

Analyzed data included individuals with chiropractic care performed between 1999 and 2002. Utilization (visits and services per person, services per visit) and costs (cost per person and cost per visit) were examined. Actual reimbursement index was developed to proxy payment policies based on actual payments made to chiropractors.

RESULTS

Utilization and costs varied significantly across the analyzed states. Restrictive payment policies were associated with lower costs of chiropractic care and lower number of services per visit, but had no impact on visits or services per person.

CONCLUSIONS

Findings indicate necessary components of effective cost containment, even in the presence of utilization adjustment.

Devastating Injuries in Healthcare Workers: Description of the Crisis and Legislative Solution to the Epidemic of Back Injury from Patient Lifting

The purpose of this report is to describe a crisis in healthcare, disabling back injuries in US healthcare workers. In addition, outlined is the proven solution of safe, mechanized, patient lifting, which has been shown to prevent these injuries. A "Safe Patient Handling--No Manual Lift" policy must be immediately instituted throughout this country. Such a policy is essential to halt hazardous manual patient lifting, which promotes needless disability and loss of healthcare workers, pain and risk of severe injury to patients, and tremendous waste of financial resources to employers and workers' compensation insurance carriers. Healthcare workers consistently rank among top occupations with disabling back injuries, primarily from manually lifting patients. Back injury may be the single largest contributor to the nursing shortage. Reported injuries to certified nursing assistants are three to four times that of registered nurses. A national healthcare policy for "Safe Patient Handling--No Manual Lift" is urgently needed to address this crisis. Body mechanics training is ineffective in prevention of back injury with patient lifting. Mandated use of mechanical patient lift equipment has proven to prevent most back injury to nursing personnel and reduce pain and injury to patients associated with manual lifting. With the national epidemic of morbid obesity in our country, innovative devices are available for use in emergency medical systems and hospitals for patient lifting and transfer without injury to hospital personnel. The US healthcare industry has not voluntarily taken measures necessary to reduce patient handling injury by use of mechanical lift devices. US healthcare workers who suffer disabling work-related back injuries are limited to the fixed, and often inadequate, relief which they may obtain from workers' compensation. Under workers' compensation law, healthcare workers injured lifting patients may not sue their employer for not providing mechanical lift equipment. Discarding healthcare workers disabled by preventable back injuries is an abuse which legislators must remedy. In addition, Medicare reimbursement policies must also be updated to allow the disabled community to purchase electrically operated overhead ceiling lifts. The US lags far behind countries with legislated manual handling regulations and "No Lifting" nursing policies. England and Australia have had "No Lifting" nursing policies in place since 1996 and 1998, respectively. The National Occupational Research Agenda (NORA) recognized a model in 2003 for reduction of back injuries to nursing staff in US healthcare facilities. Also in 2003, the American Nurses Association called for elimination of manual patient handling because it is unsafe and causes musculoskeletal injuries to nurses. The first state legislation for safe patient handling passed both houses in California but was vetoed by the Governor in September 2004. California and other states are preparing to (re)introduce legislation in January 2005. A national, industry-specific policy is essential to quell the outflow of nursing personnel to disability from manual patient lifting.

An evaluation of a "best practices" musculoskeletal injury prevention program in nursing homes

OBJECTIVE

To conduct an intervention trial of a "best practices" musculoskeletal injury prevention program designed to safely lift physically dependent nursing home residents.

DESIGN

A pre-post intervention trial and cost benefit analysis at six nursing homes from January 1995 through December 2000. The intervention was established in January 1998 and injury rates, injury related costs and benefits, and severity are compared for 36 months pre-intervention and 36 months post-intervention.

PARTICIPANTS

A dynamic cohort of all nursing staff (n = 1728) in six nursing homes during a six year study period.

INTERVENTION

"Best practices" musculoskeletal injury prevention program consisting of mechanical lifts and repositioning aids, a zero lift policy, and employee training on lift usage.

MAIN OUTCOME MEASURES

Injury incidence rates, workers' compensation costs, lost work day injury rates, restricted work day rates, and resident assaults on caregivers, annually from January 1995 through December 2000.

RESULTS

There was a significant reduction in resident handling injury incidence, workers' compensation costs, and lost workday injuries after the intervention. Adjusted rate ratios were 0.39 (95% confidence interval (CI) 0.29 to 0.55) for workers' compensation claims, 0.54 (95% CI 0.40 to 0.73) for Occupational Safety and Health Administration (OSHA) 200 logs, and 0.65 (95% CI 0.50 to 0.86) for first reports of employee injury. The initial investment of $158 556 for lifting equipment and worker training was recovered in less than three years based on post-intervention savings of $55 000 annually in workers' compensation costs. The rate of post-intervention assaults on caregivers during resident transfers was down 72%, 50%, and 30% based on workers' compensation, OSHA, and first reports of injury data, respectively.

CONCLUSIONS

The "best practices" prevention program significantly reduced injuries for full time and part time nurses in all age groups, all lengths of experience in all study sites.

Handle with care: The American Nurses Association's Campaign to address work-related musculoskeletal disorders

In response to the significant number and severity of work-related back injuries and other musculoskeletal disorders among nurses, the American Nurses Association (ANA) has launched the Handle With Care campaign. The campaign seeks to build a health care industry-wide effort to prevent back and other musculoskeletal injuries. This is being done through developing partnerships and coalitions, education and training, increasing use of assistive equipment and patient-handling devices, reshaping nursing education to incorporate safe patient handling, and pursuing federal and state ergonomics policy by highlighting technology-oriented safe-patient handling benefits for patients and nurses. In the absence of ergonomics regulations at national or state levels that protect health care workers, ANA has taken on alternative approaches to encourage a movement to control ergonomic hazards in the health care workplace and prevent back injuries among the nation's nursing workforce.

The workers' compensation system: worker friend or foe?

BACKGROUND

The workers' compensation system was designed to help injured workers who have substantial medical expenses and perhaps have lost a great deal of income. This study determines both similarities and differences in how workers experience their interactions with the workers' compensation systems in Florida and Wisconsin.

METHODS

Ethnographic open-ended interviews with 204 workers from Florida and 198 workers in Wisconsin were conducted. All the workers had back injuries in 1990 and were either paid workers' compensation temporary disability benefits for at least 4 weeks or received permanent disability benefits or compromise settlements.

RESULTS

Some interactions with the workers' compensation system were positive. However, the majority of respondents in both states experienced their encounters with the workers' compensation system as cumbersome, frustrating, and demeaning.

CONCLUSIONS

Mistrust, stigmatization, payment delays, and refusal of insurer personnel to pay benefits contribute to workers' negative experiences with the workers' compensation system. These insurer behaviors raise the costs to injured workers of workers' compensation benefits and thus may reduce the propensity of eligible workers to apply for benefits.

Back injury prevention: a lift team success story

Work related back injuries among hospital personnel account for high volume, high cost workers' compensation claims. These injuries can be life altering experiences, affecting both the personal and professional lives of injured workers. Lifting must be viewed as a skill involving specialized training and mandated use of mechanical equipment, rather than as a random task performed by numerous health care providers. The use of a lift team specially trained in body mechanics, lifting techniques, and the use of mandated mechanical equipment can significantly affect injury data, financial outcomes, and employee satisfaction. The benefits of a lift team extend beyond the effect on injury and financial outcomes--they can be used for recruitment and retention strategies, and team members serve as mentors to others by demonstrating safe lifting techniques. Ultimately, a lift team helps protect a valuable resource--the health care worker.

The effects of a medical care utilization review program on back and neck injury claims

A number of quality-based evaluation and treatment protocols have been developed and marketed for the management of work-related musculoskeletal problems. Yet, little is known about their effectiveness in improving patient outcomes. We evaluated one such approach adopted by the Department of Labor and Industries, which insures approximately two-thirds of the non-federal workforce in Washington State. The outcomes of back and neck injury claims (primarily sprains and strains) filed in the 2 months after the program was fully operational were compared with two comparable groups of claims from the same base population filed before the program's availability. There were no statistically significant differences between groups in the number of days of work loss, medical costs, and permanent partial disability awards granted during the 2 years after injury. The quality-based program used as an adjunct to claims management failed to improve outcomes.

Psychosocial job factors and return-to-work after compensated low back injury: a disability phase-specific analysis

BACKGROUND

Job characteristics may constitute a barrier to return-to-work (RTW) after compensated disabling low back pain (LBP). This study examines the impact of psychosocial job factors on time to RTW separately during the acute and subacute/chronic disability phases.

METHODS

This is a retrospective cohort study of 433 LBP workers' compensation claimants with 1-4 years of follow-up. The association of psychosocial job factors with duration of work disability was estimated with Cox regression models, adjusting for injury history and severity, physical workload, and demographic and employment factors.

RESULTS

High physical and psychological job demands and low supervisory support are each associated with about 20% lower RTW rates during all disability phases. High job control, especially control over work and rest periods, is associated with over 30% higher RTW rates, but only during the subacute/chronic disability phase starting 30 days after injury. Job satisfaction and coworker support are unrelated to time to RTW.

CONCLUSIONS

Duration of work disability is associated with psychosocial job factors independent of injury severity and physical workload. The impact of these risk factors changes significantly over the course of disability.

Reducing incidence of low-back injuries reduces cost

To reduce musculoskeletal injuries in employees and to lower the financial costs associated with them, a 525-bed county nursing home in upstate New York initiated a five-step ergonomics program and purchased mechanical lifting devices. The five steps in the program were (1) creation of a resident transfer evaluation team, (2) establishment of an accident review committee, (3) mandatory ergonomics training for new nursing aides, (4) regular maintenance checks for lifting equipment, and (5) direct access to the management and budget process. During the 7-year period of this study, 8 smooth movers, 10 hydraulic stretchers, 7 Hoyer lifts, 1 Arjo lift, 9 Sarita lifts, and 1 Maxilift were purchased. Comparisons in health and financial outcomes were made between the preintervention period (1992-1993) and the intervention period (1994-1998). There was a significant reduction in the number of low-back injuries per 100 full-time nursing aides from 15.7 in the preintervention period to 11.0 in the postintervention period (p<0.05). The total number of lost workdays was significantly (p<0.05) reduced from 1476 per year before the intervention to 625 per year after the intervention. In addition, the lost workdays per full-time nursing assistant was significantly reduced from 7.8 to 3.0 (p<0.05). Although the average number of lost workdays per injury decreased from 49 to 27 days, this decrease was not statistically significant. Financially, there was a significant reduction in the average yearly cost associated with low-back injuries from $201,100 before the intervention to $91,800 during the intervention.

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

Although doctors are increasingly evaluated on the basis of return-to-work (RTW) outcomes, the effect of doctor-patient communication about the workplace and RTW after an occupational injury has received little research attention. The effect of patient-reported doctor communication on duration of disability was examined retrospectively in a 3-year cohort of 325 claimants with a lost-time low back injury. Although doctor proactive communication was associated with a greater likelihood of RTW during the acute phase (< 30 days of disability), this effect disappeared when injury and workload characteristics were taken into account. A positive RTW recommendation was associated with about a 60% higher RTW rate during the subacute/chronic phase (> 30 days of disability) only. Prospective studies are needed to confirm this effect. The impact of physician communication on RTW is largely confounded by injury and workplace factors.

Disability management of low back injuries by employer-retained physicians: ratings and costs

BACKGROUND

Medico-legal models of disability determination for low back pain lack empirical support. Besides diagnostic and functional parameters, social and situational factors may influence impairment/disability ratings and costs.

METHODS

Archival data from employer-retained occupational medicine physician files and public court records were examined for 184 Workers' Compensation claimants with low back injuries. Regression was used to predict ratings, costs, and settlement duration from medical, functional, social, and situational variables.

RESULTS

Diagnosis, surgery, pain, rating year, and clinic predicted impairment ratings from employer-retained physicians. The clinic effect partially reflected claimant ethnicity. Diagnosis, surgery, tests ordered, legal representation, and impairment rating predicted disability ratings at the administrative law judge level. Diagnosis, tests, and impairment rating predicted costs. For musculoskeletal diagnoses, settlement duration was related negatively to treatment duration and positively to costs.

CONCLUSIONS

Social and situational parameters influence disability management among employer-retained physicians, while functional variables have little impact. For musculoskeletal low back pain, increased disability and cost may result from variation in treatment duration.

Prioritizing back injury risk in hospital employees: application and comparison of different injury rates

To identify high risk areas for back injury in a large teaching hospital, we calculated standard injury rates and newly developed composite statistics for nursing and non-nursing work groups. Data were extracted from the hospital's workers' compensation database. The hospital-wide total injury rate was 4.6 reports per 100 full-time equivalents (FTE); Compensation Case Rate, 1.4 cases per 100 FTE; Compensation Severity Rate, 76 days lost per 100 FTE; and the Cost Rate, $3742 per 100 FTE. The Total Injury Reports Rate for nursing varied from 14.2 per 100 FTE for Intensive Care Unit (ICU) Nursing to 3.8 per 100 FTE for Pediatric Nursing. Non-nursing areas also demonstrated increased rates for back injury. Individual statistical rates ranked areas differently in risk, whereas composite statistical measures consistently ranked ICU Nursing, Buildings and Grounds, and Orthopedics/Neurological Nursing as the top three. Patient handling was the precipitating event in the majority of nursing back injuries, indicating the need for ergonomic intervention. The use of combined statistical measures provided a more integrative measure for describing and following back injury risk over time.

Prognosis for people with back pain under a No-fault 24-hour-cover compensation scheme

STUDY DESIGN

A retrospective descriptive casenote review of consecutive back pain claimants assessing claim outcome at 12 months from onset.

OBJECTIVE

To assess prognosis for back pain claimants in a no-fault 24-hour-cover accident compensation system.

BACKGROUND

New Zealand has a unique accident compensation system that may provide incentives for health professionals to classify people with backache as having a back injury and incentives for back pain claimants to continue claims longer than would be the case in other compensation systems.

METHODS

One hundred consecutive back pain claimants were identified from a single office of New Zealand's sole accident compensation insurer (Accident Rehabilitation and Compensation Insurance Corporation; ACC), who were still receiving compensation payments 4 weeks after the initial date of the claim. The study end point was case closure in the subsequent 12 months. Case closure rate was analyzed in relation to several potential prognostic variables.

RESULTS

Of the 100 cases identified in which the claimant was receiving compensation 4 weeks from the initial date of the claim, 43 cases were not closed by 6 months, and 30 cases were not closed at 12 months. The variable most strongly associated with case nonclosure was whether the claimant was receiving earnings-related compensation (equal to 80% of previous income), with 41% of this group still receiving compensation at 12 months versus 16% of the group not receiving earnings-related compensation (chi2 = 8.55, P = 0.003). These results compare unfavorably with those from previous published studies from The Netherlands and Jersey in the United Kingdom.

CONCLUSION

New Zealand's unique accident compensation environment may discourage return to work for people with back pain. New Zealand legislators should assess the impact of the ACC scheme on people with back pain, particularly in light of the recent recommendations of the International Association for the Study of Pain Task Force on Back Pain in the Workplace, that compensation cover for workers with back pain be limited to 6 weeks.

Outcomes in work-related upper extremity and low back injuries: results of a retrospective study

BACKGROUND

The outcomes of treatment for work-related injuries and illnesses are multidimensional and complex, but have rarely been explored in detail. This study was intended to provide information on a sample of workers representing a range of jobs and employers typical of the workers compensation system.

METHODS

A mailed, self-report survey measuring multiple dimensions was conducted. Identified through the New Hampshire Division of Workers' Compensation First Report of Injury database, a sample of workers with injuries to their lower back (60%) or upper extremities (40%) a year prior to the study were surveyed. Response rate was 80% (N=169; upper extremity cases=70; low back cases=99).

RESULTS

Most (82.8%) were working one year post-injury. Over half reported residual effects of the injury on work or activities of daily living. Many working subjects reported persistent injury-related anxiety and pain at the end of the work day, worse in those with low back pain compared to those with upper extremity injuries. Almost 40% of those who returned to work suffered a reinjury. Forty-four percent of respondents suffered significant injury-related financial problems, which were worse in those who had been out of work for longer periods.

CONCLUSIONS

Occupational musculoskeletal injuries do result in significant, long-term adverse physical, economic, and psychological consequences, as demonstrated in self-reported surveys.

Decreased rate of back injuries through a wellness program for offshore petroleum employees

High rates of injury, particularly those for back injuries, at an offshore petroleum unit were addressed through an intensive wellness program initiated in 1991. The number of all types of injuries, including back injuries, decreased between 1991 and 1995. The number of back injuries decreased from nine in 1987 to four in 1992 and was zero in 1993. Although there are inadequate data to provide power for a significant result, other criteria suggest a causal relationship. The results are consistent with the few published studies that suggest a decrease in the number of injuries in association with exercise and perhaps with modification of psychosocial risk factors. Calculations suggest a cost savings of over $800,000 and a return on investment of $2.51, as well as avoidance of pain and injury.

The effects of prework functional screening on lowering an employer's injury rate, medical costs, and lost work days

STUDY DESIGN

The data in this study were gathered retrospectively after the progress of program development in terms of employee outcomes within an organization. This design characterizes a retrospective longitudinal study.

OBJECTIVE

To determine whether prework functional screens are effective in lowering the incidence of work-related back sprains or strains, related medical costs, and lost work days within an organization.

SUMMARY OF BACKGROUND

Musculoskeletal injuries are considered the leading cause of disability for people during their working years. Back injuries are the most common reason for workers' decreased work capacity and reduced leisure time. The increased rate of injury and escalating workers' compensation costs are are a major force motivating companies to implement a tool that can be effective in lowering back sprain or strain injuries and containing their workers' compensation costs. The U.S. Department of Health and Human Services reports a major objective of increasing the number of companies offering back injury prevention programs by the year 2000.

METHODS

The study follows the effects realized when a medical center institutes close case management, early return to work policies, and prework functional screens in three stages over the course of 10.5 years.

RESULTS

The severity of back sprains or strains, related medical costs, and lost work days were significantly lower with the use of prework functional screens on all new employees hired into physically laborious jobs.

CONCLUSIONS

This study offers employers a proven effective tool that can be used to help lower the severity of on-the-job back sprains or strains, resulting medical costs, and lost work days in their organization.

Predicting return to work. A long-term follow-up study of railroad workers after low back injuries

STUDY DESIGN

Evaluation of the long-term outcomes of 178 railroad employees with low back injury who had completed a multidisciplinary rehabilitation program.

OBJECTIVES

To study two major areas: 1) outcomes of the rehabilitation program in terms of the patient's improvement in function and rate of return to work and 2) factors that predict long-term retention at work, both at the railroad and elsewhere.

SUMMARY OF BACKGROUND DATA

Several studies have been published examining rehabilitation outcomes of individuals covered under workers' compensation law, but few exist that have examined railroad workers covered by the Federal Employers Liability Act, and few studies exist with follow-up periods longer than 3 years.

METHODS

Physical/medical, self-reported, and employment/financial data were collected on each patient from medical and employment records. Follow-up data regarding employment status were obtained either from the employer or from the patient by telephone interview.

RESULTS

On average, the patients improved in all objective and subjective measures after rehabilitation. Improvements in these measures were not predictive of return to work. At follow-up examination, 89% of the contacted patients were employed--61% still at the rail-road. The employment factors of lost work days and length of employment and the financial factor of wage rate were the most predictive of long-term work status.

CONCLUSIONS

The multidisciplinary program in the current study was found to improve patient physical functioning and reduce pain. However, success in these measures was not predictive of long-term work status, suggesting that other factors have an impact on work status. Clinicians must be aware that employment and financial factors may have a strong influence on return-to-work outcomes.