Radoslaw Wasiak

Measuring Return to Work

Background It is argued that one of the factors limiting the understanding of return to work (RTW) following work disability is the use of measurement tools that do not capture a complete picture of workers’ RTW experiences. To facilitate the investigation of RTW, the current authors proposed a developmental conceptualization of RTW, which argues for an expanded awareness that encompasses four phases: off work, work reintegration, work maintenance and advancement. This paper reports on work undertaken with the aim of operationalizing the conceptualization. Methods A review of the RTW and related literature, with databases searched including PubMed, EconLit, and PsycInfo. We began by extracting details of RTW instruments used by previous researchers. We then interpreted these within the context of the phases of RTW. Using the International Classification of Functioning, Disability, and Health (ICF) to inform our thinking and coding structure, we conceptualized phase-based RTW outcomes and categorized them as ‘tasks and actions’, ‘contextual’ or ‘process driven’. Iteratively, we reviewed existing instruments for their use as measures of RTW. Where gaps in instrumentation were found, the wider vocational and career assessment literature was searched for instruments that could be adapted for use in RTW research. Results indicate that, although numerous research instruments have been used to assess RTW, within the scientific literature some important dimensions of RTW lack instrumentation. In particular, we found that outcomes such as goal setting, motivation, expectation, job seeking, work maintenance, and career advancement require operationalization. Amongst the outcomes had been operationalized, we found considerable variation in conceptual development and application. Conclusions The lack of consistency and comprehensiveness of RTW measurement is one of the factors compromising the advancement of the field of RTW research. It is suggested that a more complete and psychometrically sound array of research instruments, grounded within a commonly adopted paradigm, would further the understanding of RTW and the factors affecting it.

Risk factors for recurrent episodes of care and work disability: case of low back pain.

Recurrences of injuries are common and have significant socioeconomic consequences; it is important to identify associated risk factors as potential opportunities for prevention. This study was conducted to identify risk factors for low back pain (LBP) recurrence and the extent that variation in recurrence definition impacts identified risk factors. Patients with new claims for LBP reported in New Hampshire to a workers’ compensation provider were selected (n = 2023) with a minimum of 3-year follow up. Alternative definitions of recurrence included a new episode of medical care and a new episode of lost work time (work disability). Risk factors better predicted disability-based than treatment-based recurrence. Longer durations of the initial episode of care or work disability were the most powerful predictors of recurrence, implying that shorter episodes of care and early return to work contribute to better outcomes.

Recurrence of Low Back Pain : Definition-Sensitivity Analysis Using Administrative Data

Study Design. Retrospective analysis of administrative claims data in a single workers’ compensation jurisdiction. Objectives. To evaluate the effects of alternative definitions and follow-up parameters on rates of low back pain recurrence based on detailed administrative data. Summary of Background Data. Previous studies reported low back pain recurrence rates ranging from 14% to 45%, without consistency in definitions of recurrence or specifications of follow-up. Methods. Patients with new claims for low back pain reported in New Hampshire to a large workers’ compensation provider in 1996 and 1997 were selected (N = 2944). Definitions of recurrence included: new workers’ compensation claim, new episode of care, and new episode of lost work time (work disability). For the latter two definitions, various minimum between-episode gaps were applied and related to recurrence rates. Two follow-up structures (constant length of follow-up post end of the first episode and fixed-period length of follow-up since the onset of low back pain) were examined for sensitivity of recognizing low back pain recurrence, with a maximum of 3-year follow-up. Results. Recurrence rate using a claims-based definition was 7.9% and 7.1% for the entire cohort and the subset with work disability days, respectively, for the 3 years of follow-up. Care-based recurrence rates ranged between 12% and 49%, whereas disability-based recurrence rates ranged between 6% and 17% over the 3 years, inversely related to the length of the minimum between-episode gap (R = −0.86 for disability and care, P < 0.001). Two-year follow-up was sufficient to identify 85% to 100% of recurrences regardless of the follow-up structure. Conclusions. Recurrence rates are highly sensitive to variations in definitions. Consistency of definitions and application across studies is required to enable valid comparisons.

Methodological challenges in studying recurrence of low back pain.

Recurrences of low back pain (LBP) have been shown to be both frequent and costly, with reported recurrence rates ranging from 5 to 82%. Numerous methodological approaches have been developed to identify recurrence but there has been no standardized definition of LBP recurrence or required follow-up time. The objective of this study was to compare the methodological approaches used to analyze LBP recurrence in seminal contributions and to describe the differences in definitions of LBP recurrence and follow-up structure. Twelve seminal articles were identified for review during which four types of LBP recurrence definition and two types of follow-up structure were recognized. Definitional and follow-up differences considerably contributed to variations in computed recurrence rates due either to measurement or other methodological shortcomings, such as loss to follow-up and sick person effect. The results suggest that there is a need to develop a standardized definition of LBP recurrence and a standardized approach to follow-up to allow direct comparisons of published research findings. The use of alternative definitions is also likely to impact analyses of risk factors contributing to LBP recurrence and direct and indirect costs associated with treating LBP.

Workers' perspectives on low back pain recurrence: ''It comes and goes and comes and goes, but it's always there''

&NA; Although various measures of low back pain (LBP) recurrence have been proposed, none have been tested to determine if they are consistent with what those with LBP perceive a “recurrence” to be. To further the understanding of LBP recurrence and how to measure it, we examined how individuals with a history of LBP describe their back pain experiences. A qualitative approach was chosen and six mixed‐gender focus groups were conducted. Discussions were facilitated by two researchers and structured around predetermined questions. All four authors were involved in the data analysis and thematic congruence was achieved through an iterative process of coding and discussion. Participants included 31 individuals (14 female, 17 male), with ages ranging from early 20s to mid 70s. When asked about LBP recurrence, participants had difficulty understanding the concept. There was a sense that, although the pain may disappear, the condition was always there. Three states were defined: “normal,” “flared‐up,” and “attack.” “Normal” could include experiencing pain, but generally represented a tolerable state. “Flared‐up” was associated with increased pain, the use of strategies to overcome difficulties, and modified participation. “Attack” state was described as severely disabled: “I just have to lay there.” Participants described their experiences in a way that is consistent with the idea that LBP is a fluctuating and disabling health condition. Results cast doubt on the validity of currently available measures of LBP recurrence. Focusing on recurrence of pain without consideration of broader contextual factors will result in an incomplete understanding of the meaning of the pain experience.

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

Study Design. Literature review. Objective. To present a framework for future analyses of back pain recurrence and explore the applicability and relevance of existing recurrence indicators. Summary of Background Data. Empirical studies of back pain have included a variety of indicators of recurrence, resulting in a range of findings about recurrence rates and associated factors. Little is known about the relationships between existing indicators. Methods. Literature overview, expert panel, and workshop discussion at the IX International Forum on Primary Care Research on Low Back Pain. Results. Using the International Classification of Functioning, Disability, and Health (ICF), disabling back pain was conceptualized as a health condition, i.e., back pain disorder (BPD), and BPD recurrence was conceptualized as involving a return of atypical back pain and/or back-pain-related difficulty performing tasks and actions related to the initial episode. Using the ICF, 2 types of recurrence indicators were identified: those directly describing components of BPD and those indirectly doing so (e.g., recurrence of health care utilization). Conclusion. In light of the difficulty in measuring BPD recurrence, transparent definitions and a clear understanding of the implications of using particular indicators is required. Future research should focus: on examining the capture BPD recurrence by various research instruments, improving understanding of the relationship between indicators, and gaining insight into how individuals experiencing BPD view recurrence.

Primary Care Involvement and Outcomes of Care in Patients with a Workers' Compensation Claim for Back Pain

Study Design. A retrospective case series of primary care patients receiving Workers’ Compensation (WC) for back pain. Objective. To describe the extent of primary care provider (PCP) involvement in work-related low back pain (WRLBP), and whether PCP involvement is a significant determinant of patterns of care or outcomes. Summary of Background Data. In general, WRLBP has inferior outcomes compared with nonoccupational LBP. Although it has been suggested that better outcomes are achieved when care for WRLBP involves specialists such as occupational medicine physicians rather than a PCP, limited evidence supports this claim. Methods. Adult patients were identified by electronic records from four hospital-affiliated PCP practices in fiscal years 1996 to 1998. Those with a WRLBP claim filed during the same time period were identified by searching a WC claims database. Medical records were reviewed to assess past medical history, the extent of prior PCP contacts for any visits before and for visits 2 years after the reported onset of the WRLBP claim, and detailed information on visits for this condition. Disability outcomes (total costs and days of work disability) were obtained from the WC database. Results. Among 68,710 individuals with a PCP practice visit, 118 with a WRLBP claim were identified. The final study sample included 87 patients with a WRLBP claim and at least 1 documented PCP practice visit during the study period. Seventy-eight percent of patients saw the PCP at least once in the 2 years after the claim onset date, but only 34 patients (39%) visited the PCP for their WRLBP, and 20 (23%) had more than 1 visit. Although almost all patients with a PCP visit for WRLBP saw a physician (not the PCP in 79% of cases) within a week of the claim onset date, the median number of days between the onset date and the first WRLBP visit to the PCP was 47.5. Patients with a prior history of back problems were more likely to have a PCP visit for WRLBP (odds ratio 2.9, 95% confidence interval 1.1–7.7). Patients with PCP visits for WRLBP had higher total and medical costs than those without PCP visits, but a similar number of paid disability days. After controlling for other potential predictors, involvement of the PCP was not a significant predictor of the total cost of the WRLBP claim. Conclusions. Many individuals with a WC claim do not have a stable PCP relationship around the onset of their WRLBP episode. Those with PCP relationships uncommonly involve the PCP in their WRLBP, and if they do, it is usually later in the course because of persistent or recurrent symptoms. Disability outcomes appear to be similar regardless of whether a PCP was involved. However, PCP involvement is associated with greater medical costs, which may reflect confounding based on duration of symptoms rather than the nature of the care provided. Additional research is needed to understand how different patterns of care for patients with a WRLBP claim relate to outcomes and how these patients compare with individuals without such a claim, as well as the factors that lead patients to involve their PCP or not.

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.

Urban-Rural Differences in Work Disability Following Occupational Injury: Are They Related to Differences in Healthcare Utilization?

Objective: To investigate urban-rural differences in health care utilization following compensable work-related injury and determine whether differences relate to work disability. Methods: Analysis of worker’s compensation data relating to 4889 people with a bone fracture. Regression analyses were used to test the associations between rurality, work disability, and health care utilization. Results: Place of residence was found to relate to health care utilization and work-disability duration; however, the direction of this relationship depended on the amount of health care used. At lower levels of utilization, more rural residents had less time off; however, as health care usage increased this trend reversed. Conclusions: The observed interaction between health care utilization, work-disability, and rurality raises important questions regarding causality and implies that people in both urban and rural areas have the potential to benefit from further investigation into health care practices and associated outcomes.

The direct cost burden of 13 years of disabling workplace injuries in the U.S. (1998-2010): findings from the Liberty Mutual Workplace Safety Index

INTRODUCTION Although occupational injuries are among the leading causes of death and disability around the world, the burden due to occupational injuries has historically been under-recognized, obscuring the need to address a major public health problem. METHODS We established the Liberty Mutual Workplace Safety Index (LMWSI) to provide a reliable annual metric of the leading causes of the most serious workplace injuries in the United States based on direct workers compensation (WC) costs. RESULTS More than