J Occup Rehabil. 2018 (Jun); 28 (2): 298–306 ~ FULL TEXT
Tyler J. Lane, Rebbecca Lilley, Sheilah Hogg-Johnson, Anthony D. LaMontagne, Malcolm R. Sim, Peter M. Smith
Department of Epidemiology and Preventive Medicine,
School of Public Health and Preventive Medicine,
Monash University, Level 2,
553 St Kilda Road,
Melbourne, VIC, 3004, Australia.
BACKGROUND: Work disability is a major personal, financial and public health burden. Predicting future work success is a major focus of research.
OBJECTIVES: To identify common prognostic factors for return-to-work across different health and injury conditions and to describe their association with return-to-work outcomes.
METHODS: Medline, Embase, PsychINFO, Cinahl, and Cochrane Database of Systematic Reviews and the grey literature were searched from January 1, 2004 to September 1, 2013. Systematic reviews addressing return-to-work in various conditions and injuries were selected. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria to identify low risk of bias reviews.
RESULTS: Of the 36,193 titles screened and the 94 eligible studies reviewed, 56 systematic reviews were accepted as low risk of bias. Over half of these focused on musculoskeletal disorders, which were primarily spine related (e.g., neck and low back pain). The other half of studies assessed workers with mental health or cardiovascular conditions, stroke, cancer, multiple sclerosis or other non-specified health conditions. Many factors have been assessed, but few consistently across conditions. Common factors associated with positive return-to-work outcomes were higher education and socioeconomic status, higher self-efficacy and optimistic expectations for recovery and return-to-work, lower severity of the injury/illness, return-to-work coordination, and multidisciplinary interventions that include the workplace and stakeholders. Common factors associated with negative return-to-work outcomes were older age, being female, higher pain or disability, depression, higher physical work demands, previous sick leave and unemployment, and activity limitations.
CONCLUSIONS: Expectations of recovery and return-to-work, pain and disability levels, depression, workplace factors, and access to multidisciplinary resources are important modifiable factors in progressing return-to-work across health and injury conditions. Employers, healthcare providers and other stakeholders can use this information to facilitate return-to-work for injured/ill workers regardless of the specific injury or illness. Future studies should investigate novel interventions, and other factors that may be common across health conditions.
Absenteeism; Intervention; Presenteeism; Prognosis; Return to work; Sick leave; Work disability
From the FULL TEXT Article:
In 2010, an estimated 313 million people worldwide experienced
an occupational injury or disease requiring at least
4 days off work, with a total estimated cost of 4% of global
GDP.  Time off work due to injury is associated with
poorer physical, mental, and social health outcomes, while
good quality work—even for those who are ill or recovering —
promotes recovery, improves health, and reduces
the negative effects of long-term work absence. [2–5] We
investigated whether workplace-based return-to-work
(RTW) Coordinators can reduce the burden of occupational
injury by improving the likelihood of RTW among injured
Throughout North America, Europe, and Australasia,
Coordinators manage injured workers’ transition back to
the job [6, 7] and are regarded as an important component
of successful RTW interventions. [8–10] Known by various
titles including rehabilitation coordinator, injury management
coordinator, and case manager [11, 12], their common
feature is management of the RTW process through
workplace assessment, RTW planning, and fostering communication,
negotiation, and conflict resolution between
injured workers, employers, and other stakeholders. [7, 8, 11–14] Coordinators may be located in the workplace, a
government agency, hospital or other healthcare organisation,
or be an independent consultant. [6, 7] Interventions
that include a Coordinator have shorter disability durations,
lower costs, and may improve functioning and quality of
life. [8, 9, 15] A recent Cochrane review of 14 randomised
controlled trials suggested that compared to usual practice,
Coordinators do not improve RTW outcomes.  However,
the studies in the review were rated at low- to moderate-
quality and did not account for different Coordinator
activities, which may be an important factor in their impact.
For instance, recent research suggests that both management
and interpersonal skills are essential for success in
the Coordinator role [6, 11, 14, 17], but to our knowledge
their impact on RTW outcomes has not been quantitatively
This paper describes a study of Coordinators in Victoria,
Australia, where employers are required to appoint a
workplace-based Coordinator from within the organisation.
Selection criteria for Coordinators include having
sufficient seniority within the organisation and competence
to speak on the employer’s behalf and assist them
in meeting their RTW obligations.  We developed the
following research questions to guide this study: do Coordinators’
interpersonal and functional activities improve
RTW outcomes? Do their effects vary over time? And are
they observed over and above other workplace factors?
We hypothesised that better Coordinator interpersonal
activities and fulfilment of functional obligations would be
associated with better RTW outcomes, and that these associations
would be observed over time and over and above
other workplace factors.
We investigated workplace-based Coordinators’ impact on
RTW outcomes using prospective cohort survey data from
injured workers in Victoria, Australia. Eligible participants
were workers’ compensation claimants with an upper-body
musculoskeletal (MSK) or mental health condition who
had received at least ten days of workers’ compensation
wage-replacement payments, were at least 18 years old, and
gave responses to both baseline and 6 month follow-up surveys.
Condition type was classified using VCode, the injury
and disease classification system for workers’ compensation
claims in Victoria.  VCode is based on the Type of
Occurrence Classification System, which was designed for
injury coding in workers’ compensation claims in Australia
and incorporates elements of ninth revision of the International
Classification of Diseases. 
Sampling Strategy and Data Collection
WorkSafe Victoria (WSV), the OHS and workers’ compensation
agency for Victorian employers, identified eligible
claimants in their claims database beginning in May 2014,
at around 5 weeks after their claim had been submitted.
Each was sent a primary approach letter informing them of
the study and providing an opportunity to opt-out. Contact
details of those who did not opt-out were sent to an interviewing
agency for data collection. At least six attempts
were made to establish contact with eligible claimants over
a 2–month period.
Data were collected at two time points: a baseline survey,
administered around 4 months post-injury, and a follow-
up, administered 6 months later. Baseline interviews
were conducted between June 2014 and July 2015 and
follow-up interviews between January 2015 and February
2016. The lag between injury and baseline interview was
due to time to report injury and lodge claim, time to make
claim liability decision, employer excess period (ten working
days), the opt-out window, and transfer of information
from WSV to interviewing agency. Participants were interviewed
using Computer-Assisted Telephone Interviewing.
To protect participant privacy, responses were stored in a
secure physical location. The final data files were de-identified
and stored in a password-protected electronic system.
The research team received the de-identified version, which
was stored on a password-protected server.
The outcome was whether the participant achieved sustained
RTW at the time of interview, assessed at both baseline
and follow-up interview. We defined sustained RTW as
being back at work for at least 1 month at time of interview
(28 days/4 weeks/1 month, depending on the time unit
reported) following 10 days of compensated work absence.
Sustained RTW was preferred over simple RTW (i.e., being
back at work for any duration at time of interview) due to
high rates of relapses/failed RTW attempts.  Our definition
of sustained RTW is based on clinical observations
that work disability relapses tend to occur within a month
of first RTW , and was recommended by the Cochrane
review of Coordinator impact on RTW. 
The main exposures for this study were the stressfulness
of Coordinator interactions and whether the participant
had a RTW plan. Both were captured at baseline
Stressfulness of interactions was considered a proxy
for Coordinators’ interpersonal activities. Ability to deal
with stress has been identified as a “very important” or
“essential” Coordinator competency.  Participants
rated Coordinator interactions on a five-point scale,
which ranged from “extremely stressful” to “not at all
stressful”. Interactions were categorised as poor if participants
rated them as either “quite a bit” or “extremely
stressful” and good if rated as “not at all”, “not very”,
and “a bit stressful”. Those who reported no contact
with a Coordinator served as the reference group.
Having a RTW plan was considered a proxy for Coordinators’
fulfilment of their functional activities. RTW
planning involves collecting information about the
worker, their injury, their pre-injury job, current work
capacity, reasonable accommodations and modifications,
consulting with the worker and their health care
practitioner, communicating with the worker, and reaching
agreement about the plan , and is considered
an important Coordinator activity  and part of best
practice for managing work absence and RTW. 
Figure 1 presents a conceptual diagram illustrating
these Coordinator activities and their hypothesised
impact on RTW outcomes (paths A and B). We anticipated
that as measured, the two activities would overlap
(path C). For instance, injured workers may be more
likely to rate their Coordinator interactions as good if the
Coordinator fulfilled their functional role (i.e., provided
a RTW plan). Further, Coordinators may be more likely
to fulfil their functional activities when the interactions
are good. As such, we anticipated unadjusted path A and
B would capture effects of both interpersonal and functional
activities, while adjustment in multivariable models
would isolate direct effects.
The following were identified as potential confounders of
the association between Coordinator activities and RTW
outcomes. All were captured at baseline survey. Demographic
variables included participant gender and age.
Age was categorised into three groups (18–34, 35–54, and
55+) to account for the non-linear relationship observed
between age and disability duration among claims with at
least 10 days of compensated time loss.  Condition type
was classified as either a mental health or MSK condition.
Workplace factors were assessed using standardised measures.
These included supervisor and co-worker response to
injury [24, 25], supervisor and co-worker social support,
sense of community, and workplace size , physical 
and mental [28, 29] workplace demands, and job autonomy.  We also included participant recovery expectations. [24, 25]
Participant demographics and survey responses were summarised
with frequencies or means for each variable, in
addition to the proportion of missing values. Attrition
analysis was conducted using Pearson’s Chi square on several
characteristics (Coordinator interactions, RTW status
at baseline, age, gender, and condition type) to determine
whether those lost to follow-up differed significantly from
those who participated in both surveys.
Associations between Coordinator activities and
RTW outcomes were evaluated via logistic regression
models for each time point. These included crude (unadjusted)
for each activity, separate adjusted for each activity,
and adjusted for both activities. Potential confounders
were included in adjusted regression models if they
had a substantial effect on the association between Coordinator
activities and RTW outcomes, which was considered
changing main exposure coefficients by at least 10%
when added to crude regression models.  While this
methodology is vulnerable to a high false-positive rate , it is considered superior to significance testing in
exposure models.  Demographic variables and injury
type variables were included in adjusted regression models
regardless of whether they met the 10% threshold.
Missing scale values were imputed with person scale
means, provided at least 50% of the participant’s scale
items were complete. Person scale means are a reliable
method of imputing missing scale values.  While
the missing threshold is higher than typically used, previous
research has found that as long as the total number
of missing items and cases is low (>20%), person
scale mean imputation can accurately reflect the original
data and does not seriously increase scale reliability
(i.e., reducing variance and increasing the likelihood
of a Type I Error).  Further, each non-imputed scale
was highly reliable [lowest α = 0.834 (mental demands),
complete baseline sample of n = 869], had low missing
rates [maximum missing = 14 (2%), analysable sample
of n = 632], and was transformed into tertile groups,
minimising the impact of bias. Otherwise, cases with
missing data were listwise deleted from regression analysis.
All independent variables were evaluated for multicollinearity
by assessment of Variance Inflation Factor
(VIF). Statistical significance was set at p ≤ 0.05. Analyses
were conducted in SPSS 23 (IBM Corp., Armonk,
A total of 2,95 claimants were identified as eligible for
inclusion in the survey, of whom 321 (13%) opted out. Of
the 2,74 for whom contact was attempted, 869 responded
to the baseline survey (40%) and 632 (73% of baseline) to
follow-up. The most common reason for not participating
following contact was refusal (n = 769).
Attrition analysis found that baseline participants lost to
follow-up were not significantly different in baseline rating
of Coordinator interactions, RTW status, gender, or condition
type. There were significant differences between age
groups, with the youngest (18–34 years) being lost to follow-
up at the highest rate (38%, n = 81) and the proportion
decreasing with each successive age group: 27% (n = 125)
of those aged 35–54 and 17% (n = 31) of those 55+. The
majority of those lost to follow-up could not be recontacted
(59%; n = 139).
Participant characteristics are summarised in Table 1.
Average participant age was 46 years. The sample was
45% (n = 285) female. Just over one-fifth were claiming
for a mental health condition (22%; n = 137). The median
time between injury and baseline interview was four
months (inter-quartile range: 3–5 months). Forty-six
percent (n = 287) of participants had achieved sustained
RTW at baseline and 65% (n = 393) at follow-up. Half
the sample rated their Coordinator interactions as good
(49%; n = 125), one in ten as poor (11%; n = 70), and 40%
(n = 252) had no contact with a Coordinator. The majority
of those with no contact reported they did not have
a designated Coordinator (28% of sample; n = 168). Half
the sample said they had a RTW plan (51%; n = 325).
Associations Between Coordinator Activities and RTW Outcomes
Crude and adjusted associations between Coordinator
activities and RTW outcomes are presented in Table 2.
Variables meeting the threshold for inclusion as a confounder
in adjusted analyses were supervisor response to
injury and supervisor social support for both baseline and
follow-up models, and RTW status at baseline for followup
analysis. All VIFs were below 2.5, indicating low risk of
In crude models, good Coordinator interactions and
RTW plans were significantly associated with greater odds
of achieving sustained RTW. Most associations remained
significant when adjusting for demographics and confounders,
the exception being RTW plans at follow-up. Including
both Coordinator activities in one regression resulted
in only one being significant at either time point: RTW
plans were associated with doubled odds of RTW at baseline
(OR 2.02, 95% CI 1.40–2.90), while good Coordinator
interactions nearly doubled odds of RTW at follow-up (OR
1.90, 95% CI 1.22–2.90). At no point were poor Coordinator
interactions significantly associated with RTW outcomes
in comparison to no Coordinator interaction.
We investigated the impact of workplace-based RTW Coordinators
on the RTW outcomes among workers who had
taken time off following occupational injury, focusing on
two Coordinator activities: having a good interaction with
the injured worker and providing a RTW plan. We expected
both Coordinator activities to improve RTW outcomes
over and above other workplace factors and to observe the
association in both cross-sectional and prospective analyses.
The findings mostly supported our hypotheses, though
there were some surprising results concerning how and
when Coordinators affected RTW.
Participant rating of the stressfulness of Coordinator
interactions, which we assessed as a proxy for Coordinators’
interpersonal activities, was a major factor in RTW
outcomes. When adjusting for demographics and confounders,
good interactions were significantly associated with
better RTW outcomes, while poor interactions were not
significantly different from having no Coordinator contact.
However, RTW plans, which we assessed as an indicator of
Coordinators’ fulfilment of their functional roles, doubled
the odds of RTW at baseline and attenuated the impact of
good interactions to non-significance. At follow-up interview,
which was administered 6 months after the baseline
interview, we found the opposite: good interactions doubled
the odds of achieving RTW while RTW plans were
not significantly associated with RTW, nor did they substantially
attenuate the impact of good interactions.
The findings may be attributable to differences between
claimants returning to work at either time point. Earlier in
the claims process, injury-related factors such as severity
are more important predictors of RTW. [35, 36] Claimants
that RTW early tend to do so with little to no intervention.  In contrast, psychosocial factors such as psychological
job demands, low job control, and work schedule flexibility
are more important for those returning later.  Such
claims are associated with higher rates of secondary mental
health conditions, disputes, and resistance to intervention. [37, 38] Henceforth, we refer to these as shorter- and
longer-duration claims for simplicity.
Coordinators’ functional role—indicated by the RTW
plan—may be the important catalyst for RTW among
shorter-duration claims, as suggested by the attenuation
of the effect of good interactions when adjusting for RTW
plans. The inversion of associations between baseline and
follow-up — good interactions were significant while having
a RTW plan was not — suggests that Coordinators’ interpersonal
activities are more important for fostering RTW
among longer-duration claims. As noted above, such claims
are vulnerable to secondary mental health conditions and
disputes, which better interactions may prevent or mitigate.
Longer-duration claims — sometimes referred to as “complex” —
are of particular interest to workers’ compensation
organisations, since they are estimated to account for 20%
of claims yet 90% of liabilities. 
In crude analyses, both good interactions and RTW
plans were significantly associated with better RTW outcomes
at baseline and follow-up interview. When considered
with findings of adjusted analyses, this suggests that
paths A and B in Fig. 1 capture both the interpersonal
and functional Coordinator activities. In other words, the
nature of interactions (path A) can reflect Coordinators’
delivery of functional activities, and that functional activities
such as drafting a RTW plan (path B) can reflect good
There are considerable implications for improving Coordinator
effectiveness. While previous research has suggested
various characteristics of effective Coordinators [6, 11, 14, 17], our results indicate that injured workers are
more responsive to different interventions depending on
their likely trajectory. For instance, workers likely to RTW
earlier in the process may do so more speedily if provided
with a RTW plan, while those likely to take more time may
benefit from good interactions with their Coordinator. As
numerous characteristics are associated with longer-duration
claims [39, 40], Coordinator effectiveness and efficiency
could be improved through targeted intervention
based on injured workers’ likely trajectory, though how this
would be done is beyond the scope of this paper. However,
as both Coordinator activities were captured at baseline,
the findings suggest that regardless of type they should be
implemented early in the claims process. Functional activities,
as indicated by RTW plans, appeared to have a more
immediate effect, while the interpersonal activity was comparatively
Most participants rated their Coordinator interactions
as minimally stressful, though one in six rated them quite
or extremely stressful. While the proportion should not be
considered generalisable, it hints at what could be a sizeable
number of injured workers who could achieve RTW
more quickly if they had better interactions with their
Coordinator. However, the interactions were rated by the
participant, making it difficult to determine why they were
deemed stressful. In addition to reflecting how Coordinators
treated participants, their ratings could have reflected
frustration at failure to achieve RTW, the nature of injury,
unmeasured aspects of the workplace or employer, or participant
Regardless, the only practical means of improving
injured workers’ interactions with their Coordinator is
through Coordinator selection and training. Some interpersonal
traits of successful Coordinators may be inherent and
immutable  and selecting Coordinators for such attributes,
rather than solely on seniority and competence as per
current guidelines in Victoria , could improve their
effectiveness. Revising training, which Coordinators across
Australia often feel is irrelevant, with too much focus on
legislative requirements and not enough on more practical
skills such as counselling , may also improve Coordinator
We expected workplace size to confound the association
between Coordinator activities and RTW outcomes. There
were several reasons for this: Coordinator experience varies
based on workplace size: larger organisations (remuneration
of $2 million or more in 2013 AUD) must have a Coordinator
appointed at all times, while smaller organisations
must only appoint them for the duration of the employer’s
RTW obligations.  This suggests differences in experience.
Further, Coordinators from larger organisations
in Victoria are more likely to participate in training. 
However, workplace size did not meet the 10% threshold
for impact on associations between main exposures and
RTW outcomes at either time point.
One surprising finding was that 40% of participants
reported having no contact or interaction with their Coordinator,
the majority of whom said they had no designated
Coordinator, and half did not have a RTW plan. Employer
appointed Coordinators and RTW plans are both are
required by WSV.  There are several possible reasons
for the gaps between Coordinator and RTW plan obligations
and provision: employers or Coordinators not meeting
their RTW obligations, participants failing to recall their
Coordinator interactions or RTW plans, or participants not
recognising a co-worker as their Coordinator. Regardless of
the reason, improving employer and Coordinator adherence
to RTW obligations could have considerable benefits. Evidence
on the effectiveness of regulatory workplace inspections  suggests that this strategy could be one approach
to achieve this.
Strengths and Limitations
A major strength of this study is the use of cross-sectional
and longitudinal outcomes, which allowed us to identify
shorter- and longer-term impacts of two Coordinator activities
on RTW outcomes. Further, while cross-sectional findings
were vulnerable to issues of reverse causality (e.g.,
frustration at failure to achieve sustained RTW causing the
participant to view Coordinator interactions negatively),
prospective analyses strengthened causal interpretations.
Use of sustained RTW outcomes, which required that the
injured worker be back at work for at least 1 month by
time of interview, mitigated methodological and conceptual
issues associated with failed RTW attempts and arbitrary
measurement points that plague single point-in-time
measures of RTW. Use of two outcome points revealed differences
in how and when Coordinators were effective at
increasing likelihood of RTW. Had analyses been limited to
a single time point, we would have failed to identify at least
one of the ways Coordinators can improve RTW outcomes
and misattributed effectiveness to a single activity.
Those lost to follow-up were significantly younger
than those who were retained in the sample. However, the
majority of those lost could not be recontacted and there
were no other differences between these groups, suggesting
this was the result of greater mobility among younger
people. As such, it was unlikely to affect the association
between Coordinator interactions and RTW outcomes or to
be a serious source of bias.
Limitations included restriction of participants to claimants
with upper-body musculoskeletal and mental health
conditions, whose disability durations tend to be more
variable than other conditions like fracture or disease. 
Channelling bias, or the assignment to a treatment condition
based on prognostic factors  (e.g., injury severity
and/or employer’s perception of the likelihood of recovery)
and a low participation rate may limit the findings’ generalisability
and validity. Coordinators in this study were
workplace-based, and as such the findings may not apply to
Coordinators based at hospitals, insurers, or other locations.
The relatively small sample size (n = 632) limited statistical
power and may have prevented analyses from identifying
other associations, such as the impact of poor Coordinator
interactions. Measures of Coordinator intervention
were limited to stressfulness of interactions and RTW
plans, though there are likely other Coordinator activities
that may improve RTW outcomes, such as coordination of
RTW across stakeholders and adherences to rules and regulations
. The findings do not provide specific details on
what makes an interaction good, nor how Coordinators may
The findings suggest that workplace-based RTW Coordinators
are an effective intervention for improving RTW
outcomes among injured workers. Their functional activities
appeared beneficial for shorter-duration claims, while
interpersonal activities appeared beneficial for longer-duration
claims. Therefore different Coordinator activities may
be more effective depending on injured worker trajectory.
However, a large proportion of participants had not been
contacted by a Coordinator nor had RTW plans, despite
requirements for both.
In many countries, Coordinators help injured workers
transition back to the job. Our findings could be used to
improve their effectiveness through changes to Coordinator
policy and practice, selection and training, and targeted
intervention. Future research could further unpack the role
to maximise Coordinator impact on RTW outcomes.
This research was funded by the Australian
Research Council via a Linkage Grant (LP130100091).
TJL conceived the study, conducted analyses,
and drafted the manuscript. PMS, SH-J, RL, ADL, and MRS
were responsible for the overall cohort design and data collection.
TJL, PMS, SH-G, and MRS
Conflicts of Interest
TJL receives salary support from a WorkSafe Victoria
grant. WorkSafe Victoria regulates workers’ compensation policies
affecting the participants in this study. PMS, RL, SH-J, ADL, and
MRS declare they have no conflict of interest.
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