Initial Return to Work and Long-term Employment Patterns:
Associations with Work-related Permanent Impairment and
with Participation in Workers' Compensation-based
Return-to-work ProgramsThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Am J Ind Med 2021 (May); 64 (5): 323337 ~ FULL TEXT
OPEN ACCESS Jeanne M. Sears PhD, MS, RN | Deborah Fulton-Kehoe PhD, MPH | Sheilah Hogg-Johnson PhD, MMath
Department of Health Services,
University of Washington,
Seattle, Washington, USA.
Canadian Memorial Chiropractic College,
Toronto, Ontario, Canada.
FROM: Texas Workers' Compensation ReportBackground: Roughly 10% of injured workers experience work injuries that result in permanent impairment and a permanent partial disability (PPD) award. This study aimed to characterize and quantify long-term employment outcomes for injured workers, by the degree of whole body impairment (WBI) and by participation in several workers' compensation (WC)-based return-to-work (RTW) programs.
Methods: A retrospective cohort of 43,968 Washington State workers were followed for up to 10 years after WC claim closure (2009-2017). Degree of impairment was classified as:(1) no PPD award,
(2) PPD award with WBI < 10%, or
(3) PPD award with WBI ≥ 10%.State wage files were used to construct employment outcomes for regression, modeling:
(1) time to first RTW,
(2) time to first RTW interruption,
(3) RTW volatility, and
(4) employment gaps.Results: Wage patterns and employment outcomes differed significantly by the degree of impairment. Compared to other workers, workers with WBI ≥ 10% had delayed RTW, shorter average times to first RTW interruption, and higher rates of both RTW interruptions and quarters without wages. Time to first RTW averaged over a year, increasing with the degree of impairment. About 9% overall-and 27% of workers with ≥10% WBI-had no observed wages after claim closure. In adjusted models, workers with WBI ≥ 10% had significantly poorer employment outcomes, compared to workers with no PPD award (p < 0.001).
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WORKERS' COMPENSATION PageConclusions: State wage files provide an efficient approach to identifying RTW patterns. Workers with permanent impairment were at substantially higher risk of poor employment outcomes. WC-based RTW programs may promote better employment outcomes.
Keywords: Functional Comorbidity Index; disability evaluation; occupational injuries; permanent impairment; permanent partial disability; return to work; unemployment; vocational rehabilitation; workers' compensation.
From the FULL TEXT Article:
INTRODUCTION
In Washington State and across the United States, roughly 10% of all workers injured at work experience serious work injuries that result in permanent impairment and a permanent partial disability (PPD) award. [1] Workers' compensation (WC)-based PPD awards provide compensation for Work-related permanent impairments that do not preclude return to work (RTW) but do prevent working at full physical capacity (e.g., vision or hearing loss, amputation, spinal impairment). Work-related permanent impairment is associated with longterm functional disability, pain, and unstable health, all of which may interfere with timely and sustained RTW. [28] Compared to other workers, disabled workers have 50% higher unemployment rates, and they are more likely to work part-time and in entry-level jobs. [9, 10] Disabled workers may also face negative treatment by managers and co-workers, lack of accommodation, and discrimination. [1113] Moreover, workers with permanent impairments are at higher risk for reinjury [14] and mortality. [15]
Initial RTW does not necessarily indicate successful RTW. After RTW, many injured workers with permanent impairments face RTW interruption (i.e., breaks in employment due to reinjury, unstable health, disability, lay-off, etc.). [2] For example, in an early Ontario-based study of workers with permanent impairments, 85% of workers were observed to RTW at least briefly, while only 50% exhibited sustained RTW. [2] A more recent Australian study, which did not specifically assess permanent impairment, found that time to sustained RTW was 1.8 times longer than time to initial RTW (proxied by the cessation of time-loss payments); further, although 94% of injured workers had RTW at least briefly, only 79% achieved sustained RTW during the 2-year follow-up period. [16] Among Canadian workers who were 5064 years of age and had a permanent impairment, a higher (more severe) impairment rating was associated with earlier labor force exit. [17]
Employment is a critical social determinant of health, [18, 19] and sustained RTW after occupational injury or illness is important for the health and economic stability of workers, as well as for workplace productivity. Substantial economic disparities for permanently impaired workers have been documented using a variety of economic measures, including wage losses (based on unemployment insurance data), [2022] earnings losses more broadly (based on tax data), [23] and poverty. [24] Estimates of the magnitude of these disparities vary substantially by jurisdiction, which may be due in part to the impairment rating system used, and to jurisdictional variation in benefit adequacy. [20] Nevertheless, there is consistent evidence that workers with permanent impairments are economically disadvantaged relative to the general working population, [24] to matched uninjured workers, [22] and to injured workers without permanent impairment. [21, 23] The negative economic impact of permanent impairment may lessen over time, but it persists long-term. For example, a RAND study of California workers with permanent impairments documented that earnings for permanently impaired workers in the first quarter after injury were 60% of earnings for a matched control group of uninjured workers; at 5 years after injury, earnings remained only 72% of those for the control group. [22]
Injured workers with permanent impairments account for a large share of WC-based vocational rehabilitation program participants. [14] Accumulating evidence suggests that vocational rehabilitation and other RTW programs affect injured workers in both positive and negative ways. [5, 2529] Even after vocational retraining to facilitate RTW, workers disabled by an occupational injury face substantial employment challenges. [5] A Washington State study found that about 50% of workers who completed a vocational retraining plan RTW within 2 years, while fewer than 45% of workers with incomplete plans had RTW nearly 5 years later. [27] However, there is little existing research on the impact of WC-based programs on employment outcomes beyond initial RTW, such as sustained RTW and RTW interruption. To understand how vocational rehabilitation and other RTW programs can best assist workers, we need to better understand the impact of these programs on specific employment patterns.
In sum, injured workers often face delayed, temporary, or intermittent RTW, or may never RTW at all. The primary aim of this study was to characterize and quantify long-term employment outcomes, including RTW and subsequent RTW interruption, by the degree of permanent impairment. To broadly characterize various attributes of long-term employment patterns, we used several regression approaches designed to model a set of employment metrics that were based on the timing, order, volatility, and prevalence of presence/absence of quarterly wages after WC claim closure. Secondarily, we explored the potential impact of several WC-based RTW programs on employment outcomes.
DISCUSSION
In this study, we found that wage patterns and employment outcomes significantly differed by the degree of impairment. For the most part, there were monotonic associations between a higher degree of impairment and poorer employment outcomes; however, there was little difference between workers with no PPD and workers with WBI < 10% regarding timing or frequency of RTW interruption. Workers with WBI ≥ 10% took longer on average to RTW, and then had shorter average times to the first RTW interruption, compared to workers in the other two impairment categories. Workers with WBI ≥ 10% also had the highest frequency of RTW interruptions and the highest frequency of quarters with no wages. A higher risk of reinjury among workers with ≥10% WBI may contribute to their higher risk of RTW interruption. In a previous related study, workers with ≥10% WBI had an estimated 34% higher risk of reinjury, compared to workers with no PPD award, based on adjusted models that accounted for working time at risk. [14]
It is important to note that all workers in this cohort would have been classified as having RTW, had we used cessation of time-loss compensation or WC claim closure as a proxy. Yet 8.98% of the overall cohort, and 27.32% of workers with ≥10% WBI, had no observed wages after claim closure. Although most workers RTW within the same calendar quarter that their claim first closed, many workers experienced lengthy delays before the first RTW. The average time from first claim closure to first RTW was more than a year (restricted mean: 4.18 quarters), monotonically increasing with increasing degree of impairment.
Several recent studies have demonstrated the importance of characterizing employment trajectories beyond simply measuring initial RTW, whether that be via measuring time to sustained RTW, [16] or via using sequence and/or cluster analysis to identify specific employment patterns. [43, 44] In this cohort, some workers exhibited intermittent RTW patterns over an extended period; for other workers, intermittent RTW patterns eventually stabilized into a longer stretch of either employment or unemployment (Table 3). By modeling four different employment outcomes in this study (i.e., time to first RTW, time to first RTW interruption, RTW volatility, employment gaps), we were able to broadly characterize various attributes of long-term employment patterns. In adjusted models (Table 4), workers with WBI ≥ 10% had substantially and significantly poorer employment outcomes, compared to workers with no PPD award, for all four modeling approaches. However, findings were mixed for workers with WBI < 10%. Compared to workers with no PPD award, workers with WBI < 10% had significantly poorer outcomes with respect to time to first RTW and employment gaps, but not with respect to first RTW interruption and RTW volatility. There may be quite different mechanisms of effect for initial RTW versus RTW interruption; RTW may depend on the availability of the preinjury (perhaps modified) job or the ability to be hired into a new job, while RTW interruption may depend more upon workplace conditions that support or interfere with sustained RTW, reinjury incidence, etc. RTW volatility (rate of transitions from periods of employment to periods of unemployment) is related to the intermittent nature of RTW, whether due to employment type (seasonal, temporary), workplace characteristics, or worker/injury characteristics. Strikingly, as many as 15 RTW interruptions for an individual worker were observed over 10 years of follow-up. This observation is even more striking when we consider that these data represented quarterly intervals, and thus RTW interruptions lasting less than a calendar quarter would not have been observed.
We found that participation in the Stay at Work program was associated with significantly and substantially better employment outcomes, compared to outcomes for those who did not participate. Employment outcomes for injured workers participating in WC vocational rehabilitation programs were of particular interest because nearly 90% of these workers had a Work-related permanent impairment. Further, the choice of Option 2 was more prevalent among workers with permanent impairment; 56.7% of the WBI ≥ 10% group chose Option 2, compared to only 36.6% of those with no PPD award. Among workers who chose the conventional retraining plan, workers with permanent impairment were less likely to complete their plan; 38.2% of the WBI ≥ 10% group completed their plan, compared to more than half (51.7%) of those with no PPD award. Consistent with findings from an earlier evaluation, [27] completion of a conventional vocational retraining plan was associated with significantly and substantially better employment outcomes, compared to outcomes for those who did not complete their plan. In contrast, we found that choosing self-directed retraining funds (Option 2) was significantly and substantially associated with poorer employment outcomes, compared to choosing a conventional retraining plan (whether completed or not). In an earlier related study, [14] we found a higher risk of reinjury among injured workers who: (1) did not complete their approved vocational retraining plan, compared to those who did; and (2) chose Option 2, compared to those who chose a conventional retraining plan (the Stay at Work program was not assessed).
These program-related findings are descriptive and exploratory, and, at least in part, they likely reflect selection effects into each of these programs (whether by WC staff, employers, or workers themselves). However, these findings merit further inquiry into the underlying mechanisms, especially as these programs operate at the WC system level and thus could have important impacts on the health and safety of large numbers of workers. Every year, roughly 300,000 U.S. workers experience serious work injuries that result in permanent impairment and a PPD award. [1] However, there has been little systematic research regarding the impact of WC-based programs on long-term employment outcomes for workers with permanent impairments. In a California study, researchers found that RTW programs led to significant reductions in the duration of workinjury absences, and that most of that impact was driven by a large improvement in RTW for injured workers with permanent impairments. [28] Previous research documenting WC benefit inadequacy demonstrates the importance of promoting good employment outcomes to minimize workers' economic losses. In a Wisconsin study of injured workers (19891990), WC benefits for workers with PPD awards were estimated to cover 83% of 10-year after-tax projected losses for men, and 63% for women. [21] In a more recent New Mexico study linking WC claims (19942000) to federal tax data, WC benefits for workers with PPD awards were estimated to cover 35% of 10-year after-tax losses for men, and 28% for women. [23]
While our regression models were not specifically designed to assess other covariates, most had strong associations with employment outcomes, and the observed associations may provide exploratory fodder for further research. A higher score on the Functional Comorbidity Index was significantly associated with poorer employment outcomes for three of the four modeling approaches, but was not associated with time to first RTW. This suggests that, for workers with comorbidities, sustained RTW is more challenging than initial RTW. Other research has found that injured workers with multiple chronic comorbidities had significantly higher odds of not working post-injury and poorer hours and earnings recovery (using state wage data) compared to those with no chronic comorbidities. [45] Using data from the Health and Retirement Study, researchers found that workers with multimorbidity had a higher risk of transitioning to partial retirement and to full retirement, when compared to workers without chronic conditions or to those who had just one comorbidity. [46] Our findings that women, compared to men, had delayed RTW followed by quicker RTW interruption, along with more quarters with no wages, generally comport with other studies showing women at higher risk for RTW interruption [16] and economic losses [21, 23] after work injury. Our findings that older workers generally exhibited poorer employment outcomes compared to younger workers, particularly in the upper age categories, comport with other studies showing older age as a risk factor for both RTW interruption16 and early retirement after work injury. [17, 47] Higher pre-injury wages were associated with better employment outcomes. Other studies have documented that workers with low income before a work injury are particularly likely to exit the labor force early, [17] are more vulnerable to poverty, [24] and face a substantially greater risk of being unable to escape poverty after Work-related permanent impairment. [24]
Strengths and limitations
Strengths of this study included the large cohort, and identification of the first-known WC claim filed in Washington State. Assembling the cohort based on the first-known WC claim allowed for definitive identification of the PPD rating with the initial injury; for subsequent claims, the PPD rating can reflect the adjustment of a rating from a prior injury that caused permanent impairment a circumstance that would not be clearly distinguishable using the available WC claims data. Washington State is one of only four states with no private WC insurers, which facilitates population-based research. [32, 33] In addition, access to state wage files enabled us to avoid conflating the end of time-loss compensation with actual RTW, thereby avoiding an inherent limitation of studies that rely solely on WC claims data and do not measure employment directly. [16, 4850] Though common practice, using the end of time-loss compensation as a proxy for RTW leads to the underestimation of time lost from work. [51] State wage files are an efficient but underutilized approach for identifying RTW patterns. [52]
This study also had several limitations. First, with respect to the initial claim closure quarter (Q0), we were unable to determine from wage files whether the worker was already working when the WC claim closed, or whether RTW occurred after claim closure but within the same quarter (up to 3months later). Second, our addition of a small constant term to the time variable would have no impact on estimates based on the regression models, but would have a minor impact on estimates of mean and median times to first RTW. Third, state wage files do not capture earnings for workers who are self-employed or work in exempt occupations. [34] A study based on the Current Population Survey found that self-employment rates were higher among workers with limitations, compared to workers without limitations, and the self-employment differential also increased with education and age.53 Such differential inclusion in wage files may have affected our estimates for permanent impairment and age subgroups, to an unknown degree. Finally, all covariates were also based on administrative data, and thus have measurement limitations. The Functional Comorbidity Index was almost certainly underestimated, because diagnoses unrelated to theWC injury may not be reported toWC for billing purposes. [38] The WBI variable was essentially a lower bound estimate, [8] and the strength of association between impairment ratings and economic losses varies by jurisdiction and rating system. [20, 5457] Although there is evidence that impairment ratings are associated with earnings losses,56 there is also strong evidence that impairment ratings are inaccurate representations of work disability and at best explain a small amount of related earnings losses.54,55,57 This may in part explain the relatively small and inconsistent directions of effect (along with inconsistent statistical significance) that we found across the four employment outcomes, when comparing workers with <10% WBI to workers with no PPD award.
CONCLUSIONS
Injured workers may face delayed RTW, may RTW temporarily or intermittently, or may never RTW at all. Though underutilized, state wage files provide an efficient approach to identifying RTW patterns, and can be used as an alternative to proxies that overestimate successful RTW, such as the end of time-loss compensation or WC claim closure. We found that workers with permanent impairment were at substantially higher risk of poorer employment outcomes compared to other workers, and that WC-based vocational rehabilitation and RTW programs may be useful to promote better employment outcomes.
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