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Journal ArticleDOI

Patterns and Predictors of Return to Work After Major Trauma: A Prospective, Population-based Registry Study.

TL;DR: A range of personal, occupational, injury, health, and compensation system factors influence RTW patterns after serious injury, and early identification of people at risk for delayed, failed, or no RTW is needed so that targeted interventions can be delivered.
Abstract: Objective:To characterize patterns of engagement in work during the 4-year period after major traumatic injury, and to identify factors associated with those patterns.Background:Employment is an important marker of functional recovery from injury. There are few population-based studies of long-term

Summary (2 min read)

INTRODUCTION

  • Employment is an important determinant of health status [1] and engagement in employment or return to work (RTW) is associated with recovery and improved health status after injury [2].
  • In developed countries, markers of functional recovery from injury, such as participation in employment, represent a key rehabilitation goal [3, 4].
  • Follow-up is usually limited to the first year or two post injury [11].
  • Individuals may experience disrupted, delayed or failed return to work before ultimately achieving a successful employment outcome [11, 14].

Setting and Participants

  • The state of Victoria has a population of approximately 5.8 million residents, representing one quarter of the Australian population.
  • The Registry captures data about all hospitalised major trauma cases.
  • The REcovery after Serious Trauma--Outcomes, Resource use and patient Experiences study extended follow-up to 36-, 48- and 60-months post-injury for all individuals with a date of injury from July 2011 to June 2012 [16].
  • The Registry and RESTORE project have been approved by the Human Research Ethics Committee of each participating hospital and Monash University.
  • While Australia’s publicly funded health care system provides health care coverage for all Australian citizens and permanent residents, 57% of the adult population purchase private health insurance [17].

Procedures

  • The protocol for the RESTORE study is described elsewhere but summarised here [16].
  • Predictors Demographic factors, injury event, injury type and severity, pre-existing conditions and other relevant variables were extracted from the Registry and RESTORE for analysis.
  • The Charlson Comorbidity Index (CCI) was mapped from the ICD-10-AM codes for each individual using published algorithms [18, 19].
  • Return to work (in paid employment: yes or no) was recorded at each time point when the individual reported working for income prior to injury.
  • Delayed RTW – Individual not at work initially but then reported returning to work for at least two consecutive interviews.

Data Analysis

  • Frequencies and percentages were used to describe the population given that outcomes were categorical.
  • Lasagna plots were used to visualise the trajectories of individuals, and the whole cohort, between working and non-working states over time [21].
  • As the categories in the outcome variable were discrete, nominal and unordered, the association between predictors and outcomes were assessed using multinomial logistic regression models.
  • The early and sustained RTW pattern was defined as the reference category.
  • Initially, univariate models were run for each predictor with those demonstrating statistical significance retained in the final model.

Patterns of Return to Work

  • Figure 1 summarises the movement of individuals between working states over the follow-up period.
  • These are indicated by green and red bands at the top and bottom of the columns in the lasagne plot.
  • Seventy-one percent without a CCI condition recorded a sustained RTW (early or delayed) compared with 58% with any CCI condition.
  • In contrast, individuals whose occupation was labourer, intermediate production/transport or elementary clerical worker recorded higher prevalence of no RTW.
  • The adjusted predicted probability of transitioning from working at 6 months to not working at any subsequent time point was 47%.

Predictors of Return to Work Patterns

  • Table 2 presents the findings from multivariate multinomial logistic regression models.
  • Two associations were observed for injury group, in which the comparator group was individuals with isolated head injury.
  • For occupation, both labourers and those in occupations classified as intermediate production/transport/elementary clerical had higher risk of no RTW.
  • Gender, whether the individual was managed at a major trauma service and pre-injury disability were not important predictors of No RTW (Table 2).
  • Individuals with any pre-injury disability compared to those without pre-injury disability were 2.6 times more likely to have a failed attempt to RTW than have an early sustained RTW.

DISCUSSION

  • Engagement in employment is an important marker of functional recovery following injury, associated with better health and well-being. [2].
  • These findings are consistent with patterns of functional recovery reported from this cohort, where individuals with SCI demonstrated significantly poorer outcomes, while those with isolated chest or abdominal injuries experienced better functional recovery and quality of life [13].
  • However there is currently limited evidence regarding the effectiveness of clinical and workplace-based employment interventions in older workers [33].
  • This finding suggests that a focus on occupational rehabilitation in the early post injury phase may be important for both short-term and longer-term employment outcomes, although the authors note the absence of quality trial evidence in this area [36].
  • Together, these findings demonstrate that a range of personal, occupational, injury, health and compensation system factors influence RTW patterns after serious injury.

Figure Legends

  • Figure 1. Lasagna plot and marginal distribution table of return to work status by time since injury in the RESTORE study.
  • Green sections indicate individuals who have returned to work at each followup assessment.
  • Red sections indicate individuals who were not working at that follow-up assessment.
  • Figures in the table above the graph are marginal probabilities of return to work and no return to work states based on regression models.

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Cronfa - Swansea University Open Access Repository
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This is an author produced version of a paper published in:
Annals of Surgery
Cronfa URL for this paper:
http://cronfa.swan.ac.uk/Record/cronfa50346
_____________________________________________________________
Paper:
Collie, A., Simpson, P., Cameron, P., Ameratunga, S., Ponsford, J., Lyons, R., Braaf, S., Nunn, A., Harrison, J. et. al.
(2019). Patterns and Predictors of Return to Work After Major Trauma. Annals of Surgery, 269(5), 972-978.
http://dx.doi.org/10.1097/SLA.0000000000002666
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1
PATTERNS AND PREDICTORS OF RETURN TO WORK AFTER MAJOR TRAUMA: A
PROSPECTIVE, POPULATION BASED REGISTRY STUDY.
AUTHORS
Alex Collie PhD
1,2
, Pamela M Simpson GradDipBiostats
2
, Peter A Cameron MD
2,3
, Shanthi
Ameratunga PhD
4
, Jennie Ponsford PhD
5,6
, Ronan A Lyons PhD
2,7
, Sandra Braaf PhD
2
, Andrew Nunn
MBBS
8
, James E Harrison MBBS
9
, & Belinda J Gabbe PhD
2,7
.
1
Insurance Work and Health Group, Faculty of Medicine Nursing and Health Sciences, Monash
University, Melbourne, Victoria, Australia
2
School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
3
Emergency and Trauma Centre, The Alfred, Melbourne, Victoria, Australia
4
Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland,
Auckland, New Zealand
5
Monash-Epworth Rehabilitation Research Centre, Melbourne, Victoria, Australia
6
School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
7
Farr Institute, Swansea University Medical School, Swansea University, Swansea, United Kingdom
8
Victorian Spinal Cord Service, Austin Health, Heidelberg, Victoria, Australia
9
Research Centre for Injury Studies, Flinders University, Adelaide, South Australia, Australia
Corresponding author
Prof Alex Collie
Director, Insurance Work and Health Research Group

Faculty of Medicine Nursing and Health Sciences
Monash University
Level 4, 553 St Kilda Road
Melbourne, Victoria 3004
Australia
Phone: +61 3 9903 0525
Email: alex.collie@monash.edu
Sources of Support
This project was funded by the Australian Government’s National Health and Medical Research
Council (GNT1061786). The Victorian State Trauma Registry (VSTR) is funded by the Department
of Health, State Government of Victoria and the Transport Accident Commission. Belinda Gabbe was
supported by a Future Fellowship (FT170100048) from the Australian Research Council.
Running Head
Return to work after major trauma

1
ABSTRACT
Objective
To characterise patterns of engagement in work over the four-year period following major traumatic
injury, and to identify factors associated with those patterns.
Summary Background Data
Employment is an important marker of functional recovery from injury. There are few population-based
studies of long-term employment outcomes, and limited data on the patterns of return to work post
injury.
Methods
A population-based, prospective cohort study using the Victorian State Trauma Registry. A total of
1086 working age individuals, in paid employment or full-time education before injury, were followed-
up through telephone interview at 6, 12, 24, 36, and 48-months post-injury. Responses to return to work
(RTW) questions were used to define four discrete patterns: early and sustained; delayed; failed; no
RTW. Predictors of RTW patterns were assessed using multivariate multinomial logistic regression.
Results
Slightly more than half of respondents (51.6%) recorded early sustained RTW. A further 15.5% had
delayed and 13.3% failed RTW. One in five (19.7%) did not RTW. Compared with early sustained
RTW, predictors of delayed and no RTW included being in a manual occupation and injury in a motor
vehicle accident. Older age and receiving compensation predicted both failed and no RTW patterns.
Pre-injury disability was an additional predictor of failed RTW. Presence of co-morbidity was an
additional predictor of no RTW.
Conclusions
A range of personal, occupational, injury, health and compensation system factors influence RTW
patterns after serious injury. Early identification of people at risk for delayed, failed or no RTW is
needed so that targeted interventions can be delivered.

INTRODUCTION
Employment is an important determinant of health status [1] and engagement in employment or return
to work (RTW) is associated with recovery and improved health status after injury [2]. In developed
countries, markers of functional recovery from injury, such as participation in employment, represent a
key rehabilitation goal [3, 4]. This follows improvements in prevention and acute care that have
contributed to significant increases in survival [5, 6]. Identifying the early prognostic factors associated
with RTW can help avoid the personal, financial and social impact of non-RTW, and may help alleviate
the burden of injury through more effective occupational rehabilitation.
Studies of RTW following traumatic injury have been limited to specific mechanisms such as
occupational or transport injury [7, 8]. Return to work studies also typically assess employment status
at a single time point post injury [9] or in single centres [10]. Follow-up is usually limited to the first
year or two post injury [11]. In one of the few population-based studies of RTW following major trauma,
Gabbe and colleagues [12] reported improvements in RTW status up to 24 months post injury. Recovery
trajectories differed by individual characteristics including gender, age, pre-existing conditions,
socioeconomic status, injury type and occupation. There is now evidence that recovery continues
beyond these time points following major trauma [13] , though we have little evidence of longer-term
RTW outcomes.
Effective service planning and design of occupational rehabilitation interventions requires an
understanding of the patterns of employment post-injury. Individuals may experience disrupted,
delayed or failed return to work before ultimately achieving a successful employment outcome [11, 14].
Others may fail to RTW at all, or may experience an initial successful return followed by a longer-term
exit from the workforce. The aim of this population based, longitudinal study was to characterise
patterns of work engagement in the 4-year period following major trauma, and to identify factors
associated with those patterns.

Citations
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TL;DR: Collection of postdischarge outcomes identified patient factors, such as female sex and low education, associated with worse recovery, which suggests that social support systems are potentially at the core of recovery rather than traditional measures of injury severity.
Abstract: Objective The aim of this study was to determine factors associated with patient-reported outcomes, 6 to 12 months after moderate to severe injury. Summary of background data Due to limitations of trauma registries, we have an incomplete understanding of factors that impact long-term patient-reported outcomes after injury. As 96% of patients survive their injuries, several entities including the National Academies of Science, Engineering and Medicine have called for a mechanism to routinely follow trauma patients and determine factors associated with survival, patient-reported outcomes, and reintegration into society after trauma. Methods Over 30 months, major trauma patients [Injury Severity Score (ISS) ≥9] admitted to 3 Level-I trauma centers in Boston were assessed via telephone between 6 and 12 months after injury. Outcome measures evaluated long-term functional, physical, and mental-health outcomes. Multiple regression models were utilized to identify patient and injury factors associated with outcomes. Results We successfully followed 1736 patients (65% of patients contacted). More than half (62%) reported current physical limitations, 37% needed help for at least 1 activity of daily living, 20% screened positive for posttraumatic stress disorder (PTSD), all SF-12 physical health subdomain scores were significantly below US norms, and 41% of patients who were working previously were unable to return to work. Age, sex, and education were associated with long-term outcomes, while almost none of the traditional measures of injury severity were. Conclusion The long-term sequelae of trauma are more significant than previously expected. Collection of postdischarge outcomes identified patient factors, such as female sex and low education, associated with worse recovery. This suggests that social support systems are potentially at the core of recovery rather than traditional measures of injury severity.

78 citations

Journal ArticleDOI
TL;DR: The challenges of inviting workers back to the workplace mirror some of the issues that are commonplace in the return-to-work and occupational rehabilitation literature—the idiosyncratic nature of health and work, individual disease vulnerability, susceptibility to environmental hazards, the need for job flexibility and modification, and differences in workstyle, social capital, and organizational support.
Abstract: The on-going COVID-19 crisis has had an unprecedented effect on workplaces across the globe. The extent of viral infection, illness, and fatalities has transformed or closed many workplaces and resulted in large numbers of temporarily furloughed or unemployed workers. Those most susceptible to the virus and its effects are the elderly or medically vulnerable, but physical distancing, stay-at-home orders, and isolation have produced drastic social, economic and health consequences for workers of all ages, with a disproportionate impact on those more disadvantaged. Some businesses and workplaces are beginning to reopen, albeit under extraordinary rules pertaining to physical distancing, personal protective equipment, and physical guards. The efficacy of such measures in the workplace are unknown, and we have much to learn about how workers adapt and function under these circumstances. Some of the challenges of inviting workers back to the workplace mirror some of the issues that we recognize as commonplace in the return-to-work and occupational rehabilitation literature—the idiosyncratic nature of health and work, individual disease vulnerability, susceptibility to environmental hazards, the need for job flexibility and modification, and differences in workstyle, social capital, and organizational support. A recurring theme in the work disability literature is the heterogeneity of return-to-work outcomes for workers with a wide range of injuries, illnesses, and medical procedures (e.g., cardiac arrest, major trauma) [1, 2]. Within medical conditions, this variation has been attributed to demographic and health variables (age, fitness, health status, anthropometry), to workplace factors (e.g., supervisor support, ability to accommodate, physical demands), to psychological factors (e.g., perceived impairment, job stress, coping, fears of re-injury or worsening health conditions, catastrophizing), and to social factors (e.g., family caregiving roles, social support, economic factors) [3–7]. The COVID-19 workplace opening process may also need to address this complexity of factors.

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TL;DR: Major trauma, lower GCS and increased hospital length of stay predicted inability to return to work due to health at six‐months post‐ICU admission, and compared to employed patients, those who had not returned to work reported poorer functional recovery.

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TL;DR: This is the largest study to collectively examine factors associated with RTW among survivors of OHCA and highlights which patients are at risk of not RTW and who may benefit from targeted rehabilitation strategies.

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References
More filters
Journal ArticleDOI
TL;DR: It is shown that the risk of death is significantly lower when care is provided in a trauma center than in a non-trauma center and argue for continued efforts at regionalization.
Abstract: BACKGROUND Hospitals have difficulty justifying the expense of maintaining trauma centers without strong evidence of their effectiveness. To address this gap, we examined differences in mortality between level 1 trauma centers and hospitals without a trauma center (non-trauma centers). METHODS Mortality outcomes were compared among patients treated in 18 hospitals with a level 1 trauma center and 51 hospitals non-trauma centers located in 14 states. Patients 18 to 84 years old with a moderate-to-severe injury were eligible. Complete data were obtained for 1104 patients who died in the hospital and 4087 patients who were discharged alive. We used propensity-score weighting to adjust for observable differences between patients treated at trauma centers and those treated at non-trauma centers. RESULTS After adjustment for differences in the case mix, the in-hospital mortality rate was significantly lower at trauma centers than at non-trauma centers (7.6 percent vs. 9.5 percent; relative risk, 0.80; 95 percent confidence interval, 0.66 to 0.98), as was the one-year mortality rate (10.4 percent vs. 13.8 percent; relative risk, 0.75; 95 percent confidence interval, 0.60 to 0.95). The effects of treatment at a trauma center varied according to the severity of injury, with evidence to suggest that differences in mortality rates were primarily confined to patients with more severe injuries. CONCLUSIONS Our findings show that the risk of death is significantly lower when care is provided in a trauma center than in a non-trauma center and argue for continued efforts at regionalization.

2,222 citations

Journal ArticleDOI
TL;DR: This review confirmed low employment rates after SCI and future research should explore interventions aimed at helping people with SCI to obtain and sustain productive work.
Abstract: Purpose. To review literature on return to work (RTW) and employment in persons with spinal cord injury (SCI), and present employment rates, factors influencing employment, and interventions aimed at helping people with SCI to obtain and sustain productive work.Methods. A systematic review for 2000 – 2006 was carried out in PubMed/Medline, AMED, (ISI) Web of Science, EMBASE, CINAHL, PsycInfo and Sociological abstracts database. The keywords ‘spinal cord injuries’, ‘spinal cord disorder’, ‘spinal cord lesion’ or ‘spinal cord disease’ were cross-indexed with ‘employment’, ‘return to work’, ‘occupation’ or ‘vocational’.Results. Out of approximately 270 hits, 110 references were used, plus 13 more found elsewhere. Among individuals with SCI working at the time of injury 21 – 67% returned to work after injury. RTW was higher in persons injured at a younger age, had less severe injuries and higher functional independence. Employment rate improved with time after SCI. Persons with SCI employed ranged from 11.5% ...

253 citations

Journal ArticleDOI
TL;DR: The issues faced by VSTORM in developing, implementing and maintaining a statewide trauma registry are described.
Abstract: Trauma registries, like disease registries, provide an important analysis tool to assess the management of patient care Trauma registries are well established and relatively common in the USA and have been used to change legislation, promote trauma prevention and to evaluate trauma system effectiveness In Australia, the first truly statewide trauma registry was established in Victoria in 2001 with an estimated capture of 1700 major trauma cases annually The Victorian State Trauma Registry, managed by the Victorian State Trauma Outcomes Registry and Monitoring (VSTORM) group, was established in response to a ministerial review of trauma and emergency services undertaken in 1997 to advise the Victorian Government on a best practice model of trauma service provision that was responsive to the particular needs of critically ill trauma patients This taskforce recommended the establishment of a new system of care for major trauma patients in Victoria and a statewide trauma registry to monitor this new system The development of the Victorian state trauma registry has shown that there are certain issues that must be resolved for successful implementation of any system-wide registry This paper describes the issues faced by VSTORM in developing, implementing and maintaining a statewide trauma registry

169 citations

Journal ArticleDOI
TL;DR: Beneficial health effects of returning to work have been documented in a variety of populations, times, and settings, suggesting that return-to-work programs may improve not only financial situations but also health.
Abstract: Objectives. We systematically reviewed the literature on the impact of returning to work on health among working-aged adults.Methods. We searched 6 electronic databases in 2005. We selected longitudinal studies that documented a transition from unemployment to employment and included a comparison group. Two reviewers independently appraised the retrieved literature for potential relevance and methodological quality.Results. Eighteen studies met our inclusion criteria, including 1 randomized controlled trial. Fifteen studies revealed a beneficial effect of returning to work on health, either demonstrating a significant improvement in health after reemployment or a significant decline in health attributed to continued unemployment. We also found evidence for health selection, suggesting that poor health interferes with people’s ability to go back to work. Some evidence suggested that earlier reemployment may be associated with better health.Conclusions. Beneficial health effects of returning to work have be...

153 citations

Journal ArticleDOI
TL;DR: There is strong evidence for level of education and blue collar work and moderate evidence for self-efficacy, injury severity and compensation as prognostic factors for the duration of work disability.
Abstract: Introduction: Acute orthopaedic trauma is a major contributor to the global burden of disease. This study aims to synthesise and summarise current knowledge concerning prognostic factors for return to work and duration of work disability following acute orthopaedic trauma. Methods: A systematic review of prognostic studies was performed. The Medline, Embase, PsychINFO, CINAHL and AMED electronic databases were searched for studies between 1985 and May 2009. Included studies were longitudinal, reported results with multivariate statistical analyses appropriate to prognostic studies, comprised persons employed at the time of the injury, included prognostic factors measured proximal to the injury and focused on upper and lower extremity injuries. Results: Searches yielded 980 studies of which 15 met the inclusion criteria and were rated for methodological quality. Analysis focused on the 14 factors considered in more than one study. There was limited evidence for the role of any factor as a predictor of return to work. There is strong evidence for level of education and blue collar work and moderate evidence for self-efficacy, injury severity and compensation as prognostic factors for the duration of work disability. Significant methodological issues were encountered in the course of the review that limited interpretation of the evidence and the conclusions that could be drawn from the findings. Conclusion: People who have sustained acute orthopaedic trauma regardless of severity experience difficulties in returning to work. Due to the lack of factors considered in more than one cohort, the results of this review are inconclusive. The review highlights the need for more prospective studies that are methodologically rigorous, have larger sample sizes and considers a comprehensive range of factors.

137 citations

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To characterise patterns of engagement in work over the four-year period following major traumatic injury, and to identify factors associated with those patterns. 

Over half of individuals had returned to work by six months post injury and remained in employment throughout the follow-up period., whilst a further 16 % returned to work after more than six months absence, but then remained at work for at least 12 months, demonstrating a sustained reengagement in the labour force. Nearly 1 in 5 seriously injured individuals did not RTW at any time during the follow-up period, while a further 13 % recorded an unsuccessful attempt to RTW. Evidence from work injury cohorts suggests that a range of compensation processes and policies may contribute to this effect [ 26 ], and that navigating complex compensation system processes can contribute to both poorer functional recovery and poorer RTW [ 27, 28 ]. Consistent with prior studies, these findings suggest that reductions in physical capacity following severe injury has a larger impact in those whose occupation is physically demanding [ 34 ], or with lower job control [ 35 ].