Reducing disability andimproving return to work – where

do we go next?

Reducing disability andimproving return to work – where

do we go next?

Glenn Pransky MD MOccH

Director, Center for Disability Research

Liberty Mutual Research Institute for Safety

Assoc. Professor, Univ of Mass. Med. School

Glenn Pransky MD MOccH

Director, Center for Disability Research

Liberty Mutual Research Institute for Safety

Assoc. Professor, Univ of Mass. Med. School

Today…Today…

n Who are disabled and not working ?n What has been done about it ?n What are the results ?n What could we do better ?n Where could we go in the future ?

n Who are disabled and not working ?n What has been done about it ?n What are the results ?n What could we do better ?n Where could we go in the future ?

Focus - People who have worked inthe past and are now out of work

WC - Low back pain - applicable toother disabling problems

Focus - People who have worked inthe past and are now out of work

WC - Low back pain - applicable toother disabling problems

Why focus on MSD’s??Why focus on MSD’s??

n Annual total cost of MSD’s inCanada = $17.8B

n Second only to cardiovascular disease

n Of 95,000 WSIB claims, 72% MSD

n Annual total cost of MSD’s inCanada = $17.8B

n Second only to cardiovascular disease

n Of 95,000 WSIB claims, 72% MSD

Back pain: Persistent but not disabling(Vingard E, Spine, 2002, 2159)

Back pain: Persistent but not disabling(Vingard E, Spine, 2002, 2159)

n 17,000 Swedes age 18-60, followed toidentify those with onset of LBP severeenough to require treatment (5%)

n Course : 3 month improvement, thenplateau through 24 months (pain / funct)

n 70% never lost a day from work

n 17,000 Swedes age 18-60, followed toidentify those with onset of LBP severeenough to require treatment (5%)

n Course : 3 month improvement, thenplateau through 24 months (pain / funct)

n 70% never lost a day from work

Disability Prevalence, Selected Countries(1991)Disability Prevalence, Selected Countries(1991)

3.412United States

4.513Germany

4.410France

6.412Netherlands

2.812United Kingdom

<60 yo andreceiving disability

pension (%)

Self-ReportedDisability (%)

The origins of work disability(Waddell and Aylward, Royal Soc. Of Med., 2002)

The origins of work disability(Waddell and Aylward, Royal Soc. Of Med., 2002)

n Major differentiators:– Available cash benefits

– Economic context

– Acceptable disabling conditions

– Culture around return to work

n Major differentiators:– Available cash benefits

– Economic context

– Acceptable disabling conditions

– Culture around return to work

Trends over the last 20 yearsTrends over the last 20 years

n Escalating rates of work disabilityn “The single greatest social security problem in

the developed world is the increasing numberof persons under age 55 transitioning to long-term disability due to health problems.” Waddell,2004

n WC: Fewer injuries - more disability

n Escalating rates of work disabilityn “The single greatest social security problem in

the developed world is the increasing numberof persons under age 55 transitioning to long-term disability due to health problems.” Waddell,2004

n WC: Fewer injuries - more disability

The primary response: more medicaltreatmentThe primary response: more medicaltreatment

nMedical = 57% of claims cost– 3-fold increase in cost per claim over

10 yearsn WC CPI (11%) > Med CPI (8%) in the US

nMedical = 57% of claims cost– 3-fold increase in cost per claim over

10 yearsn WC CPI (11%) > Med CPI (8%) in the US

Manipulation (Mior, Clin J Pain, 2001)Manipulation (Mior, Clin J Pain, 2001)

n Slight advantage over placebo – notover other effective Rx - only short-term/acute (<6 wks. Rx)

n Problems – belief system, dependence– direct conflict with self-management

n Slight advantage over placebo – notover other effective Rx - only short-term/acute (<6 wks. Rx)

n Problems – belief system, dependence– direct conflict with self-management

Opioids (Fanciullo, G., Spine, 2002)Opioids (Fanciullo, G., Spine, 2002)

n Recent ↑ in usage and dose– Treat chronic back pain just like cancer

– 35% acute LBP in one study

n Typical pain reduction only 30% inchronic treatment (Turk, Clin J Pain, 2002)

n Recent ↑ in usage and dose– Treat chronic back pain just like cancer

– 35% acute LBP in one study

n Typical pain reduction only 30% inchronic treatment (Turk, Clin J Pain, 2002)

High-dose oral narcotics in WC(> 80 mg/d MEq)High-dose oral narcotics in WC(> 80 mg/d MEq)

n >10% iatrogenic addiction

n >20% of all work-related deaths in WAstate in 1999 – 2004 (Franklin et al AJIM 2005)

n >10% iatrogenic addiction

n >20% of all work-related deaths in WAstate in 1999 – 2004 (Franklin et al AJIM 2005)

Despite evidence that …Despite evidence that …

n No recent medical innovation has had asignificant impact on work disability

n Most are unhelpful, or actually prolongtime away from work

n Even those that seemed promising forRTW in early studies failed togeneralize Sinclair et al, ECC study, Spine, 1997

n No recent medical innovation has had asignificant impact on work disability

n Most are unhelpful, or actually prolongtime away from work

n Even those that seemed promising forRTW in early studies failed togeneralize Sinclair et al, ECC study, Spine, 1997

What drives unhelpful medicalinterventions?What drives unhelpful medicalinterventions?

n Provider myopia– Any clinical benefit is ample justification

– Over-generalization of indications

– Belief systems that parallel patients’misconceptions

– ‘Allegiance’ to patient requests

n Provider myopia– Any clinical benefit is ample justification

– Over-generalization of indications

– Belief systems that parallel patients’misconceptions

– ‘Allegiance’ to patient requests

Dersh, Polatin, Leeman and Gatchel, Jour Occ Rehab, Dec 2004Dersh, Polatin, Leeman and Gatchel, Jour Occ Rehab, Dec 2004

Other factors driving unhelpfulmedical interventionsOther factors driving unhelpfulmedical interventions

n Irrational economic models

n Absence of limiting market forces(shared consumer burden, prior proofof concept, pay for performance…)

n Failure – based rewards (sicknessdemonstration = more benefits)

n Adulterated consumerism– DTC advertising, lay misinformation

n Irrational economic models

n Absence of limiting market forces(shared consumer burden, prior proofof concept, pay for performance…)

n Failure – based rewards (sicknessdemonstration = more benefits)

n Adulterated consumerism– DTC advertising, lay misinformation

Misinformation in the Media(Schoene, 2003)

Misinformation in the Media(Schoene, 2003)

n 100 national press articles

n LBP usually depicted aschronic/catastrophic

n Experimental treatments _effective

n Case report > groupexperience

n Few emphasized a non-medical approach

n 100 national press articles

n LBP usually depicted aschronic/catastrophic

n Experimental treatments _effective

n Case report > groupexperience

n Few emphasized a non-medical approach

These problems are inherent andpersistent features of many healthcare systems, not just WC.

These problems are inherent andpersistent features of many healthcare systems, not just WC.

Evolving perspectives on RTWEvolving perspectives on RTW

n 1920s -Medical determinism

nPost WW2 -Physical rehabilitation– Objective end-points, static measures

n 1980s -Vocational rehab / HumanRights Act

nEconomic, cultural, social analyses

n 1992 -Biopsychosocial model

Exciting new theories about RTWExciting new theories about RTW

n State of change model (Prochaska - Franche)

– Self-efficacy, expectations, decisional balance

n Adaptational model (Shaw)

– Both worker and workplace (others as well)

– Focus on RTW process, disability > diagnosis

n RTW as negotiated process (Clarke)

– Key interaction: worker – employer communication

– External expertise secondary

n State of change model (Prochaska - Franche)

– Self-efficacy, expectations, decisional balance

n Adaptational model (Shaw)

– Both worker and workplace (others as well)

– Focus on RTW process, disability > diagnosis

n RTW as negotiated process (Clarke)

– Key interaction: worker – employer communication

– External expertise secondary

Evidence on RTW (Franche et al 2005)Evidence on RTW (Franche et al 2005)

n early contact with worker,

n work accommodation offer,

n contact between healthcare providerand workplace,

n ergonomic work site visits,

n presence of RTW coordinator,

n labor-management cooperation.

n early contact with worker,

n work accommodation offer,

n contact between healthcare providerand workplace,

n ergonomic work site visits,

n presence of RTW coordinator,

n labor-management cooperation.

Effective inter-stakeholdercommunication is at thecore of each successfulprogram.

Effective inter-stakeholdercommunication is at thecore of each successfulprogram.

Many innovative programsfully resolve medical issuesearly on – with simultaneouslinked but separate treatmentof disability.

Many innovative programsfully resolve medical issuesearly on – with simultaneouslinked but separate treatmentof disability.

Resolve medical issuesResolve medical issues

n Indahl Study - subacute LBP (Spine, 1995)

– Medical issues resolved on day 1 – multipletests and exams

– Uniform advice: avoid back fibrosis

– 2X RTW at 1-yr f/u

Sherbrook program(Loisel, 1998)

Sherbrook program(Loisel, 1998)

n > 8 wks disabilityn Disability treated separatelyn Early RTW in any capacity

(concurrent with rx / rehab)n Results: RTW 2.4 X faster,

- less pain, disability, reinjury

n These programs are excellent butexpensive, require expertise.

n How about more acute cases?

n Can we change typical practice?

n Perhaps…..– PGAP Program (Sullivan et al)

– Enhanced ergo intervention (Anema andSteenstra)

n These programs are excellent butexpensive, require expertise.

n How about more acute cases?

n Can we change typical practice?

n Perhaps…..– PGAP Program (Sullivan et al)

– Enhanced ergo intervention (Anema andSteenstra)

Psychosocial and behavioral issuesin community practicePsychosocial and behavioral issuesin community practice

n Simple cognitive / behavioral rx early– Trained PT / nurses?

– Focus on short-term goals of RTW

n Psychiatric labels not helpful fortreatment or for insurance

n Recognize importance of both internaland external factors

n Simple cognitive / behavioral rx early– Trained PT / nurses?

– Focus on short-term goals of RTW

n Psychiatric labels not helpful fortreatment or for insurance

n Recognize importance of both internaland external factors

1.1. Pain severityPain severity

2.2. Perceived limitationsPerceived limitations

3.3. Pain Pain catastrophizingcatastrophizing

4.4. Fear of pain/re-injuryFear of pain/re-injury

5.5. DepressionDepression

6.6. Attitudes, motivationAttitudes, motivation

nn Type 1 Risk FactorsType 1 Risk Factors nn Type 2 Risk FactorsType 2 Risk Factors

1.1. Work StressWork Stress

2.2. SupportSupport

3.3. Workplace conflictWorkplace conflict

4.4. Workplace relationsWorkplace relations

5.5. Employer attitudesEmployer attitudes

6.6. Lack of autonomyLack of autonomy

Psychosocial Risk Factors for WorkDisabilityPsychosocial Risk Factors for WorkDisability

n Theory: Prevent disability throughimproved employer responses to reportof injury

n Purpose: Design, test and refine amanagement-supported supervisortraining program

Employer Immediate Response Shaw, Pransky and McLellan

Employer Immediate Response Shaw, Pransky and McLellan

Supervisor Training ProgramSupervisor Training Program

n Immediate contact

n No blame/inquiry

n Positive, empathic

n “Want you back”

n Ergo/safety educ.

n Problem-solving

n Regular follow-up

n Accommodations

n Workplace update

n Functional inquiry

Two 2-hour sessions, interactiveMgmt endorsementResult: 20% less lost time

Mass media vs….mass media!Buchbinder, et al, Spine, Dec. 2001

Mass media vs….mass media!Buchbinder, et al, Spine, Dec. 2001

n 1997-99: Media campaign, Victoria,Australia

n Subsequent improvements: patient,doctor, community belief/attitudes– Less LBP claims, medical costs, disability

charges

n Surveyed 1500 persons in Vic/NSW inlate 2002

n Results – still more awareness,persistent improvements in beliefs

n 1997-99: Media campaign, Victoria,Australia

n Subsequent improvements: patient,doctor, community belief/attitudes– Less LBP claims, medical costs, disability

charges

n Surveyed 1500 persons in Vic/NSW inlate 2002

n Results – still more awareness,persistent improvements in beliefs

Risk prediction: Expectations for RTWRisk prediction: Expectations for RTW

0102030405060708090

100Def

inite

ly

Probab

ly

Not sure

Unlikel

y

0102030405060708090

100Def

inite

ly

Probab

ly

Not sure

Unlikel

y

Do you think you will be able to do your regular job, without anyrestrictions, 4 weeks from now?

% RTW after 1 month

% RTW after 1 month

Can we intervene to improve outcomes?

4.95.4

8.2

Low Moderate High

Risk Level

% w

ith

WC

cla

im

Health Risks and WC CostsHealth Risks and WC Costs

106

288

1,241

Low Moderate High

Risk Level

Me

an

co

st

pe

r e

mp

loy

ee

($

)

Source: Musich, et al. JOEM 2001; 43:534-541

Health promotion and resilienceHealth promotion and resilience

n Health promotion participants in a largetelecommunication company

n Compared to pre-program and to non-participants, extensive adjustment forconfounders

n STD episodes: same frequency, butRTW on average 8.3 days earlierSerxner et al JOEM 2001

n Health promotion participants in a largetelecommunication company

n Compared to pre-program and to non-participants, extensive adjustment forconfounders

n STD episodes: same frequency, butRTW on average 8.3 days earlierSerxner et al JOEM 2001

Based on demonstration of better health promotionoutcomes with blue collar workers with a combinedindividual and worksite-based approach to health riskreduction.

Based on demonstration of better health promotionoutcomes with blue collar workers with a combinedindividual and worksite-based approach to health riskreduction.

Provincial Health Model vs. WC ModelProvincial Health Model vs. WC Model

Provincial Objectives: Manage medical costsand provide care (80% = chronic illness)

WC Objectives: Manage medical costs(80% = acute illness) AND return employeeto productivity

Provincial Objectives: Manage medical costsand provide care (80% = chronic illness)

WC Objectives: Manage medical costs(80% = acute illness) AND return employeeto productivity

Manage MedicalCosts

Return Worker toProductivity

Aging, health risks and cumulativedisability index (Vita, et al. 1998)

Aging, health risks and cumulativedisability index (Vita, et al. 1998)

0

0.05

0.1

0.15

0.2

0.25

0.3

63 65 67 69 71 73 75 77

Age

High risk

Med risk

Low risk

Future best practices???Future best practices???

n Preventive medicine (vaccination / wellness)

n Early risk prediction – targeted approach

n Addressing all psychosocial issues andcomorbidity (depressing / dehumanizingwork)

n Focus on disability independent of medicalissues

n Pay for performance: RTW and function

n Science-based policies

n Preventive medicine (vaccination / wellness)

n Early risk prediction – targeted approach

n Addressing all psychosocial issues andcomorbidity (depressing / dehumanizingwork)

n Focus on disability independent of medicalissues

n Pay for performance: RTW and function

n Science-based policies

Professor Alf Nachemson, 1996Professor Alf Nachemson, 1996

n Referring to the poor results from backfusion surgery -

“In any other surgical specialty, suchresults would lead to abandonment ofthe technique.Only spine surgeons have repeatedconferences and books on failed backsurgery.We should stick to the facts and letthem guide us forward.“

n Referring to the poor results from backfusion surgery -

“In any other surgical specialty, suchresults would lead to abandonment ofthe technique.Only spine surgeons have repeatedconferences and books on failed backsurgery.We should stick to the facts and letthem guide us forward.“