Evaluation of the characteristics of injured workers and employer compliance with OSHA's reporting requirement for work-related amputations.

INTRODUCTION: In 2014, the Federal Occupational Safety and Health Administration (OSHA) enacted a standard requiring employers to report work-related amputations to OSHA within 24 hours. We studied the characteristics of the injured workers and employer compliance with the regulation in Michigan. METHODS: Two independent data sets were used to compare work-related amputations from 2016 to 2018: employer reports to OSHA and the Michigan Multi-Source Injury and Illness Surveillance System (MMSIISS). We deterministically linked employer reports to OSHA with the MMSIISS by employee name, employer name, date, and type of amputation. RESULTS: We identified 1366 work-related amputations from 2016 to 2018; 575 were reported by employers to OSHA and 1153 were reported by hospitals to the MMSIISS. An overlap of 362 workers were reported in both systems, while 213 workers were only reported by employers to OSHA and 791 workers were only reported by hospitals. Employer compliance with the regulation was 42.1%. Employer compliance with reporting was significantly less in: agriculture, forestry, fishing, and hunting (14.6%); construction (27.4%); retail trade (20.7%); arts, entertainment, and recreation (7.7%); accommodation and food services (13.0%); and other services (27.0%). Large employers and unionized employers were significantly more likely (67.9% and 92.7%, respectively) and small employers were significantly less likely (18.2%) to comply with the reporting rule. Enforcement inspections at 327 workplaces resulted in 403 violations; of those, 179 (54.7%) employers had not corrected the amputation hazard before the time of inspection. DISCUSSION: Michigan employers reported less than half of the work-related amputations required by OSHA's reporting regulation. Noncompliance was greatest in small employers, and agriculture, forestry, fishing, and hunting; construction; arts, entertainment, and recreation; accommodation and food services; and retail and other service industries. Inspections found that over half of the employers had not corrected the hazard that caused the amputation at the time of the inspection's initial opening date; in these cases, abatement of any hazards identified would have occurred after the inspection. Improved compliance in employer reporting of work-related amputations will identify hazards posing a high risk of recurrence of injury to other workers from the same injury source. Greater compliance can also help target safety-related preventive and intervention efforts in industries that might otherwise be overlooked.

Evaluation of the characteristics of workers injured on the job requiring hospitalization, and employer compliance with OSHA's reporting requirement for these work-related hospitalizations.

BACKGROUND: The Occupational Safety and Health Administration (OSHA) implemented a new standard in 2014 requiring employers to report nearly all work-related inpatient hospitalizations within 24 h of the event. We examined the characteristics of the injured workers who were reported and the compliance of Michigan employers with the regulation. METHODS: From 2016 to 2018, we compared reports of acute nonmotor-vehicle work-related injuries and illnesses from two independent datasets, employer reports to OSHA and the Michigan Multi-Source Injury and Illness Surveillance System (MMSIISS) which collects injured worker hospital records from the 134 hospitals in Michigan. We matched records from employer reports to OSHA with the MMSIISS by employee's first and last name, company name, date of injury/illness, and type of injury/illness. RESULTS: We identified 2887 workers hospitalized with severe injuries/illnesses from 2016 to 2018 in Michigan; 1260 workers were reported by employers to OSHA and 2238 workers were reported by hospitals to the MMSIISS. There was an overlap of 611 workers reported in both systems, while 649 workers were only reported by employers to OSHA and 1627 workers were only reported by hospitals to the MMSIISS. Employer compliance with the regulation over the 3 years showed a nonsignificant increase; from 42.0% to 43.6% to 45.0%. Fractures were the most frequent type of injury (1238, 42.9%), then head injuries, including skull fractures (470, 16.3%). The median length of hospital stay was 3 days. Manufacturing (709, 25.5%) and construction (563, 20.3%), accounted for the greatest number of hospitalizations. Employer-reported cases to OSHA significantly undercounted hospitalized workers in agriculture, forestry, fishing, and hunting; construction; finance and insurance; real estate and rental and leasing; administrative and support and waste management and remediation services; arts, entertainment, and recreation; accommodation and food services; and other services except public administration. Companies with 250 or more employees were significantly more likely to comply and small companies with 10 or fewer employees were significantly less likely to comply with the reporting rule. Enforcement inspections at 465 of the workplaces where a hospitalization had occurred resulted in $1,017,835 in fines and identified 608 violations. Of the 465 inspections, 246 (52.9%) of the employers had not corrected the hazard before the inspection. CONCLUSIONS: This study identified that workers sustained severe injuries and illnesses on the job and that over half of the companies where a worker suffered an injury/illness leading to hospitalization were not in compliance with OSHA's reporting regulation. Furthermore, at the time of an inspection 1-5 months later, 50% of the companies had not corrected the hazard causing the hospitalization. Improvement in the reporting of work-related injuries/illnesses that result in hospitalization will identify more ongoing hazards in the workplace and improve where to focus preventive actions.

Calls to a State Poison Center Concerning Cleaners and Disinfectants From the Onset of the COVID-19 Pandemic Through April 2020.

An increased use of disinfectants during the coronavirus disease 2019 (COVID-19) pandemic may increase the number of adverse health effects among people who apply them or among those who are in the area being disinfected. For the 3-month period from January 1 to March 30, 2020, the number of calls about exposure to cleaners and disinfectants made to US poison centers in all states increased 20.4%, and the number of calls about exposure to disinfectants increased 16.4%. We examined calls about cleaners and disinfectants to the Michigan Poison Center (MiPC) since the onset of the COVID-19 pandemic. We compared all calls related to exposure to cleaners or disinfectants, calls with symptoms, and calls in which a health care provider was seen during the first quarters of 2019 and 2020 and in relationship to key COVID-19 dates. From 2019 to 2020, the number of all disinfectant calls increased by 42.8%, the number of calls with symptoms increased by 57.3%, the average number of calls per day doubled after the first Michigan COVID-19 case, from 4.8 to 9.0, and the proportion of calls about disinfectants among all exposure calls to the MiPC increased from 3.5% to 5.0% (P < .001). Calls for exposure to cleaners did not increase significantly. Exposure occurred at home for 94.8%97.1% of calls, and ingestion was the exposure route for 59.7% of calls. Information about the adverse health effects of disinfectants and ways to minimize exposure should be included in COVID-19 pandemic educational materials.

Cleaning Products and Work-Related Asthma, 10 Year Update.

OBJECTIVE: To describe the frequency of work-related asthma (WRA) and characteristics of individuals with exposure to cleaning products 1998 to 2012, compared with 1993 to 1997. METHODS: Cases of WRA from products used for cleaning or disinfecting surfaces were identified from California, Massachusetts, Michigan (1998 to 2012), New Jersey (1998 to 2011), and New York (2009 to 2012). RESULTS: There were 1199 (12.4%) cleaning product cases among all 9667 WRA cases; 77.8% women, 62.1% white non-Hispanic, and average age of 43 years. The highest percentages worked in healthcare (41.1%), and were building cleaners (20.3%), or registered nurses (14.1%). CONCLUSIONS: The percentage of WRA cases from exposure to cleaning products from 1998 to 2012 was unchanged from 1993 to 1997 indicating that continued and additional prevention efforts are needed to reduce unnecessary use, identify safer products, and implement safer work processes.

Lack of an Exposure Response and Interaction With HLA-DPß1 and DRß1 Polymorphisms in the Development of Beryllium Toxicity in a High Beryllium Exposure Cohort.

OBJECTIVE: To evaluate interaction of HLA-DPß1 and DRß1 polymorphisms with metrics of beryllium exposure, in the development of beryllium sensitization (BeS) and chronic beryllium disease (CBD). METHODS: A matched case-control study of 61 CBD, 41 BeS, and 259 controls from two beryllium-processing facilities. RESULTS: BES and CBD were significantly associated with presence of DPßE69. Dose response of exposure was not observed for the development of BES and CBD with/without adjustment for DPßE69 (P > 0.05). The DRßE71 polymorphism was more common in BeS than CBD after adjusting for exposure and maybe a protective factor (aOR 0.4, 95% CI 0.2 to 0.9) against the progression of BeS to CBD. CONCLUSION: No exposure-response association was found, which may reflect that the workers in this high exposure cohort were above a threshold level where an exposure-response could be observed.

The Burden of Work-related Asthma in Michigan, 1988-2018.

Rationale: Exposure to a variety of substances in the workplace can cause new-onset asthma or aggravate preexisting asthma, both of which are considered work-related asthma (WRA). Understanding trends in the nature and causes of WRA can assist in the diagnosis and management of adult patients with asthma.Objective: To describe trends over 31 years of WRA surveillance in Michigan.Methods: Michigan law requires reporting of all known or suspected cases of occupational disease. WRA was confirmed by review of a standardized telephone interview and patient medical records. Enforcement inspections at the workplaces of the WRA cases included air monitoring and evaluation for asthma and asthma symptoms among coworkers.Results: The Michigan surveillance program identified 3,634 WRA cases from 1988 to 2018, including nine deaths. The cumulative incidence rate of WRA decreased from 3.5 to 2.0 cases per 100,000 workers. Cases most frequently worked in manufacturing (56%), health care (12%), and education (4%). The cumulative incidence rate of WRA decreased in each of those three industries, while increasing in retail trade and accommodations and food services. The most common exposures to known asthma inducers were to cleaning agents and isocyanates; the percentage exposed to cleaning agents increased from 5% to 20%, and the percentage exposed to isocyanates decreased from 20% to 7%. Fifty-one percent had not applied for workers' compensation benefits. Only 5% of the 571 workplaces where air sampling was performed were above the allowable exposure limit. Fifteen percent (1,622 of 10,493) of coworkers of the index cases reported onset of asthma since beginning to work at the facility or being bothered at work by daily or weekly chest tightness, shortness of breath, or wheezing.Conclusions: The industries and exposures where Michigan adults develop WRA have changed during the past 31 years. The identification of WRA cases, including WRA deaths, underscores the need for continued vigilance to monitor changes in where and how workers are exposed to asthma-causing agents, physician consideration of workplace exposures in new-onset or worsening adult asthma, and adoption of workplace standards that reduce exposure and require workplace medical monitoring to prevent and reduce the morbidity and mortality of WRA.

The Burden of Silicosis in Michigan: 1988-2016.

RATIONALE: Exposure to respirable crystalline silica causes silicosis, a preventable, progressive occupational lung disease. A more rigorous occupational health standard for silica could help protect silica-exposed workers. OBJECTIVES: To describe trends over 29 years of silicosis surveillance in Michigan. METHODS: Michigan law requires the reporting of silicosis. We confirmed the diagnosis of silicosis in reported cases using medical questionnaires, review of medical records, and chest radiographs. The Michigan Occupational Safety and Health Administration (OSHA) conducted enforcement inspections at the workplaces of the silicosis cases, including air monitoring for silica and evaluation of workplace medical surveillance programs. RESULTS: The Michigan surveillance program identified 1,048 silicosis cases from 1988 to 2016, which decreased from 620 during 1988-1997, to 292 during 1998-2007, to 136 during 2008-2016. The cumulative incidence rate of silicosis decreased from 3.7 to 1.4 to 0.7 cases per 100,000 men 40 years of age and older in Michigan over the same three periods. African Americans had a higher cumulative incidence rate of silicosis, with 6.0 cases per 100,000 African American men 40 years of age and older in Michigan compared with 1.2 cases per 100,000 white men 40 years of age and older in Michigan. The cases identified had severe disease; 59% had progressive massive fibrosis or category 2 or 3 small opacities per B-reading classification of the chest radiograph. Seventeen percent reported ever having active tuberculosis. On spirometry, 76% of ever smokers and 72% of never smokers demonstrated either a restrictive or an obstructive pattern. Most (65%) had not applied for workers' compensation benefits; the percentage who applied for benefits decreased from 42% to 28-16% over the three periods. Thirty-four of 55 (62%) workplace inspections found exposures above the new OSHA 50 µg/m3 respirable crystalline silica permissible exposure limit, and only 11% of inspected companies screened their workers for silicosis. CONCLUSIONS: Adults with confirmed cases of silicosis have advanced disease and morbidity. Most are not using workers' compensation to pay for their care. The new OSHA silica standard, which lowers the permissible exposure limit for silica and requires medical monitoring to identify workers with silicosis, will help reduce the burden of silica exposure. It is critical for pulmonologists to be vigilant to recognize and manage this preventable occupational lung disease.

Surveillance for Silicosis - Michigan and New Jersey, 2003-2011.

CDC's National Institute for Occupational Safety and Health (NIOSH), state health departments, and other state entities maintain a state-based surveillance program of confirmed silicosis cases. Data on confirmed cases are collected and compiled by state entities and submitted to CDC. This report summarizes information for cases of silicosis that were reported to CDC for 2003-2011 by Michigan and New Jersey, the only states that continue to provide data voluntarily to NIOSH. The data for this report were final as of January 8, 2015. Data are presented in tabular form on the number and distribution of cases of silicosis by year (Table 1), duration of employment in occupations with potential exposure to dust containing respirable crystalline silica (Table 2), industry (Table 3), and occupation (Table 4). The number of cases by year is presented graphically (Figure). This report is a part of the Summary of Notifiable Noninfectious Conditions and Disease Outbreaks - United States, which encompasses various surveillance years but is being published in 2016 (1). The Summary of Notifiable Noninfectious Conditions and Disease Outbreaks appears in the same volume of MMWR as the annual Summary of Notifiable Infectious Diseases (2).

Isocyanates and work-related asthma: Findings from California, Massachusetts, Michigan, and New Jersey, 1993-2008.

BACKGROUND: Isocyanates remain a leading cause of work-related asthma (WRA). METHODS: Two independent data systems were analyzed for the period 1993-2008: (1) State-based WRA case surveillance data on persons with isocyanate-induced WRA from four states, and (2) Occupational Safety and Health Administration (OSHA) Integrated Management Information System (IMIS) isocyanate air sampling results. RESULTS: We identified 368 cases of isocyanate-induced WRA from 32 industries and 678 OSHA isocyanate air samples with detectable levels from 31 industries. Seventeen industries were unique to one or the other dataset. CONCLUSION: Isocyanate-induced WRA continues to occur in a wide variety of industries. Two data systems uncovered industries with isocyanate exposures and/or illness. Improved control measures and standards, including medical surveillance, are needed. More emphasis is needed on task-specific guidance, spill clean-up procedures, skin and respiratory protection, and targeted medical monitoring to mitigate the hazards of isocyanate use.

Silicosis and chronic renal disease.

BACKGROUND: Silica has been associated with end stage kidney disease and kidney dysfunction. METHODS: Calculated glomerular filtration rate, history of kidney disease or chronic dialysis, elevated serum creatinine, and stages of chronic kidney disease among silicotics identified in Michigan's Silicosis Surveillance System from 1987 to 2009 were reviewed to determine the prevalence of kidney disease in confirmed cases of silicosis. RESULTS: Twenty-four percent of 1,072 silicotics had a measure of kidney dysfunction (32.3% if diabetes or hypertension present vs. 20.2% if not). Sixty-nine percent of silicotics had Stage I or greater chronic kidney dysfunction versus 38.8% of the U.S. general population ≥60 years. No association was found between kidney function and measures of silica exposure. CONCLUSIONS: Individuals with silicosis have an increased prevalence of kidney disease. More work to define the pathological changes associated with silica exposure is needed to understand the cause of silica's adverse effect on the kidney.

Swimming facilities and work-related asthma.

BACKGROUND: Exposure to chlorinated water in swimming facilities may aggravate preexisting asthma or cause new onset asthma. This may be a particular problem for individuals who work and therefore spend prolonged time at swimming facilities. Chloramines formed by the interaction of chlorine-based disinfection products with the nitrogen in water from human sweat, urine and skin cells are the suspected causal agents. METHODS: Cases were reviewed from the state surveillance systems in California (CA), Michigan (MI) and New Jersey (NJ) to identify individuals with confirmed work-related asthma (WRA) attributed to exposures in swimming pools, water parks or hydrotherapy spas. A standardized method was used to confirm cases. RESULTS: A total of 44 confirmed cases of WRA were identified; 17 from 1994 to 2011 in CA, 15 from 1991 to 2012 in MI and 12 from 1990 to 2011 in NJ. A majority (52.2%) of the cases were new onset; 31.8% secondary to an acute exposure incident and 20.4% to repeated exposure. These represented 0.3-1.6% of all confirmed cases of WRA received during these time periods. Maintenance workers (34.9%) and lifeguards (31.8%) were the most common occupations. CONCLUSIONS: Swimming pool workers were identified from three states where the pool environment was either a trigger of preexisting asthma or associated with new onset of WRA. Regulations to require air monitoring and improvements in ventilation are recommended to reduce exposure levels of chloramines, the presumed etiologic agents. Clinical assessment of patients with asthma should include consideration of the effect on respiratory symptoms from exposures in a swimming pool environment.

Gender differences in work-related asthma: surveillance data from California, Massachusetts, Michigan, and New Jersey, 1993-2008.

OBJECTIVE: To characterize work-related asthma by gender. METHODS: We analyzed state-based sentinel surveillance data on confirmed work-related asthma cases collected from California, Massachusetts, Michigan, and New Jersey during 1993-2008. We used Chi-square and Fisher's Exact Test statistics to compare select characteristics between females and males. RESULTS: Of the 8239 confirmed work-related asthma cases, 60% were female. When compared to males with work-related asthma, females with work-related asthma were more likely to be identified through workers' compensation (14.8% versus 10.6%) and less likely to be identified through hospital data (14.2% versus 16.9%). Moreover, when compared to males, females were more likely to have work-aggravated asthma (24.4% versus 13.5%) and less likely to have new-onset asthma (48.0% versus 56.5%). Females were also more likely than males with work-related asthma to work in healthcare and social assistance (28.7% versus 5.2%), educational services (11.8% versus 4.2%), and retail trade (5.0% versus 3.9%) industries and in office and administrative support (20.0% versus 4.0%), healthcare practitioners and technical (13.4% versus 1.6%), and education training and library (6.2% versus 1.3%) occupations. Agent groups most frequently associated with work-related asthma were miscellaneous chemicals (20.3%), cleaning materials (15.3%), and indoor air pollutants (14.9%) in females and miscellaneous chemicals (15.7%), mineral and inorganic dusts (13.2%), and pyrolysis products (12.7%) in males. CONCLUSIONS: Among adults with work-related asthma, males and females differ in terms of workplace exposures, occupations, and industries. Physicians should consider these gender differences when diagnosing and treating asthma in working adults.

A study of characteristics of Michigan workers with work-related asthma exposed to welding.

OBJECTIVE: To describe the characteristics of subjects with work-related asthma (WRA) secondary to welding exposure. METHODS: As part of statewide surveillance, WRA reports were received from health care professionals. These reports were followed up with a telephonic interview using a standardized questionnaire; lung function tests were reviewed, and final assessment regarding the diagnosis was made. RESULTS: Welding exposure was the fifth leading cause of WRA (n = 142; age, 43.3 ± 11.4 years; male to female ratio, 94:48). Several workers (n = 72) were nonwelders but all worked around welding fumes. More than a third had predicted forced expiratory volume in one second less than 80% (38 of 106, 35.8%). Most had sought medical treatment (95.8%) and had emergency room visits (n = 86, 60.6%), and several had required hospitalization (n = 50, 36.7%). CONCLUSION: Welding exposure is a common cause of WRA. It is seen in workers from different industries engaged in diverse jobs. Spirometry changes are common. Work-related asthma is associated with high morbidity and health care costs.

Prevalence of connective tissue disease in silicosis (1985-2006)-a report from the state of Michigan surveillance system for silicosis.

BACKGROUND: The risk of developing clinical connective tissue disease (CTD) has been reported to be increased among individuals with silica exposure. METHODS: We reviewed the medical records of individuals reported to the Michigan Silicosis Surveillance system from 1985 to 2006 to confirm the diagnosis of silicosis and determine the presence of CTDs. RESULTS: From 1985 to 2006, 1,022 cases were confirmed to have silicosis. Medical records of 790 cases were available. Thirty-three individuals had rheumatoid arthritis (RA) [prevalence 4.2% (prevalence ratio (RR) ranged from 2.26, 95% CI: 1.57-3.25 to 6.96, 95% CI: 2.93-16.53) depending on the reference rate used], two had scleroderma [prevalence 0.3% (RR 28.3, 95% CI: 6.09-129.98)], one had systemic lupus erythematosus [prevalence 0.1% (RR 2.53, 95% CI: 0.30-21.64)], two had Sjogrens syndrome [prevalence 0.3% (RR 0.42, 95% CI: 0.09-2.08)], and six had anti-neutrophil cytoplasm antibody (ANCA) vasculitis [prevalence 0.8% (RR 25.3, 95% CI: 6.34-101.04)]. There was no difference between those with and without CTD with respect to age, race, industry type, history of tuberculosis, application for workers' compensation, or severity of fibrotic changes on chest X-ray. CONCLUSIONS: A two- to eightfold risk for RA and systemic lupus erythematosus, with a greater than 24-fold risk for scleroderma and ANCA vasculitis was found in individuals with silicosis. The most common CTD among silicotics in the Michigan disease registry was RA. Though not classically included in the category of CTD, ANCA-associated vasculitis was found to have a much greater prevalence amongst silicosis patients than the general population.

Results of spirometry among individuals in a silicosis registry.

OBJECTIVE: To determine whether individuals with simple silicosis have obstructive and restrictive decrements. METHODS: The prevalence of spirometric abnormalities by radiograph profusion, smoking, duration, and latency from first silica exposure was evaluated among confirmed silicotics. RESULTS: Among 526 silicotics, 17.3% who had never smoked and 26.5% of smokers had obstruction, 30.1% and 28.1% had restriction, and 22.4% and 25.7% had a mixed obstructive and restrictive pattern. Individuals with category 3 profusion or progressive massive fibrosis were more likely to have abnormalities. CONCLUSION: Both obstructive and restrictive patterns were observed regardless of smoking status with a low profusion category of simple silicosis. There was an increased prevalence of restrictive changes with increased profusion. After controlling for age, smoking, and duration of exposure to silica, there was a statistically significant increased risk of obstructive and mixed changes with progressive massive fibrosis.

Work-related asthma in the educational services industry: California, Massachusetts, Michigan, and New Jersey, 1993-2000.

OBJECTIVES: To characterize work-related asthma (WRA) cases working in the educational services industry identified by state-based occupational disease surveillance systems. METHODS: We examined 2,995 WRA cases reported from 1993 to 2000 to four states: California, Massachusetts, Michigan, and New Jersey. RESULTS: A total of 265 (9%) WRA cases were employed in the educational services industry; 69% of cases were classified as new-onset asthma and 31% as work-aggravated asthma. New-onset asthma cases were further classified as occupational asthma (61%) or as reactive airways dysfunction syndrome (8%). The most frequently reported occupation was teachers and teachers' aides (54%). The most frequently reported agents were indoor air pollutants (28%), unspecified mold (16%), dusts (14%), and cleaning products (7%). CONCLUSIONS: Asthma within the educational services industry is an occupational health problem. The health of school employees should also be considered when initiatives addressing asthma among schoolchildren are instituted. The identification, elimination, and/or control of respiratory hazards are important factors for the protection of staff and students alike.

Evaluating the Michigan SENSOR Surveillance Program for work-related asthma.

BACKGROUND: Most Occupational Safety and Health Administration (OSHA) inspections are based on employee complaints or targeting of industry groupings. Limited use has been made of illness data to target inspections and evaluation of such targeting is even more limited. METHODS: This study compared 545 Michigan OSHA (MIOSHA) inspections performed as follow up to reports of work-related asthma (WRA) with 12,268 non-disease initiated OSHA inspections performed during the same time period (1989-2002). RESULTS: SENSOR asthma inspections were more likely to be conducted in larger, unionized employers. Although the likelihood of citations ( approximately 50%), type of citation, and monetary penalties ( approximately 30%) were not different between disease and non-disease initiated inspections, the number of citations and amount of monetary penalties were less in disease initiated inspections. Citations and penalties were more likely for small as compared to large employers, and were less likely at unionized worksites. CONCLUSIONS: Even without the availability of specific standards for agents that cause WRA, inspections triggered by a WRA index case are very much like other inspected worksites in terms of the prevalence of violations observed at the worksite. The advisability of making referrals to OSHA and additional ways to evaluate the effectiveness of this type of intervention model are discussed.

Variations in worker compensation claims by company: the potential for achieving a significant reduction in claims.

BACKGROUND: The objective of our study was to examine the potential reduction in paid worker compensation claims if the rate of claims were as low as the rates of the top companies in that industry category. METHODS: Using Michigan data for the years 1999-2001, we first excluded companies who had no paid worker compensation claims for wage replacement and then calculated the top 10th, 25th, and 50th percentile rates of paid worker compensation claims for wage replacement of all the remaining companies combined and by 2 digit SIC. The percent reduction was calculated separately for small (<20 employees) and large companies based on the differences in observed minus expected if all companies did as well as the top companies in their industry grouping. RESULTS: Fifty-nine percent of large companies and 90% of small companies had no paid worker compensation claims for wage replacement over the 3-year period. Controlling for industry type there would have been 91,504 fewer paid workers' compensation claims if all companies with at least one claim did as well as the 10th percentile or better as the companies in their industry grouping. Reductions were found across all industries and for both small and large companies. CONCLUSION: Variations in worker compensation claims between states are highlighted when legislators consider "reforms" to reduce workers' compensation costs. These reforms overlook the larger variation between companies within the same type of industry in the same state. Possible reasons for this variation between companies and its implication on reducing morbidity and health care costs are discussed.