The direct cost burden of 13years of disabling workplace injuries in the U.S. (1998-2010): Findings from the Liberty Mutual Workplace Safety Index.

INTRODUCTION: Although occupational injuries are among the leading causes of death and disability around the world, the burden due to occupational injuries has historically been under-recognized, obscuring the need to address a major public health problem. METHODS: We established the Liberty Mutual Workplace Safety Index (LMWSI) to provide a reliable annual metric of the leading causes of the most serious workplace injuries in the United States based on direct workers compensation (WC) costs. RESULTS: More than $600 billion in direct WC costs were spent on the most disabling compensable non-fatal injuries and illnesses in the United States from 1998 to 2010. The burden in 2010 remained similar to the burden in 1998 in real terms. The categories of overexertion ($13.6B, 2010) and fall on same level ($8.6B, 2010) were consistently ranked 1st and 2nd. PRACTICAL APPLICATION: The LMWSI was created to establish the relative burdens of events leading to work-related injury so they could be better recognized and prioritized. Such a ranking might be used to develop research goals and interventions to reduce the burden of workplace injury in the United States.

Recurrence of work-related low back pain and disability: association between self-report and workers' compensation data.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To explore the ability to capture low back pain (LBP) recurrence using wage-replacement (WR) data. SUMMARY OF BACKGROUND DATA: LBP can be a recurrent, fluctuating, and disabling condition. Because of its largely nonspecific and subjective nature, the condition poses challenges for research and clinical management, as speaking directly with the affected individuals is not always practical. Little information is available on how indicators of LBP recurrence that can be extracted from administrative databases relate to patients' self-report. METHODS: Participants with a compensated claim for work-related LBP (N = 90) were interviewed regarding their LBP-related experiences after their initial return to work. Interview data were compared with WR data, which was provided by the participants' workers' compensation provider. RESULTS: Concordance was observed between WR-based indicators and self-reports of additional time off due to LBP. The best performing WR-based indicator reflected a payment history that began with more than 7 consecutive days of initial WR payments, followed by a gap in WR payments of more than 7 consecutive days, followed by another WR payment period of more than 7 consecutive days (sensitivity = 55%, specificity = 73%, overall accuracy = 69%). Although concordance was observed between the 2 measures of additional time off, the best performing WR indicator was not related to participants' other self-reports of post-return-to-work LBP recurrence which included LBP being significantly worse usual; LBP experiences; seeking health care for LBP; and the experience of difficulties related to the back condition. CONCLUSION: Results indicate that compensation data can be used to capture what a claimant would self-report as additional time off after their initial return to work due to their LBP condition. However, the use of self-report recurrence indicators is recommended if there is a desire to capture a fuller extent of workers' ongoing pain and/or disability experiences. LEVEL OF EVIDENCE: N/A.

Impact of estradiol valerate/dienogest on work productivity and activities of daily living in women with heavy menstrual bleeding.

OBJECTIVES: To quantify the change in work productivity and activities of daily living in North American women with heavy menstrual bleeding (HMB) treated with estradiol valerate/dienogest (E2V/DNG; Qlaira(®)/Natazia(®)) compared to placebo. METHODS: Women in the United States and Canada, aged 20-53 years with an objective diagnosis of HMB and no recognizable anatomical pathology, were treated with E2V/DNG or placebo for seven cycles (196 days). Main outcome measures included work productivity (i.e., productivity while at work) and activities of daily living measured using a modified Work Productivity and Activity Impairment Questionnaire (mWPAI) on a Likert scale from 0 to 10 (higher values denote higher impairment levels). RESULTS: In both countries, significant improvement was observed between baseline and end of treatment in work productivity and activities of daily living impairment. The improvements in work productivity and activities of daily living with E2V/DNG treatment relative to placebo ranged from 37.2% to 39.2% across both countries. Monthly gains due to E2V/DNG treatment (net of placebo improvement) associated with improvement in work productivity were estimated to be US$80.2 and Can$70.8 (US$58.5) and those associated with improvement in activities of daily living were estimated to be US$84.9 and Can$73.5 (US$60.7). CONCLUSIONS: E2V/DNG was shown to have a consistent positive impact on work productivity and activities of daily living in U.S. and Canadian women with HMB. In addition, these improvements in work productivity and activities of daily living were associated with a reduction in HMB-related monetary burden compared to the placebo group.

Impact of estradiol-valerate/dienogest on work productivity and activities of daily living in European and Australian women with heavy menstrual bleeding.

BACKGROUND: The purpose of this study was to quantify the impact of estradiol-valerate/dienogest (E(2)V/DNG; Qlaira(®)/Natazia(®)) on work productivity and activities of daily living in European and Australian women with heavy menstrual bleeding. METHODS: Women aged 18-54 years with a confirmed diagnosis of heavy menstrual bleeding and no recognizable pathology were recruited across nine European countries (the Czech Republic, Finland, Germany, Hungary, The Netherlands, Poland, Sweden, UK, and Ukraine) and Australia. The women were randomized to receive either E(2)V/DNG (n = 149) or placebo (n = 82) for seven treatment cycles (196 days). The outcomes assessed included work productivity (ie, productivity while at work) and activities of daily living, measured on a Likert scale from 0 to 10 (with higher values denoting higher impairment levels) at baseline and at the end of the third and seventh cycles (days 84 and 196). The equivalent monetary value associated with the changes in work productivity and activities of daily living was also calculated. RESULTS: Across all the countries, greater improvements from baseline to the end of treatment were observed with E(2)V/DNG treatment than placebo in work productivity (46.0% versus 15.1%) and activities of daily living (55.6% versus 30.8%). In 2008, savings associated with improvements in work productivity and activities of daily living due to E(2)V/DNG treatment (net of placebo improvement) were estimated to be between US$22-62 and US$18-56 per month (in purchasing power parity of US$), respectively. CONCLUSION: E(2)V/DNG has a consistent positive impact on work productivity and activities of daily living in European and Australian women with heavy menstrual bleeding. These improvements were associated with a reduction in monetary burden of heavy menstrual bleeding compared with the placebo group, consistent with the response to treatment observed.

Association of disability duration with physical therapy services provided after meniscal surgery in a workers' compensation population.

OBJECTIVE: To examine the association between physical therapy (PT) amount and type (eg, active exercise and passive modalities) received postmeniscectomy with subsequent days of work disability. DESIGN: Historical prospective study. SETTING: Workers' compensation administrative claims data source. PARTICIPANTS: Patients (N=3888) with a new knee injury filed between January 1, 2001, and December 31, 2003, who underwent meniscectomy within 6 months postinjury. INTERVENTIONS: PT services received within 42 days postmeniscectomy. Patients were divided into 9 groups based on PT service amount and type received during the exposure period (no PT, only low active, only high active, only low passive, only high passive, low active/low passive, high active/low passive, low active/high passive, high active/high passive). MAIN OUTCOME MEASURE: Number of disability days post-exposure period and truncated at the end of the 1.5-year outcome period based on lost-time payments. RESULTS: During the exposure period, 32.5% received no PT services, 15.3% had only active, 1.5% had only passive, and 50.8% had a combination of both. After controlling for covariates (including severity indicators and physical job demands), receipt of any passive services was associated significantly with a greater number of disability days, and no significant differences were found for those who received only active PT compared with those receiving no PT. Severity indicators, including opioid use pre- and postsurgery, more disability before surgery, and greater surgery severity, were associated with more disability days, whereas physical job demands were not. CONCLUSIONS: Our results suggest that passive PT services provided postmeniscectomy may be counterproductive to work resumption. In addition, disability duration was shorter or no different for those who received no PT services than for those who received any type of PT services. With better control of confounders in future studies, a beneficial effect of active PT might be found. For the development of rehabilitation guidelines, randomized controlled trials are needed to better understand the effectiveness of active and passive PT services postmeniscectomy.

Health maintenance care in work-related low back pain and its association with disability recurrence.

OBJECTIVES: To compare occurrence of repeated disability episodes across types of health care providers who treat claimants with new episodes of work-related low back pain (LBP). METHOD: A total of 894 cases followed 1 year using workers' compensation claims data. Provider types were defined for the initial episode of disability and subsequent episode of health maintenance care. RESULTS: Controlling for demographics and severity, the hazard ratio [HR] of disability recurrence for patients of physical therapists (HR = 2.0; 95% confidence interval [CI] = 1.0 to 3.9) or physicians (HR = 1.6; 95% CI = 0.9 to 6.2) was higher than that of chiropractor (referent, HR = 1.0), which was similar to that of the patients non-treated after return to work (HR = 1.2; 95% CI = 0.4 to 3.8). CONCLUSIONS: In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services or no treatment.

Workers' perspectives on low back pain recurrence: "it comes and goes and comes and goes, but it's always there".

Although various measures of low back pain (LBP) recurrence have been proposed, none have been tested to determine if they are consistent with what those with LBP perceive a "recurrence" to be. To further the understanding of LBP recurrence and how to measure it, we examined how individuals with a history of LBP describe their back pain experiences. A qualitative approach was chosen and six mixed-gender focus groups were conducted. Discussions were facilitated by two researchers and structured around predetermined questions. All four authors were involved in the data analysis and thematic congruence was achieved through an iterative process of coding and discussion. Participants included 31 individuals (14 female, 17 male), with ages ranging from early 20s to mid 70s. When asked about LBP recurrence, participants had difficulty understanding the concept. There was a sense that, although the pain may disappear, the condition was always there. Three states were defined: "normal," "flared-up," and "attack." "Normal" could include experiencing pain, but generally represented a tolerable state. "Flared-up" was associated with increased pain, the use of strategies to overcome difficulties, and modified participation. "Attack" state was described as severely disabled: "I just have to lay there." Participants described their experiences in a way that is consistent with the idea that LBP is a fluctuating and disabling health condition. Results cast doubt on the validity of currently available measures of LBP recurrence. Focusing on recurrence of pain without consideration of broader contextual factors will result in an incomplete understanding of the meaning of the pain experience.

In vitro fertilisation with recombinant follicle stimulating hormone requires less IU usage compared with highly purified human menopausal gonadotrophin: results from a European retrospective observational chart review.

BACKGROUND: Previous studies have reported conflicting results for the comparative doses of recombinant follicle stimulating hormone (rFSH) and highly purified human menopausal gonadotrophin (hMG-HP) required per cycle of in vitro fertilisation (IVF); the aim of this study was to determine the average total usage of rFSH versus hMG-HP in a 'real-world' setting using routine clinical practice. METHODS: This retrospective chart review of databases from four European countries investigated gonadotrophin usage, oocyte and embryo yield, and pregnancy outcomes in IVF cycles (± intra-cytoplasmic sperm injection) using rFSH or hMG-HP alone. Included patients met the National Institute for Health and Clinical Excellence (NICE) guideline criteria for IVF and received either rFSH or hMG-HP. Statistical tests were conducted at 5% significance using Chi-square or t-tests. RESULTS: Of 30,630 IVF cycles included in this review, 74% used rFSH and 26% used hMG-HP. A significantly lower drug usage per cycle for rFSH than hMG-HP (2072.53 +/- 76.73 IU vs. 2540.14 +/- 883.08 IU, 22.6% higher for hMG-HP; p < 0.01) was demonstrated. The median starting dose was also significantly lower for rFSH than for hMG-HP (150 IU vs. 225 IU, 50% higher for hMG-HP, p < 0.01). The average oocyte yield per IVF cycle in patients treated with rFSH was significantly greater than with hMG-HP (10.80 +/- 6.02 vs. 9.77 +/- 5.53; p < 0.01), as was the average mature oocyte yield (8.58 +/- 5.27 vs. 7.72 +/- 4.59; p < 0.01). No significant differences were observed in pregnancy outcomes including spontaneous abortion between the two treatments. There was a significantly higher rate of OHSS (all grades) with rFSH (18.92% vs. 14.09%; p < 0.0001). The hospitalisation rate due to OHSS was low but significantly higher in the rFSH group (1.07% of cycles started vs. 0.67% of cycles started with rFSH and hMG-HP, respectively; p = 0.002). CONCLUSIONS: Based on these results, IVF treatment cycles with rFSH yield statistically more oocytes (and more mature oocytes), using significantly less IU per cycle, versus hMG-HP. The incidence of all OHSS and hospitalisations due to OHSS was significantly higher in the rFSH cycles compared to the hMG-HP cycles. However, the absolute incidence of hospitalisations due to OHSS was similar to that reported previously. These results suggest that the perceived required dosage with rFSH is currently over-estimated, and the higher unit cost of rFSH may be offset by a lower required dosage compared with hMG-HP.

Modelling the clinical and economic implications of galantamine in the treatment of mild-to-moderate Alzheimer's disease in Germany.

OBJECTIVE: This analysis was to assess the long-term clinical and economic implications of galantamine in the treatment of mild-to-moderate Alzheimer's disease (AD) in Germany. METHODS: An economic model was developed using discrete event simulation to predict the course of AD through changes in cognition, behavioural disturbance, and function over time. It compares the costs and benefits of galantamine versus no-drug treatment and ginkgo biloba. Clinical data were mainly derived from analyses of pooled data from clinical trials. Epidemiological and cost data were obtained from literature and public data sources. Costs (2009 euros) from the perspective of the German Statutory Health Insurance were used. RESULTS: The mean survival time for the model population is about 3.44 years over 10 years of simulation. Galantamine delays average time to severe stage of the disease by 3.57 and 3.36 months, compared to no-drug treatment and ginkgo biloba, respectively. Galantamine reduces time spent in an institution by 2.34 and 2.21 months versus no-drug treatment and ginkgo biloba, respectively. The use of galantamine is projected to yield net savings of €3,978 and €3,972 per patient versus no-drug and ginkgo biloba treatments. These results, however, may be limited by lack of long-term comparative efficacy data as well as data on long-term care costs based on multiple outcome measures. CONCLUSION: Compared to no-drug treatment and ginkgo biloba, galantamine therapy provides clinical benefits and achieves savings in healthcare costs associated with care for patients with mild-to-moderate AD in Germany.

Back pain recurrence: an evaluation of existing indicators and direction for future research.

STUDY DESIGN: Literature review. OBJECTIVE: To present a framework for future analyses of back pain recurrence and explore the applicability and relevance of existing recurrence indicators. SUMMARY OF BACKGROUND DATA: Empirical studies of back pain have included a variety of indicators of recurrence, resulting in a range of findings about recurrence rates and associated factors. Little is known about the relationships between existing indicators. METHODS: Literature overview, expert panel, and workshop discussion at the IX International Forum on Primary Care Research on Low Back Pain. RESULTS: Using the International Classification of Functioning, Disability, and Health (ICF), disabling back pain was conceptualized as a health condition, i.e., back pain disorder (BPD), and BPD recurrence was conceptualized as involving a return of atypical back pain and/or back-pain-related difficulty performing tasks and actions related to the initial episode. Using the ICF, 2 types of recurrence indicators were identified: those directly describing components of BPD and those indirectly doing so (e.g., recurrence of health care utilization). CONCLUSION: In light of the difficulty in measuring BPD recurrence, transparent definitions and a clear understanding of the implications of using particular indicators is required. Future research should focus: on examining the capture BPD recurrence by various research instruments, improving understanding of the relationship between indicators, and gaining insight into how individuals experiencing BPD view recurrence.

Urban-rural differences in work disability following occupational injury: are they related to differences in healthcare utilization?

OBJECTIVE: To investigate urban-rural differences in health care utilization following compensable work-related injury and determine whether differences relate to work disability. METHODS: Analysis of worker's compensation data relating to 4889 people with a bone fracture. Regression analyses were used to test the associations between rurality, work disability, and health care utilization. RESULTS: Place of residence was found to relate to health care utilization and work-disability duration; however, the direction of this relationship depended on the amount of health care used. At lower levels of utilization, more rural residents had less time off; however, as health care usage increased this trend reversed. CONCLUSIONS: The observed interaction between health care utilization, work-disability, and rurality raises important questions regarding causality and implies that people in both urban and rural areas have the potential to benefit from further investigation into health care practices and associated outcomes.

Urban-rural differences in work disability after an occupational injury.

OBJECTIVES: In comparison with their urban counterparts, people living in rural areas have been found to experience higher rates of morbidity and mortality and have inferior health outcomes after illnesses and injuries. The current study sought to determine if this trend extends to work-disability outcomes after work-related injuries. METHODS: This study was a retrospective cohort study using data on workers' compensation claims. Rurality was defined at the postal-code level on the basis of United States 2000 census data. Work disability was measured using the number of full days a person was off work in the 2 years following an injury. Regression analyses were used to test the association between rurality and the duration of work disability after a work-related bone fracture. RESULTS: The claimants with higher rurality experienced less work disability than those with lower rurality. This relationship remained after control for the impact of age, gender, part of body injured, occupation, and industry. CONCLUSIONS: Rurality was found to be related to work disability. However, rather than being associated with more time off after an injury, as could be expected on the basis of past findings, increased rurality was found to be associated with less time off work. The findings suggest that features of rural environments, cultures, and behavioral patterns may facilitate return to work.

Who's in charge? Challenges in evaluating quality of primary care treatment for low back pain.

RATIONALE AND OBJECTIVES: Low back pain (LBP) is a common condition with frequent health care visits and work disability. Quality improvement efforts in primary care focused on guidelines adherence, provider selection and education, and feedback on appropriateness of care. Such efforts can only succeed if a health care provider is in charge of care over a substantial period. This study was conducted to provide insights about actual patterns of provider involvement in LBP care and implications for quality evaluation. METHODS: Established primary care patients with occupational LBP and health care covered by a workers' compensation insurer were selected. Primary care physician (PCP) involvement was examined relative to overall health care utilization. Four methods of classifying PCP involvement were used to assess the association between PCP involvement and health care and work disability outcomes over a 2-year follow-up period. RESULTS: Primary care physician was rarely the sole provider during episodes of occupational LBP. PCP was the initial non-emergency room provider in 55% of cases, and was the most prevalent provider during at least one episode of care in 45% of cases. Different methods of classification led to different conclusions about the association between PCP involvement and work disability or number of health care visits. Multiple providers were involved throughout the clinical course of the small number of cases that accounted for most of the health care visits and work disability; in these cases, the role of PCP in care was difficult to determine. CONCLUSIONS: Administrative data alone are adequate for provider comparisons only in relatively simple cases. Provider comparisons based on initial treating provider likely overstate the importance of early care, particularly in more complex cases. For LBP, quality improvement models based on PCP-directed interventions or reinforcing guideline adherence may not impact outcomes. A patient-centred model may be necessary to achieve outcome improvements.

The association between timing and duration of chiropractic care in work-related low back pain and work-disability outcomes.

OBJECTIVE: To examine the timing and duration of chiropractic care in occupational low back pain (OLBP) and their association with work-disability duration and recurrent disability using workers' compensation (WC) claims data. METHODS: Patients from four states who received chiropractic care for uncomplicated OLBP were identified through WC claims. Univariate and multivariate analyses were used, controlling for utilization of chiropractic care and other factors. RESULTS: Chiropractic care was initiated within 30 days after the onset of OLBP by 89% of claimants. Of those claimants, 48% ended chiropractic care within the first 30 days. After controlling for multiple factors, we found that shorter chiropractic care duration was still significantly associated with a lower likelihood of work-disability recurrence (OR = 0.39) and 8.6% shorter work-disability duration. CONCLUSION: Our findings did not support a benefit of longer chiropractic care in preventing work-disability recurrence or reducing work-disability duration in OLBP.

Measuring return to work.

BACKGROUND: It is argued that one of the factors limiting the understanding of return to work (RTW) following work disability is the use of measurement tools that do not capture a complete picture of workers' RTW experiences. To facilitate the investigation of RTW, the current authors proposed a developmental conceptualization of RTW, which argues for an expanded awareness that encompasses four phases: off work, work reintegration, work maintenance and advancement. This paper reports on work undertaken with the aim of operationalizing the conceptualization. METHODS: A review of the RTW and related literature, with databases searched including PubMed, EconLit, and PsycInfo. We began by extracting details of RTW instruments used by previous researchers. We then interpreted these within the context of the phases of RTW. Using the International Classification of Functioning, Disability, and Health (ICF) to inform our thinking and coding structure, we conceptualized phase-based RTW outcomes and categorized them as 'tasks and actions', 'contextual' or 'process driven'. Iteratively, we reviewed existing instruments for their use as measures of RTW. Where gaps in instrumentation were found, the wider vocational and career assessment literature was searched for instruments that could be adapted for use in RTW research. RESULTS: Results indicate that, although numerous research instruments have been used to assess RTW, within the scientific literature some important dimensions of RTW lack instrumentation. In particular, we found that outcomes such as goal setting, motivation, expectation, job seeking, work maintenance, and career advancement require operationalization. Amongst the outcomes had been operationalized, we found considerable variation in conceptual development and application. CONCLUSIONS: The lack of consistency and comprehensiveness of RTW measurement is one of the factors compromising the advancement of the field of RTW research. It is suggested that a more complete and psychometrically sound array of research instruments, grounded within a commonly adopted paradigm, would further the understanding of RTW and the factors affecting it.

The impact of procedure type, jurisdiction and other factors in workers' compensation on work-disability outcomes following carpal tunnel surgery.

Carpal tunnel syndrome (CTS) is often work-related and associated with prolonged disability. While surgical treatment is common, an alternative endoscopic procedure has been promoted as a way of achieving better outcomes. However, little is known about typical use of the procedure and whether it actually achieves outcomes in community settings. From workers' compensation claims reported to an insurer in six jurisdictions during 1995-1999, we identified 1697 individuals with a single CTS surgery, 17% were treated using the endoscopic procedure. Bivariate analyses of post-surgical outcomes demonstrated that post-surgical work disability was shorter for those with endoscopic procedures (median 27 vs. 34 days, mean 62 vs. 85 days; p< 0.01). Medical costs following the procedure were also lower in the case of endoscopic procedure for those with any post-surgical medical costs (median $1,201 vs. $1,717, mean $5,733 vs. $7,084; p< 0.01). However, controlling for jurisdiction and other factors, these differences disappeared, suggesting that in CTS the type of care received was not a major determinant of outcomes. These findings reinforce the importance of community-based evaluations which include potential confounders to accurately evaluate the impact of medical technologies on work disability in occupational conditions.

Utilization and costs of chiropractic care for work-related low back injuries: do payment policies make a difference?

BACKGROUND: Chiropractic care is frequently used in the treatment of work-related low back pain. Chiropractors have been shown to be more sensitive to cost-sharing than other providers. PURPOSE: This study examined the differences in utilization and costs of chiropractic care for work-related low back injuries in seven jurisdictions and whether these differences can be associated with workers' compensation (WC) payment policies. STUDY DESIGN: A retrospective analysis of WC data from a single insurer. METHODS: Analyzed data included individuals with chiropractic care performed between 1999 and 2002. Utilization (visits and services per person, services per visit) and costs (cost per person and cost per visit) were examined. Actual reimbursement index was developed to proxy payment policies based on actual payments made to chiropractors. RESULTS: Utilization and costs varied significantly across the analyzed states. Restrictive payment policies were associated with lower costs of chiropractic care and lower number of services per visit, but had no impact on visits or services per person. CONCLUSIONS: Findings indicate necessary components of effective cost containment, even in the presence of utilization adjustment.

Work disability and costs caused by recurrence of low back pain: longer and more costly than in first episodes.

STUDY DESIGN: Retrospective analysis of workers' compensation (WC) claims data for nonspecific low back injuries (LBI) in a single jurisdiction. OBJECTIVE: To examine whether recurrences, defined as post-initial episodes of work disability or medical care, substantially contribute to total medical and indemnity costs, and total duration of work disability. SUMMARY OF BACKGROUND DATA: Previous studies have not measured the proportion of care seeking and work disability that are associated with recurrences in claims for work-related LBI. METHODS: All persons with new lost-time claims for nonspecific LBI reported in New Hampshire to a large WC provider from 1996 to 1999 were selected (N = 1867). Three years of follow-up data, starting at the beginning of the first episode, were collected. Previously validated definitions of recurrence were used identify new episodes of care and new episodes of lost work time (work disability). Total duration of work disability, total medical costs, and total indemnity costs were investigated. For individuals with recurrences, these variables were separated into first-episode and recurrent period duration and costs. RESULTS: The rate of recurrent work disability was 17.2%, and the rate of recurrent care seeking was 33.9%. Individuals with recurrence had significantly higher total length of work disability, and higher medical and indemnity costs. For those with recurrent work disability, 69% of total lost time from work, 71% of associated indemnity costs, and 84% of total medical costs occurred during the recurrent period. For those with recurrence of care, the respective values were 48%, 47%, and 42%. CONCLUSIONS: Recurrences contributed disproportionately to the total burden of work-related nonspecific LBI, through both additional care seeking and work disability. Results imply that those who have recurrences may be an especially important target for secondary prevention efforts.

Geographic variation in surgical treatment for work-related carpal tunnel syndrome: does improved return to work matter?

Medical treatment of compensated work-related conditions has two objectives--improve injured workers' health status and allow safe and sustained return to work (RTW). Theoretically, the choice of treatment method should be based primarily on these objectives. Surgical treatment of work-related carpal tunnel syndrome (CTS) provides an opportunity to evaluate whether this occurs. The traditional method of open release has been complemented by an endoscopic procedure, particularly useful in work-related cases due to the anticipated benefit of earlier RTW. The objective of this study was to investigate the differences in surgical treatment for work-related CTS across eight US workers' compensation (WC) jurisdictions, and the factors associated with these differences. From all WC claims reported to a single insurer during the 1995-1999 period, we identified individuals with a one or two surgical procedures for work-related CTS. Among selected individuals (n=4,421), about 20% were treated using the endoscopic procedure; this percentage had a ten-fold variation across the eight jurisdictions. However, utilization of endoscopic release did not increase during the study period, despite reports of better RTW outcomes. The highly jurisdictional nature of the US WC system, with significant differences in reimbursement levels for endoscopic procedures, and geographical differences in medical training were among the potential contributors to the observed variation in utilization.