Hi Mary,

Thank you for the great work with Return to Work Matters.

I have a question:

What data is available to demonstrate the effects of early rehabilitation intervention on workers compensation claim costs? Can you provide details of research papers that have quantitatively analysed this question?

Thank you in anticipation of your response.

Regards,

Cheryl
Canberra

This is a simple question, sensibly asked and important.

Yet unfortunately there is no simple answer.

The problems start with defining “early rehabilitation intervention”.  There are many possible interventions that can be undertaken at all stages of a case: before the injury occurs, at the time of the injury, in the first few weeks after the injury occurs. Which of these do we call early?

In the 80s and early 90s we considered early intervention was in the first few months of a case.  In the late 90s this moved to the first few weeks, and then to the first few days of a case. Now forward thinking companies recognise that having systems in place before an injury occurs together with a positive workplace culture are the best opportunities for early intervention. Early intervention results from what is set up before an injury occurs.

The next challenge to the question is that the quality of an intervention has a major bearing on the outcome, whether it is early or late. And this quality is subtle and often hard to measure. A supervisor saying “so you have had an injury” with a caring look and an interested tone is vastly different to the same words said with a cold stare and offhand response. 

The next challenge is the blending of interventions. Early intervention in one organisation may consist of having strong systems in place before an injury occurs, so that people understand what will happen, combined with a follow-up phone call from a case manager.  In another organisation the intervention may be a follow-up call from a supervisor, along with streamlined medical care. How does one assess the value of the early contact, i.e. separate out the quality of the early contact from the other systems in place?

Ideally, we would have a study that assessed the same interventions undertaken on day one, at one month, and at six months. This would tell us about the value of early intervention. However, such a study hasn’t been done and isn’t a practical option.

Therefore to look at the question of early intervention we have to gather as much information as we can from the available studies. 

Here are some of the ways we can approach this question, and some of the information available:

• Delayed reporting research
• What is the (early) intervention - medical rehabilitation and vocational (return to work) rehabilitation?
• What types of early intervention are there, and what makes a difference?
• What about other early interventions?

Delayed reporting

If early intervention is good, we would expect to see poorer outcomes when there is late reporting and therefore late intervention. Data on delayed reporting is available.

One of the best-known studies was the Hartford study, analysing the cost of claims by the reporting lag in days. If the claim was reported on day seven the costs were about twice as much as if the claim was reported on day one. This was particularly for back problems, but also for other musculoskeletal conditions.

A Tasmanian study also found that a condition reported on day one was significantly less expensive than a problem reported later.

It is possible that a poorer outcome is not secondary to late reporting, but that the type of condition that has a poorer outcome tends to be reported later. For example, a back problem that is worsening over time may have a poorer outcome than one that starts quickly and settles quickly. 

The studies on late reporting do not dogmatically tell us that early intervention is important, but they do suggest it.

What is the (early) intervention?

Some of the initial experiences with ‘early intervention’ focused on medical rehabilitation rather than on Return to Work. The Early Claimant Cohort Study undertaken in Canada found that employees referred to active work-hardening rehabilitation programs did not improve return to work rates, and was very expensive. It seems that the focus was on the person's condition: they were taken through a standard process that did not alter their beliefs about their condition and little attention was paid to return to work. 

Some early experiences at major Australian companies also resulted in people believing that ‘early intervention’ was not appropriate. In retrospect, this appears to be the consequence of the type of intervention used; again, there was not a strong focus on workplace rehabilitation or RTW.

What of early medical rehabilitation that supports people getting back to work? There is some good evidence about this, but unfortunately we are not using it enough. 

A medical intervention regarding back pain was undertaken when people were off work for two months, it tackled their beliefs and provided the individual with a good understanding of their back problem, this reduced long-term disability by 50%. The intervention was run over four hours for people off work for eight weeks, and produced a highly cost-effective result - 50% reduction in long term disability. 

On the other hand some say that an early intervention that medicalises the condition increases a person's fear and worry, and is counter-productive to rehabilitation. For example, if a person has a CT or MRI scan in the first week and is told they have degenerate discs this will often cause the person worry and result in them over-protecting their back. This is commonly counterproductive to rehabilitation.

Over the last 15 years the proportion of people having shoulder investigations has grown hugely. We simply didn’t have the tests available in the 80s. There has been a significant rise in shoulder claims in Victoria, which can’t be explained by the aging population, and have occurred at the same time that we have sent much of our manufacturing industry to China. Is the early intervention with a shoulder scan causing more treatment, more claims and potentially poorer outcomes?

What types of early intervention are there, and what makes a difference?

Back to workplace-based rehabilitation, that is, rehab that involves the workplace in return to work. The Toronto Institute for Work and Health has undertaken a major review of workplace interventions. Their analysis found that early contact with the worker and a return to work offer improved return to work outcomes. Their systematic review concluded that workplace components that reduce work disability duration are:

1.    Early contact with worker
2.    Return to work offer
3.    Contact between healthcare provider and workplace
4.    Ergonomic visits and participatory ergonomics

In terms of workplace systems that improve outcomes, they found better results with:

1.    Educating supervisors and managers
2.    Labour management cooperation
3.    People oriented culture
4.    Conditions of good will and mutual confidence

The best kind of study is one that randomises the approach. This takes out any false results that occur when the selection of the patient in the intervention group may influence or distort the end results.  

In 2007 a Dutch study looked at early rehabilitation for people with back pain. They compared medical treatment of back pain to a workplace intervention. The workplace intervention had a significant impact on return to work. The intervention included a workplace assessment, modified duties and case management involving all stakeholders. This is one of the best quality studies exploring an early intervention approach. It concluded the workplace intervention was better than medical treatment if disability was the outcome being assessed. This study emphasised the importance of all players being involved, including the employee and their treating practitioner.

Most studies point out that a team approach is considered important for early intervention. A review of partnership approaches to return to work found that while many in the industry indicated a shared vision was important, little time was invested in developing a shared and collaborative approach.

The researcher concluded there was substantially less time and energy spent on developing collaboration and teamwork than would be expected based on statements about the importance of it.

Those interviewed also said the motivation of the work was important, yet there was little focus on what the motivations for workers are, and on approaches to exploring motivation.

Loisel, P., M. Falardeau, et al. (2005). "The values underlying team decision-making in work rehabilitation for musculoskeletal disorders." Disability & Rehabilitation 27(10): 561-9.

In 2005 an unpublished study that looked at an early intervention model found that claim costs were reduced by over 50%. There was no significant change in the number of claims, but a dramatic reduction in the number of days off work.

What did the intervention involve? It was a day one model that provided a coordinated approach to supporting the person back to work. Treatment was streamlined, all stops were pulled out to avoid delays and the supervisor became an important part of the return to work approach.  There was a strong focus on supporting the person rather than questioning the claim, and because the focus was on supporting the person and they felt comfortable, the treating doctor rarely disagreed with the return to work program.

For short term cases, one or two phone calls were made. For more complicated cases, the case management approach would continue for months.

While this study was not a randomised study and has not yet been published in a peer-review journal, it provides strong evidence that early intervention can be highly effective. This model dealt with all kinds of cases, simple and complex.

Other studies have explored intervening early in high risk cases. The difficulty here is in identifying high-risk cases. Many studies have shown they can achieve 75% accuracy using various predictive models, however that is a similar level to someone experienced in the field. It is no more than asking general practitioners about their view of a particular patient and the likelihood they will get back to work. 

75% might sound good, but if you rely on this model you will be missing out on an important group who can remain off work in the longer term.

Other studies have indicated that the best identifier of outcomes is the individual themselves. A simple question, asking the person about whether they think they will be back to work in the next month and /or the next three months, is likely the best way of predicting results.

What about other early interventions?

Supervisors are a key component of return to work management.

Training supervisors, a topic we talk about quite a bit at RTWMatters, has been shown to have a major impact on preventing new claims and reducing time off work. Supervisors also report that they are more satisfied when they have been trained in this area.

The Michigan study of employer practices found that senior management commitment has a strong influence on work disability. Like the Institute for Work and Health study, they found that workplace culture was a key component of reducing work disability. Companies that have clearly outlined policies and procedures, and staff who are aware of the policies and procedures, have reduced work absence.

Conclusion:

We have dipped into the maze and mix of research in this area. Bringing all the information together suggests that early intervention is a must. Where should early intervention focus and energy be concentrated? Team spirit, policies and procedures that are clear and understood, senior management input and supervisor training, and early support that both streamlines treatment and supports the worker, offer the best opportunities for reducing work absence.