Effect of preinjury wage levels on socioeconomic outcomes of chronic disabled work-related spinal disorder patients

Abstract

Christopher Anagnostes, PhD Candidate, Tom Mayer, MD, Robert J. Gatchel, PhD, Dallas, TX, USAIntroduction: It has been observed clinically that high-wage earners with work-related injuries appear to possess a higher level of motivation to return to work than low-wage earners. High-wage earners are believed to have better socioeconomic outcomes upon treatment completion. However, no research has systematically evaluated wage-earner status as a factor in treatment outcomes for the chronic disabled work-related spinal disorder (CDWRSD) population. The present study was designed as a prospective cohort investigation comparing demographic and socioeconomic outcomes for CDWRSD patients. Patient groups were divided by preinjury earnings status as related to workers compensation benefits.Methods: A cohort of 1,961 consecutive CDWRSD participants in a functional restoration program was divided into four groups. Group A (high-wage earners) consisted of 210 state workers compensation or FECA federal workers compensation patients with a spinal disorder whose weekly earnings before injury were greater than $800, or whose benefits reached a ceiling so that they received disability payments of less than 50% of their preinjury wage (average age, 43.6 ± 10 years). Group B (low-wage earners) consisted of 272 state workers' compensation or FECA patients whose weekly earnings before injury were less than or equal to $240 (average age, 39.8 ± 10 years). Group C (railroad workers) consisted of 31 FELA patients whose federal jurisdiction operates essentially as a personal injury system (average age, 44.9 ± 7 years). Group D (intermediate wages) consisted of the remaining 1,448 patients from the original cohort who did not qualify for any of the aforementioned groups (average age, 41.5 ± 10 years). All patients underwent a 3-week functional restoration program combining quantitatively directed exercise progression with a multimodal disability management approach using psychological and case management techniques. Preprogram preparation included drug detoxification, psychotropic medication management and preparatory aerobic and mobilization training. A structured clinical interview examining socioeconmic outcomes as conducted at 1 year after program completion, and at least partial information was obtained from this interview on all patients in the present study.Results: Pretreatment demographic factors were paradoxical from the common expectation. The high-wage earner (Group A) patients had the longest prerehabilitation disability period of 20 months compared with the other groups (Group B = 16.8; Group C = 9.4; Group D = 17.9; p<.01), even though they appeared to have the greatest financial incentive to return to work. Group A patients also felt the need to retain an attorney at a 25% rate, considerably higher than the other groups (Group B = 22%; Group C = 13%; Group D = 14%; p<.001). Group A patients also had considerably more pretreatment surgery (42%) than the other groups (Group B = 30%; Group C = 26%; Group D = 29%; p<.001). With regard to posttreatment findings, the high-wage earners unexpectedly had the highest dropout rate from program completion (15%) compared with the other groups (Group B = 11%; Group C = 13%; Group D = 8%; p<.01). At 1 year, the middle-wage earner group had a higher rate of both work return and work retention than the high-wage, low-wage and personal injury groups. Work return for Group D was 87% versus 79% for Groups A, B and C (p<.01). Work retention at 1 year for Group D was 81% (Group A = 76%, Group B = 75%; Group C = 55%; p<.001). The railroad workers (Group C) had nearly double (61%) the health-care-seeking behaviors from new providers than others (Group A = 32%; Group B = 24%; Group D = 25%; p<.001). The railroad workers (Group C) also had by far the highest rate (47%) of persistent litigation (Group A = 10%; Group B = 6%; Group D = 7%; p<.001).Conclusion: Contrary to popular belief, high-wage earners return to work and retain work at 1 year after rehabilitation at the same rate as low-wage earners, both having considerably lower work status than intermediate-wage earners whose salaries are near the median average weekly wage on which most jurisdictions set weekly disability benefits. High-wage earners in this sample had greater length of disability, more pretreatment surgery, a higher tendency to hire an attorney and the highest dropout rate of any of the groups, including groups traditionally believed to have lower motivation to return to work because of “secondary gain” financial benefits. In this large cohort study of CDWRSD patients, we must infer that the hypothesis that low-wage earning or high settlement payments strongly demotivate patients from completing rehabilitation or returning to work must be seriously questioned.