Injured workers' assessment of vocational rehabilitation services before and after retraining

Using the Functional Comorbidity Index with administrative workers' compensation data: Utility, validity, and caveats

BACKGROUND

Chronic health conditions impact worker outcomes but are challenging to measure using administrative workers' compensation (WC) data. The Functional Comorbidity Index (FCI) was developed to predict functional outcomes in community-based adult populations, but has not been validated for WC settings. We assessed a WC-based FCI (additive index of 18 conditions) for identifying chronic conditions and predicting work outcomes.

METHODS

WC data were linked to a prospective survey in Ohio (N = 512) and Washington (N = 2,839). Workers were interviewed 6 weeks and 6 months after work-related injury. Observed prevalence and concordance were calculated; survey data provided the reference standard for WC data. Predictive validity and utility for control of confounding were assessed using 6-month work-related outcomes.

RESULTS

The WC-based FCI had high specificity but low sensitivity and was weakly associated with work-related outcomes. The survey-based FCI suggested more comorbidity in the Ohio sample (Ohio mean = 1.38; Washington mean = 1.14), whereas the WC-based FCI suggested more comorbidity in the Washington sample (Ohio mean = 0.10; Washington mean = 0.33). In the confounding assessment, adding the survey-based FCI to the base model moved the state effect estimates slightly toward null (<1% change). However, substituting the WC-based FCI moved the estimate away from null (8.95% change).

CONCLUSIONS

The WC-based FCI may be useful for identifying specific subsets of workers with chronic conditions, but less useful for chronic condition prevalence. Using the WC-based FCI cross-state appeared to introduce substantial confounding. We strongly advise caution-including state-specific analyses with a reliable reference standard-before using a WC-based FCI in studies involving multiple states.

Appraisal of Washington State workers' compensation-based return-to-work programs and suggested system improvements: A survey of workers with permanent impairments

BACKGROUND

Following a work-related permanent impairment, injured workers commonly face barriers to safe and successful return to work (RTW). Examining workers' experiences with the workers' compensation (WC) system could highlight opportunities to improve RTW outcomes. Objectives included summarizing workers': (1) appraisal of several WC-based RTW programs, and (2) suggestions for vocational rehabilitation and WC system improvements to promote safe and sustained RTW.

METHODS

In telephone interviews, 582 Washington State workers with work-related permanent impairments were asked whether participation in specified WC-based RTW programs helped them RTW and/or stay at work. Suggestions for program and system improvements were solicited using open-ended questions; qualitative content analysis methods were used to inductively code responses.

RESULTS

Most respondents reported positive impacts from RTW program participation; for example, 62.5% of vocational rehabilitation participants reported it helped them RTW, and 51.7% reported it helped them stay at work. Among 582 respondents, 28.0% reported that no change was needed to the WC system, while 57.6% provided suggestions or critiques. Reduce delays/simplify process/improve efficiency was the most frequent WC system theme-mentioned by 34.9%. Among 120 vocational rehabilitation participants, 35.8% reported that no change was needed to vocational rehabilitation, while 46.7% (N = 56) provided suggestions or critiques. More worker choice/input into the vocational retraining plan was the most frequent vocational rehabilitation theme-mentioned by 33.9%.

CONCLUSIONS

This study's findings suggest that there is substantial room for improvement in workers' experience with the WC system. In addition, injured workers' feedback may reflect opportunities to reduce administrative burden and to improve worker health and RTW outcomes.

Expanding vocational retraining options for injured workers: An experiment in worker choice

BACKGROUND

An innovative self-directed vocational retraining alternative (Option 2) has been offered to eligible Washington State injured workers since 2008.

OBJECTIVE

We aimed to describe: (1) how frequently Option 2 was selected and by whom, (2) the extent to which Option 2 workers used their reserved retraining funds, and (3) how worker satisfaction and employment outcomes for Option 2 workers compared with those of workers undergoing traditional vocational retraining.

METHODS

Five-year cohort study involving workers' compensation data, state wage files, and two worker surveys.

RESULTS

Fewer than 25% of Option 2 workers used their retraining funds. Retraining fund use was associated with better employment outcomes. Workers who were older, whose preferred language was not English, or who had lower pre-injury wages or less education, were least likely to use Option 2 retraining funds. Many workers chose Option 2 because they thought the approved traditional retraining plan was not a good fit for them.

CONCLUSIONS

Self-directed retraining may benefit workers who have the ability, resources, and motivation to independently identify and complete retraining. Additional efforts may be needed to ensure that traditional retraining plans are well-suited to workers' circumstances, and to identify and remove barriers to use of reserved retraining funds.

Vocational rehabilitation program evaluation: comparison group challenges and the role of unmeasured return-to-work expectations

PURPOSE

Despite the importance and cost of workers' compensation (WC)-based vocational rehabilitation (VR) programs, outcome evaluations are rare, in part due to the scarcity of suitable comparison groups. The aims of this study were to assess (1) the adequacy of a commonly recommended internal comparison group, i.e., workers who were eligible for but did not receive services, and (2) return-to-work (RTW) expectations as a potential source of bias.

METHODS

In this prospective cohort study, we used WC claims data and worker-reported RTW expectations to compare workers who received vocational retraining services to eligible workers who did not receive such services. Workers were surveyed after retraining eligibility determination, prior to the initiation of retraining activities. VR progress and RTW wage outcomes were followed for 3 years. The magnitude of confounding contributed by RTW expectations and other covariates was quantified.

RESULTS

Workers who were somewhat or very certain they would RTW had significantly better outcomes. RTW expectations played a strong confounding role, reducing the retraining plan effect estimate by about 23 %, while education and physical capacity each changed the effect estimate by <5 %.

CONCLUSIONS

RTW expectations predicted long-term RTW outcomes and can play a strong confounding role if unmeasured. We found that the internal comparison group approach, commonly recommended for VR program evaluation, is inappropriate for WC-based VR evaluations. Ultimately, there is no simple solution to the challenge of identifying a comparison group; however, measurement of RTW expectations, an easily-measured multi-dimensional construct, may be a useful addition to the VR evaluation toolbox.