Preventing Needless Work Disability by Helping People Stay Employed:

Occupational Health and Quality of Life of Health Care Workers in the "Return to Work" Stage

Globally, over 59 million people are employed as health care workers [...].

Dynamic prediction of work status for workers with occupational injuries: assessing the value of longitudinal observations

OBJECTIVE

Occupational injuries (OIs) cause an immense burden on the US population. Prediction models help focus resources on those at greatest risk of a delayed return to work (RTW). RTW depends on factors that develop over time; however, existing methods only utilize information collected at the time of injury. We investigate the performance benefits of dynamically estimating RTW, using longitudinal observations of diagnoses and treatments collected beyond the time of initial injury.

MATERIALS AND METHODS

We characterize the difference in predictive performance between an approach that uses information collected at the time of initial injury (baseline model) and a proposed approach that uses longitudinal information collected over the course of the patient's recovery period (proposed model). To control the comparison, both models use the same deep learning architecture and differ only in the information used. We utilize a large longitudinal observation dataset of OI claims and compare the performance of the two approaches in terms of daily prediction of future work state (working vs not working). The performance of these two approaches was assessed in terms of the area under the receiver operator characteristic curve (AUROC) and expected calibration error (ECE).

RESULTS

After subsampling and applying inclusion criteria, our final dataset covered 294 103 OIs, which were split evenly between train, development, and test datasets (1/3, 1/3, 1/3). In terms of discriminative performance on the test dataset, the proposed model had an AUROC of 0.728 (90% confidence interval: 0.723, 0.734) versus the baseline's 0.591 (0.585, 0.598). The proposed model had an ECE of 0.004 (0.003, 0.005) versus the baseline's 0.016 (0.009, 0.018).

CONCLUSION

The longitudinal approach outperforms current practice and shows potential for leveraging observational data to dynamically update predictions of RTW in the setting of OI. This approach may enable physicians and workers' compensation programs to manage large populations of injured workers more effectively.

Improving Outcomes for Work-Related Concussions: A Mental Health Screening and Brief Therapy Model

OBJECTIVE

This study assessed the efficacy of a neurocognitive screening evaluation and brief therapy model to improve RTW outcomes for workers who experienced mild head injuries.

METHODS

Patients referred were evaluated using a neurocognitive and psychological screening battery. Work-focused cognitive behavioral therapy was provided when appropriate, addressing the role of negative emotional adjustment and functional sleep disturbance in prolonging recovery.

RESULTS

Average time to RTW was 7 weeks post-evaluation, despite workers being off an average of 10 months between injury and referral dates. Overall, 99% were released to full-duty work without restrictions or accommodations.

CONCLUSIONS

This study demonstrates the favorable outcomes achieved via a structured, clinically driven program for workers who experience head-involved injuries, validating previous research on the importance of recognizing the role of psychological factors in prolonging concussion recovery.

Clinical Guidance to Optimize Work Participation After Injury or Illness: The Role of Physical Therapists

Work rehabilitation refers to the process of assisting workers to remain at work or return to work (RTW) in a safe and productive manner, while limiting the negative impact of restricted work, unemployment, and work disability. The primary purpose of this clinical practice guideline (CPG) is to systematically review available scientific evidence and provide a set of evidence-based recommendations for effective physical therapy evaluation, treatment, and management of individuals experiencing limitations in the ability to participate in work following injury or illness. J Orthop Sports Phys Ther 2021;51(8):CPG1-CPG102. doi:10.2519/jospt.2021.0303.

Return to work after coronary artery bypass grafting and aortic valve replacement surgery: A scoping review

BACKGROUND

Coronary artery bypass grafting surgery and aortic valve replacement surgery are essential treatment options for people suffering from angina pectoris or aortic valve disease. Surgery aims to prolong life expectancy, improve quality of life, and facilitate participation in society for the individuals afflicted. The aim of this review was to explore the literature on work participation in patients following coronary artery bypass grafting or aortic valve replacement surgery, and to identify demographic and clinical characteristics associated with returning to work.

METHODS

A scoping review framework of Arksey and O'Malley was chosen. Four electronic databases: Medline, CINAHL, Embase, and Google Scholar were searched for studies in English, Swedish, Danish or Norwegian between January 1988 and January 2020. A blinded selection of articles was performed. The data were then charted and summarized by descriptive numerical analyses and categorized into themes.

RESULTS

Forty-five out of 432 articles were included in the final full-text analysis. Absence from work following coronary artery bypass graft grafting or aortic valve replacement surgery lasted on average 30 weeks, whereas 34% of the patients never returned to work. Being female, suffering from pre-existing depression, having limited secondary education, or low income were associated with decreased return to work rates. Previous employment was a decisive factor for returning to work after surgery. Data on return to work after aortic valve replacement were scarce.

CONCLUSIONS

A significant number of patients never return to work following coronary artery bypass grafting or aortic valve surgery, and the time interval until work return is longer than expected. Failure to resume work represents a threat to the patients' finances and quality of life. Nurses are in a unique position to assess work-related issues and have an active part in the multi-disciplinary facilitation of tailored occupational counselling after cardiac surgery.

Supporting return to work through appropriate certification: a systematic approach for Australian primary care

Primary care practitioners play a critical role in supporting return to work (RTW) and minimising the detrimental physical and psychosocial sequelae of unnecessary and prolonged work absence in injured and ill workers. Accurate and consistent certification of capacity is an essential component of this role that has been scrutinised recently given the identified variation in certification practices between and within professions. This Perspective outlines the importance of correct certification of capacity for injured workers and provides a RTW flowchart to support systematised and appropriate certification. The flowchart is aimed at primary care practitioners (e.g. general practitioners or physiotherapists). The flowchart was developed at the Transport Accident Commission and WorkSafe Victoria as a guide for Australian primary care practitioners when certifying capacity. A more systematised approach to certification coupled with professional education and support may reduce variations and inaccuracies in certification, improve RTW rates and reduce the increasing burden of disease related to workplace injuries.

Practical approach to a patient with chronic pain of uncertain etiology in primary care

Chronic pain of uncertain etiology often presents a challenge to both patients and their health care providers. It is a complex condition influenced by structural and physiological changes in the peripheral and central nervous systems, and it directly influences, and is modulated by, psychological well-being and personality style, mood, sleep, activity level and social circumstances. Consequently, in order to effectively treat the pain, all of these need to be evaluated and addressed. An effective management strategy takes a multidisciplinary biopsychosocial approach, with review of all current medications and identification and careful withdrawal of those that may actually be contributing to ongoing pain. The management approach is primarily nonpharmacological, with carefully considered addition of medication, beginning with pain-modulating treatments, if necessary. In this article, we present a primary care approach to the assessment and management of a patient with chronic pain where the cause cannot be identified.

Medicolegal Expert Core Competencies and Professionalism

Medicolegal expert opinions can be the source of long and senseless acrimonious debates when they lack the necessary qualities to be considered good evidence. In contrast, quality medicolegal expert reports contribute significantly to the proper and prompt resolution of personal injury claims in civil litigation. To this end, expert physiatrists must develop the medicolegal mindset necessary to survive and thrive in the civil litigation arena. Medicolegal core competencies needed for this endeavor are identified and addressed for what is a lifelong learning project.

How to Determine Whether Our Patients Can Function in the Workplace: A Missed Opportunity in Medical Training Programs

Patients often hand their physicians disability forms, and physicians too often struggle to complete them. Many physicians lack the training to complete these forms. This article aims to provide a clear understanding of impairment, limitations, restrictions, and disability. It explains how physicians can use skills they already possess to appropriately assess limitations, restrictions, and functional capacity, and it explains why accurate determinations are a vital part of good patient care.

Discussion group networks in occupational medicine: A tool for continuing education to promote the integration of workers with disabilities

BACKGROUND

Despite their legal rights, individuals with disabilities face numerous obstacles to integration in the workplace which can result in their discharge from the labor force. Currently occupational physicians have few resources to help decide whether to integrate disabled workers in pre-placement, or in cases of return-to-work.

METHODS

A network of 13 discussion groups comprised of the occupational physicians of each regional clinic of a large Health Maintenance Organization (HMO) in Israel was created to deal with disability management dilemmas. A moderator compiles and shares the physicians' opinions and experiences with all network members thus assisting the consulting physician in decision-making.

RESULTS

Successful management of three representative cases is described to illustrate real-life implementations of this network.

CONCLUSION

The network enables both the consulting and other physicians to tap a large knowledge base and decision-making experience concerning cases of occupational disability management, contributing to professional development and improved service delivery.

The Role of the Orthopaedic Surgeon in Workers' Compensation Cases

Workers' compensation is an employer-funded insurance program that provides financial and medical benefits for employees injured at work. Because many occupational injuries are musculoskeletal in nature, the orthopaedic surgeon plays an important role in the workers' compensation system. Along with establishing the correct diagnosis and implementing an appropriate treatment plan, the clinician must understand the fundamental components of the workers' compensation system to manage an injured employee. Ultimately, effective claim management requires collaboration among the employer, the employee, the legal representatives, the insurance company, and the orthopaedic surgeon.

Workplace Interventions to Prevent Disability from Both the Scientific and Practice Perspectives: A Comparison of Scientific Literature, Grey Literature and Stakeholder Observations

Purpose The significant individual and societal burden of work disability could be reduced if supportive workplace strategies could be added to evidence-based clinical treatment and rehabilitation to improve return-to-work (RTW) and other disability outcomes. The goal of this article is to summarize existing research on workplace interventions to prevent disability, relate these to employer disability management practices, and recommend future research priorities. Methods The authors participated in a year-long collaboration that ultimately led to an invited 3-day conference, Improving Research of Employer Practices to Prevent Disability, held October 14-16, 2015, in Hopkinton, Massachusetts, USA. The collaboration included a topical review of the literature, group conference calls to identify key areas and challenges, drafting of initial documents, review of industry publications, and a conference presentation that included feedback from peer researchers and a question/answer session with an expert panel with direct employer experience. Results Evidence from randomized trials and other research designs has shown general support for job modification, RTW coordination, and organizational support, but evidence is still lacking for interventions at a more granular level. Grey literature reports focused mainly on job re-design and work organization. Panel feedback focused on organizational readiness and the beliefs and values of senior managers as critical factors in facilitating changes to disability management practices. While the scientific literature is focused on facilitating improved coping and reducing discomforts for individual workers, the employer-directed grey literature is focused on making group-level changes to policies and procedures. Conclusions Future research might better target employer practices by tying interventions to positive workplace influences and determinants, by developing more participatory interventions and research designs, and by designing interventions that address factors of organizational change.

Factors affecting return to work after injury or illness: best evidence synthesis of systematic reviews

Background

Work disability is a major personal, financial and public health burden. Predicting future work success is a major focus of research.

Objectives

To identify common prognostic factors for return-to-work across different health and injury conditions and to describe their association with return-to-work outcomes.

Methods

Medline, Embase, PsychINFO, Cinahl, and Cochrane Database of Systematic Reviews and the grey literature were searched from January 1, 2004 to September 1, 2013. Systematic reviews addressing return-to-work in various conditions and injuries were selected. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria to identify low risk of bias reviews.

Results

Of the 36,193 titles screened and the 94 eligible studies reviewed, 56 systematic reviews were accepted as low risk of bias. Over half of these focused on musculoskeletal disorders, which were primarily spine related (e.g., neck and low back pain). The other half of studies assessed workers with mental health or cardiovascular conditions, stroke, cancer, multiple sclerosis or other non-specified health conditions. Many factors have been assessed, but few consistently across conditions. Common factors associated with positive return-to-work outcomes were higher education and socioeconomic status, higher self-efficacy and optimistic expectations for recovery and return-to-work, lower severity of the injury/illness, return-to-work coordination, and multidisciplinary interventions that include the workplace and stakeholders. Common factors associated with negative return-to-work outcomes were older age, being female, higher pain or disability, depression, higher physical work demands, previous sick leave and unemployment, and activity limitations.

Conclusions

Expectations of recovery and return-to-work, pain and disability levels, depression, workplace factors, and access to multidisciplinary resources are important modifiable factors in progressing return-to-work across health and injury conditions. Employers, healthcare providers and other stakeholders can use this information to facilitate return-to-work for injured/ill workers regardless of the specific injury or illness. Future studies should investigate novel interventions, and other factors that may be common across health conditions.

Employment Status and Participation in Cardiac Rehabilitation: DOES ENCOURAGING EARLIER ENROLLMENT IMPROVE ATTENDANCE?

PURPOSE

For patients hospitalized for a cardiac event, an earlier appointment to outpatient cardiac rehabilitation (CR) increases participation. However, it is unknown what effect hastening CR enrollment might have among employed patients planning to return to work (RTW).

METHODS

Using 2 complementary data sets from Henry Ford Hospital (HFH) and Mayo Clinic, we assessed when employed patients eligible for CR anticipated a RTW, the impact of an earlier appointment on CR enrollment, and the effect of employment status on the number of CR sessions attended. Patients at HFH attended CR at either 8 or 42 days (through randomization), whereas Mayo Clinic patients attended 10 days after hospital discharge per standard routines.

RESULTS

Among 148 patients at HFH, 65 (44%) were employed and planned to RTW. Of these, 67% desired to RTW within 1 to 2 weeks, whereas 28% anticipated an RTW within 1 to 3 days. Home financial strain predicted nonparticipation in CR (P < .001) and was associated with an earlier planned RTW. Among 1030 patients at Mayo Clinic, 393 (38%) were employed. Employed (vs nonemployed) patients enrolled in CR 3.3 days sooner (P < .001), but attended 1.6 fewer CR sessions (P = .04). In employed patients from both health systems, an earlier (vs later) appointment to CR did not result in additional exercise sessions of CR.

CONCLUSIONS

Employed patients plan to RTW quickly, in part because of home finances. They also enroll earlier into CR than nonemployed patients. Despite these findings, earlier appointments do not seem to favorably impact overall CR participation.

Not quite a win-win: the corporate agenda of the stay at work/return to work project

The idea that efforts are necessary to transform the dominant framework of workplace safety and health in the United States, from one of compensation and disability to one of stay at work/return to work (SAW/RTW) for workers injured or made ill on the job, has become increasingly widespread. SAW/RTW advocates argue that everyone "wins" when unnecessary disability is reduced. Toward this end, advocates have put forward a program and implemented a strategy with strong proponents among a coalition of corporate-connected professionals. The seemingly obvious conclusions of their arguments bear closer critical scrutiny, however. Addressing key questions-why injured workers do not SAW/RTW, who the coalition of SAW/RTW proponents includes, and what the coalition proposes-reveals that the SAW/RTW approach mainly benefits employers and the corporate-connected advocates. These assertions are detailed, and principles of an alternative approach that will serve the needs of injured workers are outlined.

Does job satisfaction predict early return to work after coronary angioplasty or cardiac surgery?

PURPOSE

Few studies have analyzed the relationship between job satisfaction and return to work (RTW) in cardiac patients. The aim of this paper was to investigate whether job satisfaction predicted early RTW in patients sick listed after cardiac invasive procedures.

METHODS

A 6-month prospective study was carried out in a sample of 83 patients in working age who had recently been treated with angioplasty or cardiac surgery. Job satisfaction was measured using the scale from the Occupational Stress Indicator during cardiac rehabilitation. Time to RTW was assessed at the 6-month occupational physician examination. Logistic regression analyses were used to study the association between job satisfaction at baseline and early RTW at follow-up, adjusted for socio-demographic, medical (type of cardiac intervention, ejection fraction) and psychological (depression, locus of control, illness perception) factors.

RESULTS

Participants with high job satisfaction were more likely to return early to work, with an odds ratio (OR) of 5.92 (95 % CI, 1.69-20.73) in the most-adjusted model, compared to participants with low job satisfaction. Satisfaction with organizational processes was the job satisfaction component most strongly associated with early RTW (OR, 4.30; 95 % CI, 1.21-15.03).

CONCLUSIONS

To the best of our knowledge, this is the first prospective study that investigated whether job satisfaction predicts time to RTW after cardiac interventions. The results suggested that when patients are satisfied with their job and positively perceived their work environment, they will be more likely to early RTW, independently of socio-demographic, medical and psychological factors.

The European influence on workers' compensation reform in the United States

Workers' compensation law in the United States is derived from European models of social insurance introduced in Germany and in England. These two concepts of workers' compensation are found today in the federal and state workers' compensation programs in the United States. All reform proposals in the United States are influenced by the European experience with workers' compensation. In 2006, a reform proposal termed the Public Health Model was made that would abolish the workers' compensation system, and in its place adopt a national disability insurance system for all injuries and illnesses. In the public health model, health and safety professionals would work primarily in public health agencies. The public health model eliminates the physician from any role other than that of privately consulting with the patient and offering advice solely to the patient. The Public Health Model is strongly influenced by the European success with physician consultation with industry and labor.

Factors promoting staying at work in people with chronic nonspecific musculoskeletal pain: a systematic review

PURPOSE

To identify determinants for staying at work (SAW) in workers with chronic musculoskeletal pain (CMP).

METHOD

A systematic review of factors that promote SAW in workers with CMP. We searched the databases of PubMed, EMBASE, PsycInfo, CINAHL and the Cochrane Library. We included studies reporting on working subjects without present CMP-related sick leave. A quality assessment of GRADE criteria and evidence synthesis was performed.

RESULTS

We identified five cross-sectional studies and two qualitative studies reporting on factors associated with SAW in workers with CMP. Consistent association with SAW was found for low perceived physical disability and low emotional distress (low-level evidence). Duration of pain, catastrophizing, self-esteem and marital status were not associated with SAW (low-level evidence). Qualitative studies indicated that personal adjustments and workplace interventions are important determinants for SAW (evidence not graded).

CONCLUSIONS

No high-level evidence for SAW determinants for workers with CMP was identified. Future interventions aimed at promoting SAW could consider reducing perceived physical disability and emotional distress, and promoting adjustment latitude at work, support from supervisors, and the workers' motivation and self-management skills. Further research is required because knowledge of SAW in workers with CMP is scarce, and the relevance of the subject is high.

A framework for evaluating OSH program effectiveness using leading and trailing metrics

INTRODUCTION

Many employers and regulators today rely primarily on a few past injury/ illness metrics as criteria for rating the effectiveness of occupational safety and health (OSH) programs. Although such trailing data are necessary to assess program success, they may not be sufficient for developing proactive safety, ergonomic, and medical management plans.

METHODS

The goals of this pilot study were to create leading metrics (company self-assessment ratings) and trailing metrics (past loss data) that could be used to evaluate the effectiveness of OSH program elements that range from primary to tertiary prevention. The main hypothesis was that the new metrics would be explanatory variables for three standard future workers compensation (WC) outcomes in 2003 (rates of total cases, lost time cases, and costs) and that the framework for evaluating OSH programs could be justifiably expanded. For leading metrics, surveys were developed to allow respondents to assess OSH exposures and program prevention elements (management leadership/ commitment, employee participation, hazard identification, hazard control, medical management, training, and program evaluation). After pre-testing, surveys were sent to companies covered by the same WC insurer in early 2003. A total of 33 completed surveys were used for final analysis. A series of trailing metrics were developed from 1999-2001 WC data for the surveyed companies. Data were analyzed using a method where each main 2003 WC outcome was dichotomized into high and low loss groups based on the median value of the variable. The mean and standard deviations of survey questions and 1999-2001 WC variables were compared between the dichotomized groups. Hypothesis testing was performed using F-test with a significance level 0.10.

RESULTS/DISCUSSION

Companies that exhibited higher musculoskeletal disorder (MSD) WC case rates from 1999-2001 had higher total WC case rates in 2003. Higher levels of several self-reported OSH program elements (tracking progress in controlling workplace safety hazards, identifying ergonomic hazards, using health promotion programs) were associated with lower rates of WC lost time cases in 2003. Higher reported exposures to noise and projectiles were also associated with higher rates of WC cases and costs in 2003.

IMPACT ON INDUSTRY

This research adds to a growing body of preliminary evidence that valid leading and trailing metrics can be developed to evaluate OSH effectiveness. Both the rating of OSH efforts and the regular trending of past loss outcomes are likely useful in developing data-driven improvement plans that are reactive to past exposures and proactive in identifying system deficiencies that drive future losses.

Occupational asthma: review of assessment, treatment, and compensation

Occupational asthma refers to asthma induced by exposure in the working environment to airborne dusts, vapors, or fumes, with or without preexisting asthma. Potential triggers of occupational asthma are diverse and involve a variety of postulated mechanisms. After confirming the presence of asthma, diagnosis hinges on obtaining a detailed and accurate occupational and environmental history and documenting a temporal association of symptoms or signs with workplace exposure. Management of occupational asthma centers on prescribing standard asthma therapies in conjunction with instituting preventive strategies, such as appropriate avoidance of environmental triggers, providing work restrictions, and using environmental controls and/or personal respiratory protection. If a worker is determined to be ill or injured, there are a variety of compensation systems that are designed to protect workers financially from disability related to respiratory impairments; however, the administrative process is frequently difficult to navigate for patients and their providers. Focusing on obtaining a detailed occupational and environmental history, establishing clear objective data to substantiate illness, and estimating or apportioning workplace contribution to the condition is important for the diagnosis and treatment of this relatively common form of asthma.

Depression as a predictor of work resumption following myocardial infarction (MI): a review of recent research evidence

BACKGROUND

Depression often coexists with myocardial infarction (MI) and has been found to impede recovery through reduced functioning in key areas of life such as work. In an era of improved survival rates and extended working lives, we review whether depression remains a predictor of poorer work outcomes following MI by systematically reviewing literature from the past 15 years.

METHODS

Articles were identified using medical, health, occupational and social science databases, including PubMed, OVID, Medline, Proquest, CINAHL plus, CCOHS, SCOPUS, Web of Knowledge, and the following pre-determined criteria were applied: (i) collection of depression measures (as distinct from 'psychological distress') and work status at baseline, (ii) examination and statistical analysis of predictors of work outcomes, (iii) inclusion of cohorts with patients exhibiting symptoms consistent with Acute Coronary Syndrome (ACS), (iv) follow-up of work-specific and depression specific outcomes at minimum 6 months, (v) published in English over the past 15 years. Results from included articles were then evaluated for quality and analysed by comparing effect size.

RESULTS

Of the 12 articles meeting criteria, depression significantly predicted reduced likelihood of return to work (RTW) in the majority of studies (n = 7). Further, there was a trend suggesting that increased depression severity was associated with poorer RTW outcomes 6 to 12 months after a cardiac event. Other common significant predictors of RTW were age and patient perceptions of their illness and work performance.

CONCLUSION

Depression is a predictor of work resumption post-MI. As work is a major component of Quality of Life (QOL), this finding has clinical, social, public health and economic implications in the modern era. Targeted depression interventions could facilitate RTW post-MI.

The Shell Disability Management Program: a five-year evaluation of the impact on absenteeism and return-on-investment

OBJECTIVE

To evaluate the impact of the Shell Disability Management Program (DMP) on U.S. manufacturing employee absenteeism.

METHODS

We estimated absence episodes and days lost per employee from 2004 to 2008 compared to pre-program values in 2002, and productivity gains from transitional duty (TD).

RESULTS

Between 2002 and 2008, absence episodes/100 employees decreased from 37.4 to 25.7 among hourly workers but increased from 9.7 to 13.1 among staff employees. Days lost per employee decreased from 7.4 to 5.2 for hourly employees and were virtually unchanged for staff employees. TD resulted in 6042 days saved in 2006 and 11,438 days in 2008, with direct cost savings of more than $4.1 million from 2006 to 2008.

CONCLUSIONS

The Shell DMP emphasizes absence tracking, timely return-to-work, and facilitation of TD. Absenteeism decreased significantly after DMP implementation, particularly among hourly employees, with an estimated 2.4:1 return-on-investment.

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.