Complexities in understanding the role of compensation-related factors on recovery from whiplash-associated disorders: discussion paper 2

[Frequency of Chronic Pain after Work-Related Trauma: A Preliminary Status Survey during Workers' Compensation Rehabilitation in a Tertiary Clinic]

BACKGROUND

Chronic pain after trauma and surgery is a long-term complication. Its relevance for patients within the workers' compensation rehabilitation process has not been adequately investigated.

OBJECTIVES

Initial evaluation of frequency of chronic pain after occupational accidents.

METHODS

In 2017, surgical inpatients (18-65 y) treated in a tertiary hospital were asked about chronic pain arising from an occupational trauma recognized by statutory occupation insurance (interval 2.8±6.9 years), regardless of care received, first at the time of hospitalization and then by telephone interview 6 months later. The focus was on patients with a work-related trauma (A) within the past month or (B) >6 months.

PRIMARY OUTCOME

frequency of work trauma-related chronic pain (>6 months) at the initial interview (point prevalence), secondary outcomes: frequency of chronicity at 6 months (A) and persistence of chronic pain (B). Tertiary outcomes: ability to work, occupational injury classification, burden based on pain intensity, localization, and medication, functional deficits due to the existence of chronic pain, and comorbidity.

RESULTS

Out of 415 patients included in the survey, 85% (160/188) reported accident-related chronic pain (predominantly moderate to highly severe in intensity, localized at joints and bones). 90% (131/145) also reported this pain six months later. 67% (64/96) reported chronic pain for the first time. Patients with chronic pain at follow-up (281/369) were less likely to return to work (p=0.003), required analgesics in 60%, were more often comorbid (p<0.002) and had greater functional deficits (p<0.002).

CONCLUSION

Despite the preliminary nature of the data, chronic pain seems to be common after occupational trauma and negatively affects the recovery of work ability in the long term. Based on the present observational data, a further differentiated re-evaluation of prospective data considering therapeutic measures is strongly recommended.

Did implementation of no-fault auto-insurance in British Columbia, Canada, impact return to work following road trauma? Protocol for a before-after survival analysis

INTRODUCTION

Road trauma (RT) is a major public health problem that often results in prolonged absenteeism from work. Limited evidence suggests that recovery after RT is associated with automobile insurance compensation schemes. In May 2021, British Columbia, Canada switched from fault-based to no-fault auto-insurance coverage. This manuscript presents the protocol for a planned evaluation of that natural experiment: We will evaluate the impact of changing automobile insurance schemes on return to work following RT.

METHODS AND ANALYSIS

The evaluation will use a before-after design to analyse auto-insurance claims (1 April 2019 to 30 April 2024) in order to compare recovery of claimants with non-catastrophic injuries who filed claims under the no-fault insurance scheme to that of those who filed claims under the previous system. Claimants will be followed from date of injury until they return to work or have been followed for 6 months (right-censored). We will perform sensitivity analyses to examine the robustness of our findings. First, we will exclude injuries that occurred during the COVID-19 provincial State of Emergency. Second, we will use propensity score methods rather than conventional covariate adjustment to address potential imbalance between characteristics of claimants pre-change and post-change. Finally, as the implementation effect may have a heterogeneous association with time off work, we will use quantile regression with right-censoring at 6 months to model differences in return to work at the 25th, 50th, 75th and 90th percentiles.

ETHICS AND DISSEMINATION

The study uses de-identified data and is approved by the University of British Columbia Clinical Research Ethics Board (H20-03644). This research is funded by the Insurance Corporation of British Columbia (ICBC). Findings will be published in the peer-reviewed literature and summarised in a report prepared for ICBC. We anticipate that our findings will inform policy decisions in other jurisdictions considering switching to no-fault auto-insurance schemes.

Polygenic risk scoring to assess genetic overlap and protective factors influencing posttraumatic stress, depression, and chronic pain after motor vehicle collision trauma

Posttraumatic stress (PTS), depressive symptoms (DS), and musculoskeletal pain (MSP) are common sequelae of trauma exposure. Although these adverse posttraumatic neuropsychiatric sequelae (APNS) are often studied separately, clinical comorbidity is high. In a cohort of European American motor vehicle collision (MVC) trauma survivors (n = 781), substantial PTS (≥33, IES-R), DS (≥26, CES-D), and MSP (≥4, 0-10 NRS) were identified via a 6-month survey. Genetic risk was estimated using polygenic risk scores (PRSs) calculated from the largest available GWAS datasets of PTSD, MDD, and back pain. We then assessed comorbidity and genetic risk influence for developing chronic PTS, DS, and MSP after MVC. Secondary analyses explored whether common social determinants of health ameliorate genetic vulnerability. We found that 6 months after MVC, nearly half 357/781 (46%) of the participants had substantial PTS, DS, and/or MSP, and overlap was common (PTS + MSP (23%), DS + MSP (18%), PTS + DS (12%)). Genetic risk predicted post-MVC outcomes. PTSD-PRSs predicted PTS and DS (R² = 2.21% and 2.77%, p_adj < 0.01), MDD-PRSs predicted DS and MSP (R² = 1.89%, p_adj < 0.01) and 0.79%, p_adj < 0.05), and back pain-PRS predicted MSP (R² = 1.49%, p_adj < 0.01). Individuals in the highest quintile of PTSD-PRSs had 2.8 and 3.5 times the odds of developing PTS and DS vs. the lowest quintile (95% CI = 1.39-5.75 and 1.58-7.76). Among these high-risk individuals, those living in non-disadvantaged neighborhoods and with college education had 47% (p = 0.048) and 52% (p = 0.04) less risk of developing PTS, and those with high social support had 60% (p = 0.008) less risk of developing DS. Overall, genetic factors influence the risk of APNS after MVC, genetic risk of distinct APNS are overlapping, and specific social determinants greatly augment genetic risk of APNS development after MVC.

Health and return to work in the first two years following road traffic injury: a comparison of outcomes between compensation claimants in Victoria and New South Wales, Australia

BACKGROUND

People who sustain road traffic injuries often have poor health outcomes. While outcomes are often worse in people with a compensation claim, especially in fault-based schemes versus no-fault schemes, few studies have directly compared outcomes across scheme types.

OBJECTIVE

To compare health and work outcomes between people who had no compensation claim, a fault-based claim, or "no-fault" transport or workers compensation claim after hospitalisation for a road traffic injury.

METHODS

Participants aged >=18 years admitted to hospital in New South Wales or Victoria for >24 hours were recruited in two separate prospective cohort studies (N=1,034). People who died or sustained minor or very severe injuries were excluded. Groups included Compulsory Third Party (fault-based, n=128), no-fault Transport Accident Commission (TAC; n=454) and workers compensation claimants (n=73), or no claim (n=226). Outcomes at six, 12- and 24-months post-injury included health [SF-12 Mental Component Score (MCS) and Physical Component Score (PCS)], and return to work for people working pre-injury. Multivariable mixed effects linear and logistic regressions, adjusting for demographic and injury covariates, examined differences in health and work outcomes between claimant groups, with fixed effects of time and random effects of participant ID.

RESULTS

Health status was better in people with a no-fault TAC claim (MCS: m=50.62, 95%CI:49.62,51.62; PCS: m=40.49, 95%CI:39.46,41.52) or no claim (MCS: m=49.99, 95%CI:49.62,51.62; PCS: m=44.36, 95%CI:43.00,45.72), than people with a workers compensation (MCS: m=45.73, 95%CI:43.46,48.00; PCS: m=38.94, 95%CI:36.59,41.30) or fault-based CTP claim (MCS: m=41.34, 95%CI:39.54,43.13; PCS: m=35.64, 95%CI:33.78,37.49). Relative to fault-based CTP claimants, the odds of returning to work were higher for people with no claim (AOR=6.84, 95%CI:1.73,27.05) but did not differ for no-fault TAC (AOR=1.21, 95%CI:0.36,4.05) or workers compensation claimants (AOR=0.83,95%CI: 0.17,3.99). While people with a fault-based CTP claim had poorer mental and physical health and return to work after injury, they showed greater improvements in mental health, and similar levels of improvement in physical health and work participation over time to the other groups.

CONCLUSION

The patterns of health and work across scheme types provide important insights against which we can contrast the effects of future scheme designs on client outcomes.

Predictors of seeking financial compensation following motor vehicle trauma: inception cohort with moderate to severe musculoskeletal injuries

BACKGROUND

Compensation related factors have been repeatedly associated with poor recovery following orthopaedic trauma. There is limited research into the factors associated with seeking financial compensation. Further understanding of these factors could facilitate injury recovery by purposeful compensation scheme design. The aim of this study was to investigate the predictors of seeking financial compensation, namely making a claim and seeking legal representation, following motor vehicle related orthopaedic trauma. The study was conducted in New South Wales (NSW), Australia, in motor vehicle crash and workers' compensation schemes.

METHODS

Participants were patients admitted with upper or lower extremity factures following a motor vehicle crash to two trauma hospitals. Data were collected at baseline within two weeks of injury. Participants were followed up at six months. Analysis involved: descriptive statistics for baseline characteristics; comparison of compensable and non-compensable participants with Analysis of Variance (ANOVA) and chi-squared tests; and logistic regression for predictor models.

RESULTS

The cohort consisted of 452 participants with a mean age 40 years; 75% male; 74% working pre-injury; 30% in excellent pre-injury health; 56% sustained serious injuries with an Injury Severity Score (ISS) 9-15; 61% had a low-middle range household income; and 35% self-reported at fault in the crash. There was no significant difference in pre-injury/baseline health between compensable and non-compensable participants. Follow up data was available for 301 (67%) participants. The significant predictor of claiming compensation in the adjusted analysis was higher body mass index (BMI) (overweight Odds Ratio [OR] 3.05, 95% Confidence Interval [CI] 1.63-5.68; obese OR 1.63, 95% CI 0.83-3.20). Participants less likely to claim were: involved in a motorcycle crash (OR 0.47, 95% CI 0.28-0.82); socioeconomically less disadvantaged (OR 0.37, 95% CI 0.17-0.82) or least disadvantaged (OR 0.39, 95% CI 0.17-0.90); at risk for short term harm (injury) due to alcohol consumption (OR 0.56, 95% CI 0.32-0.97); and with fair-poor pre-injury health (OR 0.30, 95% CI 0.09-0.94). The predictors for seeking legal representation were speaking a language other than English at home (OR 2.80, 95% CI 1.2-6.52) and lower household income (OR 3.63, 95% CI 1.22-10.72). Participants less likely to seek legal representation were least socioeconomically disadvantaged (OR 0.15, 95% CI 0.04-0.50).

CONCLUSIONS

Seeking financial compensation was associated with a higher pre-injury BMI rather than injury-related factors. Seeking legal representation was solely related to socio-economic factors.

Differences in perceived fairness and health outcomes in two injury compensation systems: a comparative study

Background

Involvement in a compensation process following a motor vehicle collision is consistently associated with worse health status but the reasons underlying this are unclear. Some compensation systems are hypothesised to be more stressful than others. In particular, fault-based compensation systems are considered to be more adversarial than no-fault systems and associated with poorer recovery. This study compares the perceived fairness and recovery of claimants in the fault-based compensation system in New South Wales (NSW) to the no-fault system in Victoria, Australia.

Methods

One hundred eighty two participants were recruited via claims databases of the compensation system regulators in Victoria and NSW. Participants were > 18 years old and involved in a transport injury compensation process. The crash occurred 12 months (n = 95) or 24 months ago (n = 87). Perceived fairness about the compensation process was measured by items derived from a validated organisational justice questionnaire. Health outcome was measured by the initial question of the Short Form Health Survey.

Results

In Victoria, 84 % of the participants considered the claims process fair, compared to 46 % of NSW participants (χ² = 28.54; p < .001). Lawyer involvement and medical assessments were significantly associated with poorer perceived fairness. Overall perceived fairness was positively associated with health outcome after adjusting for demographic and injury variables (Adjusted Odds Ratio = 2.8, 95 % CI = 1.4 – 5.7, p = .004).

Conclusion

The study shows large differences in perceived fairness between two different compensation systems and an association between fairness and health. These findings are politically important because compensation processes are designed to improve recovery. Lower perceived fairness in NSW may have been caused by potential adversarial aspects of the scheme, such as liability assessment, medical assessments, dealing with a third party for-profit insurance agency, or financial insecurity due to lump sum payments at settlement. This study should encourage an evidence informed discussion about how to reduce anti-therapeutic aspects in the compensation process in order to improve the injured person’s health.

The association between seeking financial compensation and injury recovery following motor vehicle related orthopaedic trauma

BACKGROUND

Motor vehicle related moderate-severe orthopaedic trauma has a major impact on the burden of injury. In Australia, all states and territories provide access to financial compensation following injury in a motor vehicle crash. The aim of this study was to investigate the influence of seeking financial compensation (i.e., making a claim) on injury recovery following motor vehicle related moderate-severe orthopaedic trauma.

METHODS

Patients admitted with upper/lower extremity fractures after a motor vehicle crash were recruited from two trauma hospitals. Baseline data were collected in person by written questionnaire within two weeks of injury. Follow up data were collected by a mailed written questionnaire at six, 12 and 24 months. Additional (demographic/injury-related) information was collected from hospital databases, all other measures were self-reported. Outcomes were: Short Form-36 Version 2.0 (SF36v2), Physical/Mental Component Scores (PCS/MCS); Post Traumatic Stress Disorder (PTSD) Checklist Civilian Version (PCL-C); and Global Rating of Change (GRC) scale. Analysis involved descriptive statistics and linear mixed models to examine the effect of compensation status on injury recovery over time.

RESULTS

There were 452 study participants. Baseline characteristics showed: mean age 40 years (17.1 Standard Deviation [SD]); 75 % male; 74 % worked pre-injury; 67 % in excellent-very good pre-injury health; 56 % sustained serious injuries, Injury Severity Score (ISS) 9-15; 61 % had a low-middle range household income. Overall, after controlling for possible confounders, the compensable group had poorer recovery compared to the non-compensable group for PCS (-2.97 Mean Difference (MD), 95 % CI -4.73, -1.22); MCS (-3.44 MD, 95 % CI -5.62, -1.26); PCL-C (3.42MD, 95 % CI 0.87, 5.99); and GRC (-0.66MD, 95 % CI -1.15, -0.17). Injury recovery over time for all participants showed: PCS improved from 6-12 and 12-24 months; MCS and GRC improved from 6-12 months; and PCL-C did not significantly improve from 6-12 and 12-24 months. Injury recovery over time continued for compensable and non-compensable groups but compensable participants had poorer scores at each time period, especially MCS and PCL-C.

CONCLUSIONS

Making a claim was associated with poor injury recovery following motor vehicle related orthopaedic trauma, mainly for mental health. Irrespective of claim status, the majority had poor injury recovery, especially for mental health.

The perceptions and experiences of people injured in motor vehicle crashes in a compensation scheme setting: a qualitative study

BACKGROUND

The evidence that compensation related factors are associated with poor recovery is substantial but these measures are generic and do not consider the complexity of scheme design. The objectives of this study were to understand people's perceptions and experiences of the claims process after sustaining a compensable injury in a motor vehicle crash (including why people seek legal representation); and to explore ways to assist people following a compensable injury and improve their experience with the claims process.

METHODS

A qualitative study in a Compulsory Third Party (CTP) personal injury scheme covering the state of New South Wales (NSW), Australia. A series of five focus groups, with a total of 32 participants who had sustained mild to moderate injuries in a motor vehicle crash, were conducted from May to June 2011 with four to eight attendees in each group. These were audio-recorded and transcribed. The methodology was based on a grounded theory approach using thematic analysis and constant comparison to generate coding categories for themes. Data saturation was reached. Analyst triangulation was used to ensure credibility of the results.

RESULTS

Five primary themes were identified: complexity of the claims process; requirement of legal representation; injury recovery expectations; importance of timely healthcare decision making; and improvements for injury recovery. Some participants struggled, finding the claims process stressful and subsequently sought legal advice; whilst others reported a straight forward recovery, helpful insurer interactions and no legal representation. Most participants were influenced by injury recovery expectations, and timely healthcare decision making. To assist with injury recovery, access to objective information about the claims process using online technology and social media was considered paramount.

CONCLUSIONS

Participants had contrasting injury recovery experiences and their perceptions of the claims process differed and were influenced by injury recovery expectations, and timeliness of healthcare decision making. Improvements to the claims process are required, including: simplification or streamlining (possibly using online technology and/or social media to reduce paperwork); and providing access to objective information. There is a need to trial early interventions and new claims management policies that could improve injury recovery and satisfaction with the claims process.

[Expert evidence in whiplash injury: interdisciplinary orthopaedic and biomechanical approach]

Considering the controversially discussed issue of whiplash injury a pragmatic approach based on our own experience in the area of forensic expert opinion is presented. Findings of accident analysis and biomechanics are correlated with the individual situation after the accident (initial clinical appearance), the course of the ailment and the indispensable physical examination. The latter leads to determination of the individual vulnerability (not increased/increased) which is important for the evaluation of the physical condition and estimation of the physical stress limit. These limits vary widely between individuals and must be considered carefully when relating dose and effect of accident severity to a possible physical injury. Determination of the accident severity is especially important when there are no objective signs of injury and the existence of a minor whiplash injury (Quebec Task Force degree 1 or 2) is in question.

The effect of financial compensation on health outcomes following musculoskeletal injury: systematic review

The effect of financial compensation on health outcomes following musculoskeletal injury requires further exploration because results to date are varied and controversial. This systematic review identifies compensation related factors associated with poorer health outcomes following musculoskeletal injury. Searches were conducted using electronic medical journal databases (Medline, CINAHL, Embase, Informit, Web of Science) for prospective studies published up to October 2012. Selection criteria included: prognostic factors associated with validated health outcomes; six or more months follow up; and multivariate statistical analysis. Studies solely measuring return to work outcomes were excluded. Twenty nine articles were synthesised and then assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology to determine evidence levels. The results were mixed. There was strong evidence of an association between compensation status and poorer psychological function; and legal representation and poorer physical function. There was moderate evidence of an association between compensation status and poorer physical function; and legal representation and poorer psychological function. There was limited evidence of an association between compensation status and increased pain. In seven studies the association depended on the outcome measured. No studies reported an association between compensation related factors and improved health outcomes. Further research is needed to find plausible reasons why compensation related factors are associated with poorer health following musculoskeletal injury.

The University of Queensland study of physical and psychological outcomes for claimants with minor and moderate injuries following a road traffic crash (UQ SuPPORT): design and methods

BACKGROUND

To date research investigating how mental health impacts physical recovery following a road traffic crash (RTC) has focused on cohorts with severe injuries. The UQ SuPPORT study aims to study the physical and psychological outcomes of claimants with minor injuries following an RTC under the Queensland common law compulsory insurance scheme.

OBJECTIVES

This paper outlines the protocols of this study as a platform for future publications.

METHODS

The 2-year longitudinal cohort study collected interview and survey data from claimants at 6, 12, and 24 months post-RTC. Measures used in the telephone interview included the DSM-IV Composite International Diagnostic Interview for posttraumatic stress disorder, generalized anxiety disorder, major depressive episode, panic attacks, agoraphobia; and self-reported disability (WHO-DAS-II). Quality of life (SF-36v2), alcohol use (AUDIT), social support (MSPSS), quality-adjusted life years (EQ-5D), and return to work outcomes were assessed via postal questionnaires.

RESULTS

A total of 382 claimants consented to participate at the beginning of the study, and these participants were approached at each wave. Retention was high (65%). The average age of participants at Wave 1 was 48.6 years, with 65% of the sample sustaining minor injuries (Injury Severity Score=1-3).

CONCLUSIONS

This study has collected a unique sample of data to investigate recovery patterns of claimants with minor injuries. Future publications will more fully assess the effects of the collected measures on recovery rates 2 years post-RTC.

A systematic review of predictors of posttraumatic stress disorder (PTSD) for adult road traffic crash survivors

Posttraumatic stress disorder (PTSD) is one of the most common psychological consequences for adult road traffic crash (RTC) survivors and can have serious and long-lasting consequences for recovery if left untreated. Prevalence rates of PTSD following a RTC vary from 6% to 45% (based on 51 prevalence estimates across 35 studies). Explanations for this wide variance are explored. A systematic review of published studies found 49 papers (44 unique studies) investigating predictors of later PTSD in RTC survivors. Consistent predictors of PTSD include rumination about the trauma, perceived threat to life, a lack of social support, higher Acute Stress Disorder symptom severity, persistent physical problems, previous emotional problems, previous anxiety disorder and involvement in litigation/compensation. Moderate predictors of PTSD are discussed, as well as factors, which consistently do not predict PTSD in RTC survivors. The results inform future models of post-RTC traumatic stress aetiology.

An Overview of Systematic Reviews on Prognostic Factors in Neck Pain: Results from the International Collaboration on Neck Pain (ICON) Project

Given the challenges of chronic musculoskeletal pain and disability, establishing a clear prognosis in the acute stage has become increasingly recognized as a valuable approach to mitigate chronic problems. Neck pain represents a condition that is common, potentially disabling, and has a high rate of transition to chronic or persistent problems. As a field of research, prognosis in neck pain has stimulated several empirical primary research papers, and a number of systematic reviews. As part of the International Consensus on Neck (ICON) project, we sought to establish the general state of knowledge in the area through a structured, systematic review of systematic reviews (overview).

An exhaustive search strategy was created and employed to identify the 13 systematic reviews (SRs) that served as the primary data sources for this overview. A decision algorithm for data synthesis, which incorporated currency of the SR, risk of bias assessment of the SRs using AMSTAR scoring and consistency of findings across SRs, determined the level of confidence in the risk profile of 133 different variables. The results provide high confidence that baseline neck pain intensity and baseline disability have a strong association with outcome, while angular deformities of the neck and parameters of the initiating trauma have no effect on outcome. A vast number of predictors provide low or very low confidence or inconclusive results, suggesting there is still much work to be done in this field. Despite the presence of multiple SR and this overview, there is insufficient evidence to make firm conclusions on many potential prognostic variables. This study demonstrates the challenges in conducting overviews on prognosis where clear synthesis critieria and a lack of specifics of primary data in SR are barriers.

Effectiveness of a web-based intervention for injured claimants: a randomized controlled trial

Background

There is considerable evidence showing that injured people who are involved in a compensation process show poorer physical and mental recovery than those with similar injuries who are not involved in a compensation process. One explanation for this reduced recovery is that the legal process and the associated retraumatization are very stressful for the claimant. The aim of this study was to empower injured claimants in order to facilitate recovery.

Methods

Participants were recruited by three Dutch claims settlement offices. The participants had all been injured in a traffic crash and were involved in a compensation process. The study design was a randomized controlled trial. An intervention website was developed with (1) information about the compensation process, and (2) an evidence-based, therapist-assisted problem-solving course. The control website contained a few links to already existing websites. Outcome measures were empowerment, self-efficacy, health status (including depression, anxiety, and somatic symptoms), perceived fairness, ability to work, claims knowledge and extent of burden. The outcomes were self-reported through online questionnaires and were measured four times: at baseline, and at 3, 6, and 12 months.

Results

In total, 176 participants completed the baseline questionnaire after which they were randomized into either the intervention group (n = 88) or the control group (n = 88). During the study, 35 participants (20%) dropped out. The intervention website was used by 55 participants (63%). The health outcomes of the intervention group were no different to those of the control group. However, the intervention group considered the received compensation to be fairer (P <0.01). The subgroup analysis of intervention users versus nonusers did not reveal significant results. The intervention website was evaluated positively.

Conclusions

Although the web-based intervention was not used enough to improve the health of injured claimants in compensation processes, it increased the perceived fairness of the compensation amount.

Trial registration

Netherlands Trial Register NTR2360

Do claim factors predict health care utilization after transport accidents?

BACKGROUND

Injured people who are involved in compensation processes have less recovery and less well-being compared to those not involved in claims settlement procedures. This study investigated whether claim factors, such as no-fault versus common law claims, the number of independent medical assessments, and legal disputes, predict health care utilization after transport accidents.

METHOD

The sample consisted of 68,911 claimants who lodged a compensation claim at the Transport Accident Commission (TAC) in Victoria, Australia, between 2000 and 2005. The main outcome measure was health care utilization, which was defined as the number of visits to health care providers (e.g. general practitioners, physiotherapists, psychologists) during the 5 year period post-accident.

RESULTS

After correction for gender, age, role in accident, injury type, and severity of injury, it was found that independent medical assessments were associated with greater health care utilization (β=.36, p<.001). Involvement in common law claims and legal disputes were both significantly related to health care utilization (respectively β=.05, p<.001 and β=-.02, p<.001), however, the standardized betas were negligible, therefore the effect is not clinically relevant. A model including claim factors predicted the number of health care visits significantly better (ΔR(2)=.08, p<.001) than a model including only gender, age, role in accident, injury type, and severity of injury.

CONCLUSION

The positive association between the number of independent medical assessments and health care utilization after transport accidents may imply that numerous medical assessments have a negative effect on claimants' health. However, further research is needed to determine a causal relationship.

Do different types of financial support after illness or injury affect socio-economic outcomes? A natural experiment in New Zealand

BACKGROUND

In New Zealand, people unable to work due to an illness may be eligible for a means-tested benefit whereas injured people are eligible for a wide range of support including earnings-related compensation through the no-fault Accident Compensation Corporation (ACC). The effect of this difference on socio-economic outcomes has not been investigated before.

METHODS

A comparative cohort study was undertaken of stroke versus injury. Individuals aged 18-64, who had a first-stroke (n = 109) were matched by age, sex and functional impairment with injured individuals (n = 429) participating in the Prospective Outcomes of Injury Study. Data were collected by interview 3.5 and 12 months after stroke or injury. Logistic regression adjusting for the matching variables at 3.5 months, and functional impairment at 12 months, was undertaken.

RESULTS

Median personal income declined by 60% over 12 months for the Stroke Group compared to 13% decline in the Injury Group. Decline in income was greater for those in both groups who had a higher income initially, and for those who had not returned to work. The proportion of the Stroke Group reporting 'Fairly low/low' standard of living increased from 8% to 28% and 'Just/not enough' income increased from 35% to 61% whereas the Injury Group increased only from 5% to 12% and 33%-44% respectively. The odds of reporting low standard of living and income inadequacy at 12 months were significantly less for the Injury Group. Despite earnings-related compensation (80% of income), the odds of being back at work were greater for the Injury Group compared to the Stroke Group (Adjusted Odds Ratio 3.1; 95% CI 1.7-5.6).

CONCLUSIONS

These findings support the conclusions that earnings-related compensation and rehabilitative support, available to injured people via ACC, largely prevents the downward spiral into poverty and ill health. It also appears to enhance return to work though residual confounding cannot be ruled out.