Industrial Injury Hospitalizations Billed to Payers Other Than Workers' Compensation: Characteristics and Trends by State

Using a severity threshold to improve occupational injury surveillance: Assessment of a severe traumatic injury-based occupational health indicator across the International Classification of Diseases lexicon transition

BACKGROUND

Traumatic injury is a leading cause of death and disability among US workers. Severe injuries are less subject to systematic ascertainment bias related to factors such as reporting barriers, inpatient admission criteria, and workers' compensation coverage. A state-based occupational health indicator (OHI #22) was initiated in 2012 to track work-related severe traumatic injury hospitalizations. After 2015, OHI #22 was reformulated to account for the transition from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM. This study describes rates and trends in OHI #22, alongside corresponding metrics for all work-related hospitalizations.

METHODS

Seventeen states used hospital discharge data to calculate estimates for calendar years 2012-2019. State-panel fixed-effects regression was used to model linear trends in annual work-related hospitalization rates, OHI #22 rates, and the proportion of work-related hospitalizations resulting from severe injuries. Models included calendar year and pre- to post-ICD-10-CM transition.

RESULTS

Work-related hospitalization rates showed a decreasing monotonic trend, with no significant change associated with the ICD-10-CM transition. In contrast, OHI #22 rates showed a monotonic increasing trend from 2012 to 2014, then a significant 50% drop, returning to a near-monotonic increasing trend from 2016 to 2019. On average, OHI #22 accounted for 12.9% of work-related hospitalizations before the ICD-10-CM transition, versus 9.1% post-transition.

CONCLUSIONS

Although hospital discharge data suggest decreasing work-related hospitalizations over time, work-related severe traumatic injury hospitalizations are apparently increasing. OHI #22 contributes meaningfully to state occupational health surveillance efforts by reducing the impact of factors that differentially obscure minor injuries; however, OHI #22 trend estimates must account for the ICD-10-CM transition-associated structural break in 2015.

Development and maturation of the occupational health services research field in the United States over the past 25 years: Challenges and opportunities for the future

Work is an important social determinant of health; unfortunately, work-related injuries remain prevalent, can have devastating impact on worker health, and can impose heavy economic burdens on workers and society. Occupational health services research (OHSR) underpins occupational health services policy and practice, focusing on health determinants, health services, healthcare delivery, and health systems affecting workers. The field of OHSR has undergone tremendous expansion in both definition and scope over the past 25 years. In this commentary, focusing on the US, we document the historical development and evolution of OHSR as a research field, describe current doctoral-level OHSR training, and discuss challenges and opportunities for the OHSR field. We also propose an updated definition for the OHSR field: Research and evaluation related to the determinants of worker health and well-being; to occupational injury and illness prevention and surveillance; to healthcare, health programs, and health policy affecting workers; and to the organization, access, quality, outcomes, and costs of occupational health services and related health systems. Researchers trained in OHSR are essential contributors to improvements in healthcare, health systems, and policy and programs to improve worker health and productivity, as well as equity and justice in job and employment conditions. We look forward to the continued growth of OHSR as a field and to the expansion of OHSR academic training opportunities.

Construction industry workers' compensation injury claims due to slips, trips, and falls - Ohio, 2010-2017

PROBLEM

Compared to other industries, construction workers have higher risks for serious fall injuries. This study describes the burden and circumstances surrounding injuries related to compensable slip, trip, and fall (STF) claims from private construction industries covered by the Ohio Bureau of Workers' Compensation.

METHODS

STF injury claims in the Ohio construction industry from 2010-2017 were manually reviewed. Claims were classified as: slips or trips without a fall (STWOF), falls on the same level (FSL), falls to a lower level (FLL), and other. Claim narratives were categorized by work-related risk and contributing factors. Demographic, employer, and injury characteristics were examined by fall type and claim type (medical-only (MO, 0-7 days away from work, DAFW) or lost-time (LT, ≥8 DAFW)). Claim rates per 10,000 estimated full-time equivalent employees (FTEs) were calculated.

RESULTS

9,517 Ohio construction industry STF claims occurred during the 8-year period, with an average annual rate of 75 claims per 10,000 FTEs. The rate of STFs decreased by 37% from 2010 to 2017. About half of the claims were FLL (51%), 29% were FSL, 17% were STWOF, and 3% were "other." Nearly 40% of all STF claims were LT; mostly among males (96%). The top three contributing factors for STWOF and FSL were: slip/trip hazards, floor irregularities, and ice/snow; and ladders, vehicles, and stairs/steps for FLL. FLL injury rates per 10,000 FTE were highest in these industries: Foundation, Structure, and Building Exterior Contractors (52); Building Finishing Contractors (45); and Residential Building Construction (45). The highest rate of FLL LT claims occurred in the smallest firms, and the FLL rate decreased as construction firm size increased. Discussion and Practical Applications: STF rates declined over time, yet remain common, requiring prevention activities. Safety professionals should focus on contributing factors when developing prevention strategies, especially high-risk subsectors and small firms.

The Role of Worker Age in Ohio Workers' Compensation Claims in the Landscaping Services Industry

OBJECTIVE

This study employed analysis of workers' compensation (WC) claims in the landscaping services industry to identify occupational factors associated with claims from workers of different ages.

METHODS

Private sector claims for 2005 to 2017 to the Ohio Bureau of Workers' Compensation (OHBWC) and their free-text descriptions were used along with data from the US Census Bureau American Community Survey to examine rates and types of WC claims by worker age.

RESULTS

Although the claim rate for younger workers was higher than that for older workers overall (593 vs 261 per 10,000 full-time equivalent employees, P < 0.001), claims from older workers had higher nonzero median cost ($1002 vs $522, P < 0.001).

CONCLUSIONS

Analysis of WC claim rates shows significant differences between claims in different age groups. These differences can be used to target safety interventions for the greatest impact.

Differential underestimation of work-related reinjury risk for older workers: Challenges to producing accurate rate estimates

BACKGROUND

Older workers are increasingly represented in the U.S. workforce, but frequently work part-timeor intermittently, hindering accurate injury rate estimates. To reduce the impact of reporting barriers on rate comparisons, we focused on reinjury (both injury recurrence and new injury) among workers with a workers' compensation claim, assessing: (1) reinjury risk for workers age 65+ versus <65; (2) importance of work-time at-risk measurement for rate estimates and comparisons; and (3) age distribution of potential risk factors.

METHODS

Washington State workers' compensation claims for a retrospective cohort of workers with work-related permanent impairments were linked to state wage files. Reinjury rates were calculated for the cohort (N = 11,184) and a survey sample (N = 582), using both calendar time and full-time equivalent (FTE)-adjusted time. Risk differentials were assessed using rate ratios and adjusted survival models.

RESULTS

The rate ratio for workers age 65+ (vs. <65) was 0.45 (p < 0.001) using calendar time, but 0.70 (p = 0.07) using FTE-adjusted time. Survey-based rates were 35.7 per 100 worker-years for workers age 65+, versus 14.8 for <65. Workers age 65+ (vs. <65) were more likely to work <100% FTE, but were similar regarding job strain, their ability to handle physical job demands, and their comfort reporting unsafe conditions or injuries.

CONCLUSIONS

Accounting for work-time at risk substantially improves age-based reinjury comparisons. Although the marked elevation in self-reported reinjury risk for older workers might be a small-sample artifact (n = 34), workers age 65+ are likely at higher risk than previously appreciated. Ongoing workforce trends demand increased attention to injury surveillance and prevention for older workers.

Lessons learned from Ohio workers' compensation claims to mitigate hazards in the landscaping services industry

BACKGROUND

The landscaping services industry is one of the more dangerous in the United States, with higher rates of both fatal and nonfatal injuries than the all-industry average. This study uses claims from the Ohio Bureau of Workers' Compensation (OHBWC) database to identify high rates of occupational injuries and illnesses in this industry in Ohio. The causes of those illnesses and injuries are highlighted to identify common factors.

METHODS

The OHBWC database includes injured-worker industry identification, occupation, business size, demographics, diagnoses, and free-text descriptions of injury circumstances. We identified landscaping service industry claims from 2001 to 2017, and describe annual claim counts and rates.

RESULTS

Over the 17-year period, 18,037 claims were accepted, with "Struck by object or equipment" and "Overexertion involving outside sources" being the most common events or exposures. Sprains and fractures were the most prevalent of the more serious lost-time (LT) injuries. Free-text descriptions of claims indicate that arborist work and loading/unloading of work vehicles and trailers are particularly hazardous. Younger and shorter-tenured workers were injured most frequently, although the average workers' age was higher for LT claims. The total cost of claims to the OHBWC from the landscaping services industry for 2001-2017 was over $226,000,000. Almost $214,000,000, or 94.4%, was for LT injuries and illnesses, even though LT claims comprise only 18% of total claims.

CONCLUSIONS

Targeted improvements in landscaper safety could come from controlling events leading to LT claims. Engineering controls and improved training are strongly recommended to reduce falls, overexertion, and struck-by injuries.

Estimating time to reinjury among Washington State injured workers by degree of permanent impairment: Using state wage data to adjust for time at risk

BACKGROUND

Many injured workers are reinjured, but reinjury risk is challenging to quantify. Because many injured workers face delayed return-to-work, or return to part-time or intermittent jobs, a calendar timescale may overestimate actual work-time at risk, yielding underestimated reinjury rates. Objectives included determining: (1) reinjury risk by degree of permanent impairment and other factors, and (2) how choice of timescale affects reinjury estimates.

METHODS

This retrospective cohort study included Washington State workers' compensation (WC) claims for 43,114 injured workers, linked to state wage files (2003-2018). Three timescales were used to define at-risk denominators: (1) calendar quarters; (2) quarters with any wages; and (3) full-time equivalent (FTE) quarters, defined as cumulative work hours ÷ 520. Associations between reinjury outcomes and worker, injury, job, and WC vocational rehabilitation program participation characteristics were assessed using Cox proportional hazards regression.

RESULTS

Overall reinjury rates were 5.9 per 100 worker-years using a calendar timescale (95% confidence interval [CI]: 5.8-6.0), 10.0 using any-wage quarters (95% CI: 9.9-10.2), and 12.5 using FTE quarters (95% CI: 12.3-12.7). Reinjury rates were highest in the first two quarters after initial injury, remaining elevated for about 4 years. Using FTE quarters, workers with ≥10% whole body impairment had a 34% higher risk of reinjury relative to workers with no permanent partial disability award (95% CI: 1.25-1.44); no difference was detected using calendar time.

CONCLUSIONS

Timescale substantially affects reinjury estimates and comparisons between groups with differential return-to-work patterns. Linking wage data to WC claims facilitates measurement of long-term employment, yielding more accurate reinjury estimates.

Prescription opioid overdose and adverse effect hospitalisations among injured workers in eight states (2010-2014)

OBJECTIVE

High-risk opioid prescribing practices in workers' compensation (WC) settings are associated with excess opioid-related morbidity, longer work disability and higher costs. This study characterises the burden of prescription opioid-related hospitalisations among injured workers.

METHODS

Hospital discharge data for eight states (Arizona, Colorado, Michigan, New Jersey, New York, South Carolina, Utah and Washington) were obtained from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. We calculated 5-year (2010-2014) average annual rates of prescription opioid overdose/adverse effect (AE) hospitalisations. Injured workers were identified using payer (WC) and external cause codes.

RESULTS

State-level average annual prescription opioid overdose/AE hospitalisation rates ranged from 0.3 to 1.2 per 100 000 employed workers. Rates for workers aged ≥65 years old were two to six times the overall rates. Among those hospitalised with prescription opioid overdose/AEs, injured workers were more likely than other inpatients to have a low back disorder diagnosis, and less likely to have an opioid dependence/abuse or cancer diagnosis, or a fatal outcome. Averaged across states, WC was the primary expected payer for <1% of prescription opioid overdose/AE hospitalisations vs 6% of injury hospitalisations.

CONCLUSIONS

Population-based estimates of prescription opioid morbidity are almost nonexistent for injured workers; this study begins to fill that gap. Rates for injured workers increased markedly with age but were low relative to inpatients overall. Research is needed to assess whether WC as payer adequately identifies work-related opioid morbidity for surveillance purposes, and to further quantify the burden of prescription opioid-related morbidity.

Characteristics of agricultural and occupational injuries by workers' compensation and other payer sources

BACKGROUND

Workers' compensation claims data are routinely used to identify and describe work-related injury for public health surveillance and research, yet the proportion of work-related injuries covered by workers' compensation, especially in the agricultural industry, is unknown.

METHODS

Using data from the Iowa Trauma Registry, we determined the sensitivity and specificity of the use of workers' compensation as a payer source to ascertain work-related injuries requiring acute care comparing agriculture with other rural industries.

RESULTS

The sensitivity of workers' compensation as a payer source to identify work-related agricultural injuries was 18.5%, suggesting that the large majority of occupational agricultural injuries would not be accurately identified through workers' compensation records. For rural nonagricultural, rural occupational injuries, the sensitivity was higher (64.2%). Work-related agricultural injuries were most frequently covered by private insurance (39.6%) and public insurance (21.4%), while rural nonagricultural injuries were most frequently covered by workers' compensation (65.2%).

CONCLUSIONS

Workers' compensation claims data will not include the majority of work-related agricultural injuries.

Coverage Gaps and Cost-Shifting for Work-Related Injury and Illness: Who Bears the Financial Burden?

The heavy economic burden of work-related injury/illness falls not only on employers and workers' compensation systems, but increasingly on health care systems, health and disability insurance, social safety net programs, and workers and their families. We present a flow diagram illustrating mechanisms responsible for the financial burden of occupational injury/illness borne by social safety net programs and by workers and their families, due to cost-shifting and gaps in workers' compensation coverage. This flow diagram depicts various pathways leading to coverage gaps that may shift the burden of occupational injury/illness-related health care and disability costs ultimately to workers, particularly the most socioeconomically vulnerable. We describe existing research and important research gaps linked to specific pathways in the flow diagram. This flow diagram was developed to facilitate more detailed and comprehensive research into the financial burden imposed by work-related injury/illness, in order to focus policy efforts where improvement is most needed.

What Types of Treatment Are Provided for Patients With Carpal Tunnel Syndrome? A Retrospective Analysis of Commercial Insurance

BACKGROUND

Treatment of carpal tunnel syndrome (CTS) in commercially insured patients across the spectrum of provider types rarely has been described.

OBJECTIVE

To describe patterns of types of treatment for patients with CTS using a large commercial insurance database.

DESIGN

Retrospective cohort descriptive study.

SETTING

Administrative health data from the Clinformatics Data Mart (OptumInsight, Eden Prairie, MN).

PATIENTS

Adults with a primary diagnosis of CTS seen from between January 2010 to December 2012 who had a total of 48 months of continuous data (12 months before diagnosis and 36 months after diagnosis) (n = 24,931).

OUTCOMES

Frequency of types of treatment (heat, manual therapy, positioning, steroids, stretching, surgery) by number of treatments, number of visits, provider type, and characteristics.

RESULTS

Fifty-four percent of patients received no reported treatment, and 50.4% had no additional visits. Surgery (42.5%) and positioning (39.8%) were the most frequent single treatments. Patients who were seen by orthopedist for their first visit more frequently received some treatment (75.1%) and at least 1 additional visit (74.1%) compared with those seen by general practitioners (59.5%, 57.5%, respectively) or other providers (65.4%, 68.4, respectively). Orthopedists more frequently prescribed positioning devices (26.8%) and surgery (36.8%) than general practitioners (18.8%, 14.1%, respectively) or other providers (15.7%, 19.7%, respectively). Older adults more frequently had CTS surgery, as did people who lived in the Midwest. Overall, only 24% of patients with CTS had surgery.

CONCLUSIONS

For more than one-half of patients with CTS no treatment was provided after an initial visit. Surgery rates were much lower than what has previously been reported in the literature. Generally, patients with CTS receive treatments that are supported by current treatment guidelines.

LEVEL OF EVIDENCE

NA.

State Trauma Registries as a Resource for Occupational Injury Surveillance and Research: Lessons From Washington State, 1998-2009

OBJECTIVES

Work-related traumatic injury is a leading cause of death and disability among US workers. Occupational injury surveillance is necessary for effective prevention planning and assessing progress toward Healthy People 2020 objectives. Our objectives were to (1) describe the Washington State Trauma Registry (WTR) as a resource for occupational injury surveillance and research, (2) compare the WTR with 2 population-based data sources more widely used for these purposes, and (3) compare the number of injuries ascertained by the WTR with other data sources.

METHODS

We linked WTR records to hospital discharge records in the Comprehensive Hospital Abstract Reporting System for 2009 and to workers' compensation claims from the Washington State Department of Labor and Industries for 1998 to 2008. We assessed the 3 data sources for overlap, concordance, and case ascertainment.

RESULTS

Of 9185 work-related injuries in the WTR, 3380 (37%) did not link to workers' compensation claims. Use of payer information in hospital discharge records along with the WTR work-relatedness field identified 20% more linked injuries as work related (n = 720) than did use of payer information alone (n = 602). The WTR identified substantial numbers of work-related injuries that were not identified through workers' compensation or hospital discharge records.

CONCLUSIONS

Workers' compensation and hospital discharge databases are important but incomplete data sources for work-related injuries; many work-related injuries are not billed to, reported to, or covered by workers' compensation. Trauma registries are well positioned to capture severe work-related injuries and should be included in comprehensive injury surveillance efforts.