The Effectiveness of Standard Care, Early Intervention, and Occupational Management in Workers Compensation Claims

The Effectiveness of Standard Care, Early Intervention, and Occupational Management in Workers Compensation Claims Part 2 Mark Lemstra, MSc and W. P. Olszynski, MD, PhD, FRCP(C) SPINE Volume 29, Number 14, pp 1573 1579 2004, Lippincott Williams & Wilkins, Inc. Study Design. A prospective cohort. Objectives. To compare the effectiveness of standard care, early intervention treatment, and occupational management in the management of Workers Compensation injury claims. Summary of Background Data. The current management of occupational back pain and work-related upper extremity disorders with either standard care or early intervention treatment appears to be ineffective. Methods. A prospective cohort looked at the effect of one company with access to standard care (primary care) changing to occupational management (worksite encouragement to resume activity and work as soon as safely possible) and then to early intervention treatment (offsite work hardening). This information was then compared with the control company with access to early intervention treatment, which later changed to a combined occupational management/early intervention treatment approach. Survival analysis was used to attempt to explain differences in time to injury claim closure. Results. Occupational management resulted in lower injury claim incidence, duration, and costs than early intervention treatment. Only the covariate of enhanced physical therapist (work hardening) involvement (2001 hazard rate ratio 17.41, 95% confidence interval 3.72 41.51 and 2002 hazard rate ratio 6.22, 95% confidence interval 2.51 15.40) was associated with delayed time to injury claim closure when the company had access to early intervention treatment. Only the covariate of serious injury was associated with delayed time to injury claim closure in the company when it had access to occupational management (hazard rate ratio 1.67, 95% confidence interval 1.05 27.20). Conclusions. It is recommended that an occupational management approach, in comparison to early intervention treatment and standard care, be considered for management of occupational injuries. Key words: Workers Compensation, incidence, disability, cost, early intervention, standard care, occupational management. Spine 2004;29:1573 1579 From the College of Medicine, University of Saskatchewan, Saskatoon, Canada. Acknowledgment date: April 29, 2003. First revision date: July 1, 2003. Acceptance date: September 18, 2003. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence to W.P. Olszynski, MD, PhD, College of Medicine, University of Saskatchewan, 103 Hospital Drive, Saskatoon, Saskatchewan S7N 0W8, Canada; E-mail: olszynski@webster.sk.ca Systematic literature reviews and randomized controlled trials have consistently encouraged minimal clinical intervention, reassurance of a good prognosis, encouragement to resume normal activity as soon as possible, and the provision of simple exercises as a management approach for musculoskeletal disorders. 1 7 Despite these evidence-based recommendations, the Workers Compensation Board (WCB) of Saskatchewan, Canada, initiated a standardized, treatment-focused, Early Intervention Program (EIP) to injury claims management. The EIP includes early and intensive physical therapy and work-hardening programs immediately after injury. If the injured worker is not at work at 6 weeks, the Workers Compensation Board intervenes with a multidisciplinary assessment team consisting of a family physician, chiropractor, physical therapist, and psychologist (if requested) to review the file and examine the patient. If the patient has any number of non injury-related WCB determined risk factors (28 in total), 8 the patient is referred to expanded secondary or tertiary treatment, which includes work hardening up to 4 hours a day, education on hurt versus harm, and weekly psychological intervention. The secondary or tertiary treatment provider becomes the case manager responsible for return to work based on functional findings. The multidisciplinary assessment ranges in cost from $900 to $1,800 per client depending on whether or not the psychologist is included. Secondary treatment programs are on average 34.5 treatment days at $119 per day, and tertiary treatment programs are on average 45.9 treatment days at $151 per day. 8 10 The EIP program began in September 1996 in the two largest cities in Saskatchewan with the mandate of gradually progressing to every city in the province. Currently, 75% of the multidisciplinary assessment recommendations at 6 weeks are for secondary or tertiary treatment with very few recommendations for standard care (defined as primary care by a medical physician, chiropractor, or physical therapist) or return to work on modified or light duties. 9 This is despite the knowledge that early identification of patients thought to be destined for chronicity, with the intention of offering more intensive treatment before chronicity sets in, represents a Holy Grail approach to musculoskeletal management in a workers compensation setting. 2 The population-based results of EIP in Saskatchewan have not been encouraging. In 5 years, annual medical and rehabilitation costs have increased from $23.4 million to $60.1 million. Wage replacement costs have increased from $86.7 million to $138.5 million. Total in- 1573

1574 Spine Volume 29 Number 14 2004 Table 1. WCB Injury Claims History in Saskatchewan by Year 1996* 1997 1998 1999 2000 2001 Total injury claims accepted 31,732 33,545 32,348 31,476 32,927 33,552 Total time loss injury claims accepted 13,018 13,430 13,081 13,108 14,433 14,786 Total medical and rehabilitation costs (million) $23.4 $26.4 $29.0 $31.4 $37.4 $60.1 Total wage replacement costs (million) $86.7 $98.4 $103.4 $108.2 $104.6 $138.5 Total injury costs (million) $143.4 $160.9 $172.8 $185.5 $189.8 $277.5 Average time loss injury duration (days) 21.4 22.2 23.9 24.9 25.8 27.2 Average time loss duration 4 weeks (days) 6.4 6.5 6.5 6.5 6.7 NA Average time loss duration 4 weeks (days) 81.5 82.0 84.6 86.5 86.7 NA Reopened claims within 6 months of claim closure 4,504 4,910 5,942 6,482 7,637 NA Overall return-to-work success rates 72% 72% 62% 59% NA NA NA information unavailable at time of publication. * Last year of standard care. First year of Early Intervention Program (each year more cities in the province gained access to the program). jury costs have increased from $143.4 million to $277.5 million. 11 16 These changes were observed despite nominal change in the province in health care inflation (7.6%), employee wage inflation (17.0%), and overall inflation (10.1%). 17,18 Actual WCB health care inflation, in comparison to provincial health care inflation, was negligible (approximately 1%). Average time loss injury claim duration increased from 21.4 days to 27.2 days, the rate of annual reopened claims increased from 4,504 to 7,637, and the overall return to work success rate decreased from 72% to 59% 8,9 (Table 1). Previous research by the authors has demonstrated that an occupationally based management program (hereinafter labeled as occupational management) that focused on injury prevention, minimal clinical intervention, reassurance of a good prognosis, encouragement to resume normal activity as soon as possible, simple exercises, and early return to work (on time limited and monitored modified or light duties by an independent practitioner) had significant effects on time loss injury claim incidence, duration, and costs in comparison to previous standard care in the intervention company and EIP in the control company. 19 The purpose of the current study was to determine the effect of reversing the occupational management at a company in favor of EIP protocols while monitoring the control company with EIP that had recently gained access to occupational management protocols. Materials and Methods Study Population and Design. A retrospective cohort was formed in Company A when it had access only to standard care in 1999. A prospective cohort in 2000 was formed when the company gained access to occupational management and prospective cohorts were formed in 2001 and 2002 when the company reversed its occupational management approach in favor of mandatory state regulated EIP protocols in January 2001. The entry date for each cohort was January 1 to December 31 of each particular year with a claim closure date of March 31 of the following year. Occupational management was introduced and reversed by the researchers at no cost to the company (Table 2). A retrospective cohort was formed in 1999 and prospective cohorts were formed in 2000 and 2001 for Company B when it had access to EIP. Another prospective cohort was formed in 2002 when Company B gained access to occupational management (by way of the researchers) while maintaining mandatory EIP protocols. The entry date for each cohort was January 1 to December 31 of each year with a claim closure date of March 31 of the following year. Company B was thought to be similar in all known factors to Company A (WCB industry code, WCB industry subcode, company size, company hours worked, measured work demands, company psychosocial factors, union membership, and management structure) 19 except that it had access to EIP throughout the entire 4-year period. The only other equally comparable company in the province had access to EIP and had a similar claims experience to Company B (data not shown). All of the companies were in the meat industry. A prospective cohort was also formed for Company B for 2001 in a neighboring province that did not have statesponsored and mandatory EIP requirements. Company B in Saskatchewan and Company B in Alberta were owned and Table 2. Flow Chart and Definitions Year Company A (SK) Company B (SK) Company B (AB) 1999 Standard care EIP NA 2000 Occupational EIP NA management 2001 EIP EIP Standard care 2002 EIP EIP/occupational management NA NA not available. Standard care medical doctor, chiropractor, or physical therapist. EIP No focus on injury prevention at worksite; immediate and intensive physical therapy and work hardening; Multidisciplinary assessment at 6 weeks; After 6 weeks, expanded work hardening up to 4 hours a day; Psychology, education on hurt versus harm and case management; Employer responsible only for work-related pain; no onsite healthcare assistance; Program initiated, monitored and reviewed by WCB; Standardized assessment, recommendations and treatment; WCB responsible for implementing carepatient responsible for following recommendations; Return to work based on functional information alone; Focus on injury prevention (ie. job rotations, ergonomic protocols). Occupational management Minimal clinical intervention; Reassurance of a good prognosis and education on injury; Encouragement to resume normal activity and education on self-care; Simple exercise; Early return to work on time limited and monitored light or modified duties; Employer accommodates both work and non-work related pain; Onsite assistance provided by independent and neutral health care provider; Program initiated, monitored and reviewed by management and workers (union); Consideration for individual beliefs, attitudes and expectations; Patient responsible for own self-care; Return to work based on discussion between all interested parties. SK Saskatchewan. AB Alberta.

Workers Compensation Claims Lemstra and Olszynski 1575 operated by the same company and were identical in every way including identical plant designs, physical/ergonomic influences, management structure and team, wages, and unionized workforce. Both companies also had similar gender and age makeup of its production workforce (data not shown). The only known distinction between the two companies was access to standard care in the Alberta plant and access to EIP in the Saskatchewan plant. The year 2001 was chosen because this was the last year that Company B in Saskatchewan did not have access to occupational management. Outcome Measures. The outcome measures were the number of work-related total time loss injury claims (hereinafter labeled injury claims), time loss back sprain/strain injury claims (hereinafter labeled back claims), time loss upper extremity musculoskeletal sprain/strain claims (hereinafter labeled upper extremity claims), the disability duration of all of the above, and the total compensation costs of all the above. Time loss claims (injured and off work for more than 1 day) were used for comparison instead of no time loss claims (injured but no time off work past 1 day). Upper extremity musculoskeletal injuries were defined as any strain/sprain from the wrist joint to the shoulder joint. Back injuries were defined as any strain/sprain of the lower (L5) to mid back (T6). Twelve month cumulative incidence rates were calculated with the total number of hours worked at each particular place of employment as the denominator. The primary interest of the study was to determine the effect of EIP in 2002 in Company A on back and upper extremity injury claims in comparison to occupational management in 2000 while monitoring the control company (Company B). As such, rate ratios were used to determine the effect of changing from occupational management in 2000 to EIP in 2002 in Company A. 20,21 Relative (or proportional) values of the rate ratios were then used to determine the effect of the change in Company A in comparison with the control group (Company B), which switched from EIP in 2000 to a combined EIP and occupational management approach in 2002. 20,21 The z statistic (log of rate ratio in Company A log of rate ratio in Company B/standard error, in comparison to normal distribution) determined if the change was significant. 20 The secondary interest of the study was to investigate the association between overall claim closure (WCB claim terminated due to recovery or administrative reason) from all injury claims between Company A in 2000 (occupational management) and 2001 and 2002 (EIP). Cox proportional-hazard models were constructed to determine the association between time to claim closure and the covariates of age (above or below the age of 40 years), gender, duration of employment (less or more than 3 months with company), wage (above or below mean of $67 a day), previous WCB time loss claim, injury location and severity, hospital visit, health care provider (medical physician, chiropractor, or physical therapist), and association between the employer and the injured workers physician, the injured worker s WCB client service representative, and the injured worker himself all measured by interview with the employer. To accommodate for sample size, a hierarchal well-formulated modeling approach was used instead of a computer-generated stepwise algorithm. 21 The unadjusted effect of each covariate was determined and then entered one step at a time based on changes in the 2 log likelihood and the Wald test. 22 The final model includes factors with beta values for which the P values were less than 0.05. The ph assumption was assessed by the log-log Cox adjusted survival estimate stratified by company against the log of time. 22 The results are presented as hazard rate ratios with 95% confidence intervals. All analyses were performed with an SPSS 10.0 software package. 23 Results Occupational Management (Company A; 2000) followed by EIP (Company A; 2002) Company A had substantial changes in injury claim incidence, duration, and costs when changing from an occupational management approach in 2000 to an EIP treatment approach in 2002. Injury claim incidence for upper extremity claims increased from 0.6 to 3.6 while back claims rose from 0.6 to 1.5 per 100,000 hours worked. Total days lost increased from 12.3 to 225.4 days for upper extremity claims while back claims increased from 1.1 to 95.8 days lost per 100,000 hours worked. Total costs increased from $597 to $29,182 for upper extremity claims while back claims increased from $287 to $10,011 per 100,000 hours worked (Table 3). By calculating the rate ratio, we find that the rate of injury occurrence for upper extremity and back claims combined increased by 76% in 2 years (rate ratio 0.24; 95% confidence interval 0.10 0.57). As well, we find that by calculating the rate ratio for total days lost for both upper extremity and back claims, the rate of days lost has been increased by 96% in 2 years (rate ratio 0.04; 95% confidence interval 0.03 0.05) (Table 3). EIP (Company B; 2000) Followed by EIP/Occupational Management (Company B; 2002) In comparison, injury claim incidence, duration, and costs in Company B reduced when it switched from EIP in 2000 to a combined EIP/occupational management approach in 2002. Incidence for upper extremity claims decreased from 8.9 to 3.0 while back claims declined from 5.4 to 3.8 per 100,000 hours worked. Total days lost decreased from 662.6 to 253.7 days for upper extremity claims while back claims reduced from 280.1 to 90.4 days lost per 100,000 hours worked. Total costs reduced from $73,136 to $33,986 for upper extremity claims and from $29,737 to $9084 for back claims per 100,000 hours worked (Table 3). We find that injury claim incidence per 100,000 hours worked in the control company (Company B) reduced by 52% for upper extremity and back claims combined (rate ratio 0.48; 95% confidence interval 0.28 0.80). Total days lost per 100,000 hours worked for upper extremity and back claims reduced by 63% (rate ratio 0.37; 95% confidence interval 0.34 0.39) (Table 3). To determine the significance of the change in Company A from occupational management in 2000 to EIP in 2002 in comparison to the control company (Company B) with access to EIP in 2000 and EIP/occupational management in 2002, the relative (or proportional) values of the rate ratios were compared. The z statistic for upper extremity and back time loss injury claim incidence between the two companies is 4.18 (P 0.000). The z statistic for upper extremity and back time loss days be-

1576 Spine Volume 29 Number 14 2004 Table 3. Incidence, Disability, and Cost Differences Between Three Companies in Meat Industry Total WRUEM* Back Company A (Saskatchewan) 2002 (EIP) Injury claims/100,000 hrs worked 6.6 3.6 1.5 Total days lost/100,000 hrs worked 325.7 225.4 95.8 Total compensation/100,000 hrs worked $39,863 $29,182 $10,011 2001 (EIP) Injury claims/100,000 hrs worked 6.3 1.3 2.4 Total days lost/100,000 hrs worked 208.3 88.1 76.5 Total compensation/100,000 hrs worked $16,360 $6,487 $6,647 2000 (occupational management) Injury claims/100,000 hrs worked 3.2 0.6 0.6 Total days lost/100,000 hrs worked 66.1 12.3 1.1 Total compensation/100,000 hrs worked $6,028 $597 $287 1999 (standard care) Injury claims/100,000 hrs worked 7.9 2.3 2.6 Total days lost/100,000 hrs worked 220.4 138.5 60.9 Total compensation/100,000 hrs worked $25,878 $15,777 $8,713 Company B (Saskatchewan) 2002 (EIP and occupational management) Injury claims/100,000 hrs worked 10.4 3.0 3.8 Total days lost/100,000 hrs worked 554.1 253.7 90.4 Total compensation/100,000 hrs worked $77,571 $33,986 $9,084 2001 (EIP) Injury claims/100,000 hrs worked 16.7 8.8 4.6 Total days lost/100,000 hrs worked 1,22.9 664.3 387.6 Total compensation/100,000 hrs worked $132,097 $92,398 $32,554 2000 (EIP) Injury claims/100,000 hrs worked 21.8 8.9 5.4 Total days lost/100,000 hrs worked 1,129.2 662.6 280.1 Total compensation/100,000 hrs worked $120,459 $73,136 $29,737 1999 (EIP) Injury claims/100,000 hrs worked 22.4 7.3 4.0 Total days lost/100,000 hrs worked 1,224.8 731.6 141.0 Total compensation/100,000 hrs worked $133,902 $80,816 $12,296 Company B (Alberta) 2001 (standard care) Injury claims/100,000 hrs worked 2.1 0.3 0.3 Total days lost/100,000 hrs worked 58.9 0.9 0.3 Total compensation/100,000 hrs worked $7,076 $299 $39 *Work related upper extremity musculoskeletal disorder. tween the two companies is 16.15 (P 0.000). Both z scores suggest that the change from occupational management to EIP had a statistically significant effect on increasing the incidence rate and total days lost of upper extremity and back claims in Company A in comparison to the control group (Company B). EIP (Company B, Saskatchewan; 2001) in Comparison to Standard Care (Company B, Alberta; 2001) The claims experience of Company B in Saskatchewan was compared to its sister company in Alberta for the year 2001. In Company B in Saskatchewan in 2001, injury claim incidence for upper extremity and back claims was 8.8 and 4.6 per 100,000 hours worked while the incidence for these same injuries was 0.3 and 0.3 per 100,000 hours worked in Company B in Alberta in the same year. Injury claim duration for upper extremity and back claims in Company B in Saskatchewan in 2001 was 664.3 and 387.3 days per 100,000 hours worked while these same injuries were 0.9 and 0.3 days per 100,000 hours worked in Company B in Alberta (Table 3). Table 3 puts numbers to the progressions listed in Table 2. In general, the results can be summarized as Company A lowering injury claim incidence, duration, and costs when switching from standard care in 1999 to occupational management in 2000 but then substantially increasing these same three measures when converting to EIP in 2001. In comparison, Company B had access to EIP from 1999 to 2001 and had considerably higher injury claim incidence, duration, and costs than Company A. Company B then lowered these measures significantly when gaining access to occupational management in 2002. The sister company for Company B in Alberta, with access only to standard care, had much lower injury claim incidence, duration, and costs in comparison to its Saskatchewan plant with access to EIP. Closure of Claims (Company A, with Occupational Management in 2000, Followed by EIP in 2001 and 2002) Changes in incidence, disability duration, and costs were observed after controlling for injury location, severity, and hours worked between Company A in 2000 (occupational management) and 2001 and 2002 (EIP). Because of the uncertainty about the reasons for the differences observed, a Cox proportional-hazard model for

Workers Compensation Claims Lemstra and Olszynski 1577 Table 4. Factors Associated With Time to Injury Claim Closure: Company A Hazard Rate Ratio (95% CI)* Factor Occupational Management (2000) EIP (2001) EIP (2002) Physical therapist involvement No 1.00 1.00 Yes 17.41 (3.72 41.51) 6.22 (2.51 15.40) Injury severity Minor injury (cut, bruise, other) 1.00 Back or upper extremity strain or sprain 1.50 (0.83 24.29) Serious injury (fracture, break, dislocation, head injury) 1.67 (1.05 27.20) * Hazard rate ratios have been adjusted for all other significant factors in the model. CI confidence interval. This is the reference category. total time loss injury claim closure was constructed. One case was censored in Company A in 2000 (serious injury), 5 cases were censored in 2001 (1 back, 3 upper extremity, 1 minor injury), and 5 cases were censored in 2002 (1 back and 4 upper extremity) due to nonfinalized claims on March 31 of the following year. When the company had access to EIP in 2001 and 2002, the only variable with a significant influence on delayed time to claim closure was enhanced physical therapist involvement (hazard rate ratios 17.41; 95% CI 3.72 41.51 and 6.22; 95% CI 2.51 15.40). In comparison, the only variable with an unadjusted or adjusted significant influence on delayed time to claim closure in the company when it had access to occupational management in 2000 was injury severity (serious injury hazard rate ratio 1.67; 95% CI 1.05 27.20) (Table 4). Figure 1 demonstrates that there is no noticeable difference between the adjusted survival curves representing Company A in 2001 and 2002 (EIP) but that both of these curves have a visually observable difference with the adjusted survival curve representing the year 2000 (occupational management). Figure 1. Survival curve (adjusted) estimates of the time to injury claim closure between Company A in 2000 (Occupational Management), 2001 (EIP), and 2002 (EIP). Discussion The introduction of an EIP in the province of Saskatchewan, Canada, has resulted in population-based increases in injury claim incidence, injury claim duration, injury claim medical costs, injury claim compensation costs, injury claim total costs, injury claim treatment duration, injury claim reopening rates, and overall lower return to work rates. Because of the lack of consistency associated with injury claim entitlement and termination at WCB, 8 and the nonspecific nature of most musculoskeletal injuries, 2 multidisciplinary assessments were initially intended as a form of claims adjudication. Based on concerns from the community, the focus of the assessments quickly moved from claims adjudication to treatment triage with recommendations for primary, secondary, or tertiary treatment. In 4 years, the number of referrals to secondary or tertiary treatment increased by 284%. 9 The rationale behind work-hardening programs is based on a published position at WCB that their responsibility is to ensure the worker is able to return to work, not to ensure the worker, in fact, returns to work. 8 As such, injured workers are potentially discharged at the completion of work-hardening programs as fit to return to work with little knowledge if they actually returned to work, let alone safely returned to work over a sustained period of time. This point is important because it appears ironic that injured workers with the least amount of clinical findings and the most WCB determined noninjury risk factors receive the most clinical treatment. 8 As such, work-hardening programs are used as a form of claims adjudication. Either the patient is discharged as fit to work and returns to work or the patient is discharged as fit to work and does not return to work with a subsequent termination of benefits. The large and growing rate of reopened claims within 6 months of claim closure (41% increase since EIP introduction) indicates that a process driven protocol, in comparison to an outcomes based protocol, has not been effective. 9 In the current study, the company (Company A) that switched from an occupational management approach that focused on minimal clinical intervention and maxi-

1578 Spine Volume 29 Number 14 2004 mal worksite coordination to an EIP protocol that focused on maximal clinical intervention but minimal worksite coordination had significant increases in injury claim incidence, duration, and costs. The relative or proportional increases in injury claim incidence and duration were statistically significant in comparison to the control company (Company B). The results of the Cox proportional-hazard model suggest that rapid and enhanced physical therapist involvement (EIP) negatively influenced the time to injury claim closure by a factor of 6 to 17. This association maintained its influence throughout all steps of the survival model while controlling for all other covariates, including injury severity. In other words, rapid and enhanced physical therapist involvement (EIP) is more likely a predictor of delayed claim closure than a result of it. In a previous study conducted by the authors, rapid and enhanced physical therapist involvement negatively influenced the time to injury claim closure in the control company (Company B) by a factor of 20. 19 There is a specific point to consider when reviewing the findings. Injury claim incidence, duration, and costs reduced in Company A when switching from standard care in 1999 to occupational management in 2000. These numbers then increased when the company switched from occupational management in 2000 to EIP in 2001 and 2002. It is possible that the occupational management group responded differently in comparison to the EIP and standard care groups as a result of the special attention and interest that they received, a phenomenon called the Hawthorne effect. The occupational management was designed and monitored by both management and workers. It is therefore possible that the injured workers with access to occupational management in 2000 might have wanted to assist with favorable results and early return to work despite continued presence of pain. Given the cohort design of the study, in comparison to a randomized trial, the degree of confidence that the researchers can realistically assign to any causal link is limited. However, the logistical, ethical, and legal requirements in the current situation (state sponsored and mandatory EIP program) make experimental designs impractical. As such, multiple comparisons from multiple sources on multiple levels are required in a quasi-experimental setting. If the occupational management was indeed effective in reducing injury claim incidence, duration, and cost in comparison to standard care and EIP, what is the theoretical basis supporting this argument? It is now well known that Workers Compensation claims are much more complex than simply identifying the physical injury and providing effective medical or physical treatment alone. 2 Occupational low back pain and work-related upper extremity musculoskeletal disorders are multidimensional in nature and require the recognition of other social, legal, cultural, organizational, and economic factors that contribute to the genesis of illness and disability. 2 If we accept Rothman s multiple and variable model of causation, we can then assume that many of the factors leading to Workers Compensation injury claim incidence and duration are actually present before the injury claim. 21 As such, the solution needs to be multidimensional and collaborative. Although there is still limited evidence on the effectiveness of primary prevention strategies like job rotation and ergonomic redesign, it is plausible to believe that the psychosocial and job satisfaction benefits gained might have as much benefit as the reduction in physical workload. Management retraining toward acceptance and accommodation of work (and even non work-related) injuries, the early detection and reporting of injuries (without reprimand), the onsite provision of simple exercises and management approaches, the reassurance of a good prognosis and the provision of time limited and monitored modified or light duties are all considered essential to occupational management. 2,24 As discussed by some authorities, the provision of alternate or light duties should be the responsibility of an independent and neutral health care provider with the authority to negotiate job modifications while maintaining constant communication with all interested parties including the family physician. 2,24 This component is considered essential because of the normally wide ranging and diverse interests between all parties concerned with the return to work process. As such, it is important that both management and the workers agree that the primary intention of occupational management is worker well-being and not simply reduction of costs. 2 If cost savings remains an issue, potential savings could be transferred to additional worker health and safety initiatives, such as accommodations for injured workers with permanent functional impairment. Regardless, both management and workers need to be part of the design, implementation, and monitoring process of occupational management if it is to work. The lack of knowledge at the worksite, and the multitude of factors that can influence successful and long-term return to work, is the weakness of any clinically based program. 2 There are four potential explanations for the large differences noted between Saskatchewan and Alberta in the current study. The first is the difference in treatment offered (EIP in comparison to standard care). The second is Alberta s mandate to ensure that employers actually offer and employees actually accept temporary modified or light duties. The third is Alberta s strong conservative base in comparison to Saskatchewan s strong socialist base. The fourth is Alberta s strong economy in comparison to Saskatchewan s relatively weaker economy. A combination of all four is the most likely to account for some or most of the differences observed. Recently, a systematic literature review of all of the available evidence surrounding occupational management of low back pain was concluded. 25 Overall, the evidence suggested that the variables with the strongest influence on work-related injury claim incidence and duration included the following: individual and work-

Workers Compensation Claims Lemstra and Olszynski 1579 related psychosocial factors are more important than clinical features or physical demands of work, traditional education on injuries is not effective unless it addresses individual beliefs, attitudes, and expectations, low job satisfaction and unsatisfactory psychosocial aspects of work are risk factors, advice to resume ordinary activities as quickly as possible despite moderate pain is important, encouragement is necessary for the patient to take responsibility for their own self-care, communication is required with all interested parties in the return to work process, return to work must occur as soon as safely possible despite moderate pain, the acknowledgment that most clinical interventions are ineffective at returning patients back to work, and the need for the temporary provision of light or modified duties and that active rehabilitation (in comparison to passive or symptomatic care) should occur in an occupational setting in comparison to a health care setting. 25 The authors believe that these evidence-based guidelines are consistent with the findings and recommendations of the current study. Conclusion The provision of rapid and expanded physical therapy programs (EIP) on a population-based level in the province of Saskatchewan has proven to be ineffective across varying outcomes. On an industry level, occupational management appears to be more effective than early intervention treatment. Because of the many complex factors surrounding work-related injuries, it is suggested that more employee-focused and independent occupational management protocols be initiated at the worksite to prevent disability in the workforce. Key Points Occupational management resulted in lower injury claim incidence, duration, and costs than early intervention treatment. Only the covariate of enhanced physical therapist involvement was associated with delayed time to injury claim closure when the company had access to early intervention treatment. 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