Work-related illness and injury claims among nationally certified athletic trainers reported to Washington and California from 2001 to 2011.

BACKGROUND: Little is known about the work-related injury and illnesses experienced by certified athletic trainers (AT). METHODS: The incidence and characteristics of injury/illness claims filed in two workers' compensation systems were described from 2001 to 2011. Yearly populations at risk were estimated from National Athletic Trainers' Association membership statistics. Incidence rate ratios (IRR) were reported by job setting. RESULTS: Claims were predominantly for traumatic injuries and disorders (82.7%: 45.7% sprains/strains, 12.0% open wounds, 6.5% bruises) and at these body sites (back 17.2%, fingers 12.3%, and knee 9.6%) and over half were caused by body motion and overexertion (51.5%). Compared with school settings, clinic/hospital settings had modestly higher claim rates (IRR = 1.29, 95% CI: 1.06-1.52) while other settings (e.g., professional or youth sport, nursing home) had lower claim rates (IRR = 0.63, 95% CI: 0.44-0.70). CONCLUSIONS: These first known estimates of work-related injuries/illnesses among a growing healthcare profession help identify occupational tasks and settings imposing injury risk for ATs. Am. J. Ind. Med. 59:1156-1168, 2016. © 2016 Wiley Periodicals, Inc.

Biomechanical and psychosocial exposures are independent risk factors for carpal tunnel syndrome: assessment of confounding using causal diagrams.

BACKGROUND: Between 2001 and 2010, six research groups conducted coordinated prospective studies of carpal tunnel syndrome (CTS) incidence among US workers from various industries to estimate exposure-response relationships. OBJECTIVE: This analysis examined the presence and magnitude of confounding between biomechanical and workplace psychosocial factors and incidence of dominant-hand CTS. METHODS: 1605 participants, without CTS at enrolment, were followed for up to 3.5 years (2471 person-years). Demographic information, medical history and workplace psychosocial stress measures were collected at baseline. Individual workplace biomechanical exposures were collected for each task and combined across the workweek using time-weighted averaging (TWA). CTS case criteria were based on symptoms and results of electrophysiological testing. HRs were estimated with Cox proportional hazard models. Confounding was assessed using causal diagrams and an empirical criterion of 10% or greater change in effect estimate magnitude. RESULTS: There were 109 incident CTS cases (IR=4.41/100 person-years; 6.7% cumulative incidence). The relationships between CTS and forceful repetition rate, % time forceful hand exertion and the Threshold Limit Value for Hand Activity Level (TLV-HAL) were slightly confounded by decision latitude with effect estimates being attenuated towards the null (10-14% change) after adjustment. The risk of CTS among participants reporting high job strain was attenuated towards the null by 14% after adjusting for the HAL Scale or the % time forceful hand exertions. CONCLUSIONS: Although attenuation of the relationships between CTS and some biomechanical and work psychosocial exposures was observed after adjusting for confounding, the magnitudes were small and confirmed biomechanical and work psychosocial exposures as independent risk factors for incident CTS.

The long-term burden of work-related carpal tunnel syndrome relative to upper-extremity fractures and dermatitis in Washington State.

BACKGROUND: Carpal tunnel syndrome (CTS) is among the most burdensome of all musculoskeletal disorders as measured by workers' compensation claims costs and lost earnings. But the burden of CTS extends beyond direct claim costs. METHODS: A survey covering health, social, economic and work-related outcomes was administered to 1,255 injured workers whose Washington State Fund workers' compensation claims had closed 6 years previously. Logistic and linear regression methods were used to model the outcomes of CTS claimants across four separate outcome domains. RESULTS: Workers diagnosed with CTS suffer substantial deficits across all four outcome domains as compared to the two comparison groups of claimants. Former CTS claimants were almost twice as likely not to be working as compared to the fractures cohort. CONCLUSIONS: A comprehensive measurement of the burden of CTS shows losses extend beyond direct claims costs to include continuing pain, loss of function, adverse financial impacts and household disruption which extend long after claim closure. Am. J. Ind. Med. 58:1255-1269, 2015. © 2015 Wiley Periodicals, Inc.

Contrasting patterns of care for musculoskeletal disorders and injuries of the upper extremity and knee through workers' compensation and private health care insurance among union carpenters in Washington State, 1989 to 2008.

BACKGROUND: Musculoskeletal symptoms and disorders (MSDIs) are common reasons for visits to medical providers in the general population and they are common work-related complaints. Prior reports raise concerns as to whether declines in workers' compensation (WC) rates represent true improvement in occupational health and safety or shifting of care to other payment systems. METHODS: By linking administrative records, we compared patterns of WC claims and private health care utilization for disorders of the upper extremity (UE) and knee among a large cohort of union carpenters over a 20-year period. RESULTS: As WC claim rates declined, private health care utilization increased. The increase was muted somewhat but sustained when adjusting for other patterns of health care utilization. CONCLUSIONS: Findings suggest the decline of WC claim rates do not solely represent improved occupational safety in this population, but also a considerable shifting of care to their private insurance coverage over time.

Workers' compensation claims for musculoskeletal disorders and injuries of the upper extremity and knee among union carpenters in Washington State, 1989-2008.

BACKGROUND: Numerous aspects of construction place workers at risk of musculoskeletal disorders and injuries (MSDIs). Work organization and the nature of MSDIs create surveillance challenges. METHODS: By linking union records with workers' compensation claims, we examined 20-year patterns of MSDIs involving the upper extremity (UE) and the knee among a large carpenter cohort. RESULTS: MSDIs were common and accounted for a disproportionate share of paid lost work time (PLT) claims; UE MSDIs were three times more common than those of the knee. Rates declined markedly over time and were most pronounced for MSDIs of the knee with PLT. Patterns of risk varied by extremity, as well as by age, gender, union tenure, and predominant work. Carpenters in drywall installation accounted for the greatest public health burden. CONCLUSIONS: A combination of factors likely account for the patterns observed over time and across worker characteristics. Drywall installers are an intervention priority.

Rates of and circumstances surrounding work-related falls from height among union drywall carpenters in Washington State, 1989-2008.

BACKGROUND: Drywall installers are at high risk for work-related falls from height (FFH). METHODS: We defined a 20-year (1989-2008) cohort of 5,073 union drywall carpenters in Washington State, their worker-hours, and FFH. FFH rate patterns were examined using Poisson regression. RESULTS: Drywall installers' FFH rates declined over time and varied little by worker age and time in the union. However, among FFH involving drywall sheets, workers with <10 union years were at high risk. Narratives consistently described the surface from which workers fell, commonly scaffolds (33%), ladders (21%), and stilts (13%). Work task, height fallen, protective equipment use, work speed, weather, influence of other workers/workgroups, and tool/equipment specifics were not often reported. PRACTICAL APPLICATIONS: In addition to continued efforts to prevent falls from scaffolds and ladders, efforts should address stilt use and less experienced workers who may have greater exposure. Consistency in reported narrative elements may improve FFH risk factor identification and prevention effort evaluation.

Effects of varying case definition on carpal tunnel syndrome prevalence estimates in a pooled cohort.

OBJECTIVE: To analyze differences in carpal tunnel syndrome (CTS) prevalence using a combination of electrodiagnostic studies (EDSs) and symptoms using EDS criteria varied across a range of cutpoints and compared with symptoms in both ≥1 and ≥2 median nerve-served digits. DESIGN: Pooled data from 5 prospective cohorts. SETTING: Hand-intensive industrial settings, including manufacturing, assembly, production, service, construction, and health care. PARTICIPANTS: Employed, working-age participants who are able to provide consent and undergo EDS testing (N=3130). INTERVENTIONS: None. MAIN OUTCOME MEASURES: CTS prevalence was estimated while varying the thresholds for median sensory latency, median motor latency, and transcarpal delta latency difference. EDS criteria examined included the following: median sensory latency of 3.3 to 4.1 milliseconds, median motor latency of 4.1 to 4.9 milliseconds, and median-ulnar sensory difference of 0.4 to 1.2 milliseconds. EDS criteria were combined with symptoms in ≥1 or ≥2 median nerve-served digits. EDS criteria from other published studies were applied to allow for comparison. RESULTS: CTS prevalence ranged from 6.3% to 11.7%. CTS prevalence estimates changed most per millisecond of sensory latency compared with motor latency or transcarpal delta. CTS prevalence decreased by 0.9% to 2.0% if the criteria required symptoms in 2 digits instead of 1. CONCLUSIONS: There are meaningful differences in CTS prevalence when different EDS criteria are applied. The digital sensory latency criteria result in the largest variance in prevalence.

Twenty years of workers' compensation costs due to falls from height among union carpenters, Washington state.

BACKGROUND: Falls from height (FFH) are a longstanding, serious problem in construction. METHODS: We report workers' compensation (WC) payments associated with FFH among a cohort (n = 24,830; 1989-2008) of carpenters. Mean/median payments, cost rates, and adjusted rate ratios based on hours worked were calculated using negative-binomial regression. RESULTS: Over the 20-year period FFH accounted for $66.6 million in WC payments or $700 per year for each full-time equivalent (2,000 hr of work). FFH were responsible for 5.5% of injuries but 15.1% of costs. Cost declines were observed, but not monotonically. Reductions were more pronounced for indemnity than medical care. Mean costs were 2.3 times greater among carpenters over 50 than those under 30; cost rates were only modestly higher. CONCLUSIONS: Significant progress has been made in reducing WC payments associated with FFH in this cohort particularly through 1996; primary gains reflect reduction in frequency of falls. FFH that occur remain costly.

How well are we controlling falls from height in construction? Experiences of union carpenters in Washington State, 1989-2008.

BACKGROUND: Falls from height (FFH) continue to cause significant morbidity and mortality across the construction industry. METHODS: By linking data on work hours with workers' compensation records, rates of work-related injuries resulting from FFH and associated days away from work were evaluated among a large cohort (n = 24,830) of union carpenters in Washington State from 1989 to 2008. Using Poisson regression we assessed rates of FFH over the 20-year period while adjusting for temporal trend in other work-related injuries. Patterns of paid lost days (PLDs) were assessed with negative binomial regression. RESULTS: Crude rates of FFH decreased 82% over the 20-year period. Reductions were more modest and without demonstrable change since 1996 when adjusting for the temporal reduction in other injuries. Younger workers had higher injury rates; older workers lost more days following falls. Rates of PLDs associated with falls decreased over time, but there was not a consistent decline in mean lost days per fall. CONCLUSION: These patterns are consistent with decreased FFH for several years surrounding state (1991) and then federal (1994) fall standards; the decline during this time period exceeded those seen in injury rates overall in this cohort. While crude rates of FFH have continued to decline, the decline is not as substantial as that seen for other types of injuries. This could reflect a variety of things including more global efforts designed to control risk (site planning, safety accountability) and changes in reporting practices.

Who pays for work-related traumatic injuries? Payer distribution in washington state by ethnicity, injury severity, and year (1998-2008).

BACKGROUND: Acute work-related trauma is a leading cause of death and disability for U.S. workers but it is difficult to obtain information about injured workers not covered by workers' compensation (WC). This study aimed to: (1) describe trends in expected payer and linkage to WC claims, (2) compare characteristics of injured workers who did and did not have a linked WC claim, and (3) describe variation in expected payer and linkage to WC claims by ethnicity and injury severity. METHODS: Data for injuries occurring from 1998 through 2008 were obtained from the Washington State Trauma Registry and linked to WC claims. RESULTS: We found that 27% of work-related traumatic injuries did not have WC listed as a payer, while 37% did not link to a WC claim. Among those with WC listed as a payer, the odds of having a linked WC claim were 57% lower for workers with other non-WC insurance compared with the otherwise uninsured. Latinos were more likely to have a linked WC claim compared with non-Latinos, but there was no significant difference after partially controlling for WC-covered employment and other insurance. CONCLUSIONS: This study demonstrated the importance of considering differential access to other insurance coverage and adaptation by health care settings to financial pressures when assessing trends in occupational injury incidence and reporting, especially when using WC as a proxy for work-relatedness. The addition of occupation, industry, and work status to trauma registries and hospital discharge databases would improve surveillance, research, policy and prevention efforts.

Effects of residential location and work-commuting on long-term work disability.

PURPOSE: Little is known about the independent effect of workers' residential location and work-commuting on their long-term disability due to work-related injuries. We examined 149,110 incident claims while adjusting for multiple risk factors in a large, population-based sample of Washington State workers' compensation State Fund claims during 2002-2008. METHODS: Claimants' residential addresses were geocoded with census tract and aggregated into four category classification of the Rural Urban Commuting Area Codes (RUCAs) which takes into account for tract-level work-commuting. We used logistic regressions to assess the association between RUCAs and whether or not a person was off work for more than 180 days due to injury; Quantile regressions to predict various percentiles of cumulative lost workdays by RUCAs. RESULTS: Compared to those who live in the Urban Core, workers in other areas experienced longer average paid time loss days due to work-related injury. The association between residential location and long-term disability was significant, odds ratio (OR) 1.19 (95 % confidence interval (CI) 1.11-1.27) for residents of Small Town and Isolated Rural and OR 1.17 (95 % CI 1.12-1.22) for those of Sub Urban, and persisted after controlling for injury nature, socio-demographic, employment-related, and claim administrative characteristics. The impact of residential location and work-commuting elevated as the duration of disability increased. CONCLUSIONS: This study shows that residential location and work-commuting has a significant and time-varying impact on duration of work disability. Workers living in Sub Urban and Small Town and Isolated Rural areas represent a particularly vulnerable group with respect to risk of long-term work disability.

Predicting work-related disability and medical cost outcomes: estimating injury severity scores from workers' compensation data.

PURPOSE: Acute work-related trauma is a leading cause of death and disability among US workers. The research objectives were to assess: (1) the feasibility of estimating Abbreviated Injury Scale-based injury severity scores (ISS) from ICD-9-CM codes available in workers' compensation (WC) medical billing data, (2) whether ISS predicts work-related disability and medical cost outcomes, (3) whether ISS adds value over other injury severity proxies, and (4) whether the utility of ISS differs for an all-injury sample compared with three specific injury samples (amputations, extremity fractures, traumatic brain injury). METHODS: ISS was estimated from ICD-9-CM codes using Stata's user-written -icdpic- program for 208,522 compensable nonfatal WC claims for workers injured in Washington State from 1998 to 2008. The Akaike Information Criterion and R(2) were used to compare severity measures. Competing risks survival analysis was used to evaluate work disability outcomes. Adjusted total medical costs were modeled using linear regression. RESULTS: Work disability and medical costs increased monotonically with injury severity. For a subset of 4,301 claims linked to the Washington State Trauma Registry (WTR), there was moderate agreement between WC-based ISS and WTR-based ISS. Including ISS together with an early hospitalization indicator resulted in the most informative models; however, early hospitalization is a more downstream measure. CONCLUSIONS: ISS was significantly associated with work disability and medical cost outcomes for work-related injuries. Injury severity should be considered as a potential confounder for occupational injury intervention, program evaluation, or outcome studies, and can be estimated using existing software when ICD-9-CM codes are available.

Twenty years of work-related injury and illness among union carpenters in Washington State.

BACKGROUND: Individuals who work in the construction industry are at high risk of occupational injury. Robust surveillance systems are needed to monitor the experiences of these workers over time. METHODS: We updated important surveillance data for a unique occupational cohort of union construction workers to provide information on long-term trends in their reported work-related injuries and conditions. Combining administrative data sources, we identified a dynamic cohort of union carpenters who worked in Washington State from 1989 through 2008, their hours worked by month, and their workers' compensation claims. Incidence rates of reported work-related injuries and illnesses were examined. Poisson regression was used to assess risk by categories of age, gender, time in the union, and calendar time contrasting medical only and paid lost time claims. RESULTS: Over the 20-year study period, 24,830 carpenters worked 192.4 million work hours. Work-related injuries resulting in medical care or paid lost time (PLT) from work occurred at a rate of 24.3 per 200,000 hr worked (95% CI: 23.5-25.0). Medical only claims declined 62% and PLT claims declined 77%; more substantive declines were seen for injuries resulting from being struck and falls to a lower level than from overexertion with lifting. Differences in risk based on union tenure and age diminished over time as well. CONCLUSIONS: Significant declines in rates of reported work-related injuries and illnesses were observed over the 20-year period among these union carpenters. Greater declines were observed among workers with less union tenure and for claims resulting in PLT.

Trends in the disproportionate burden of work-related traumatic injuries sustained by Latinos.

OBJECTIVE: Disproportionate occupational injury rates for Latinos are well documented, but there is limited information about whether disparity is increasing over time. This study describes trends in the burden of work-related traumatic injuries sustained by Latinos in Washington State. METHODS: Washington State Trauma Registry data from 1998 to 2008 were used to model annual change in the odds that a work-related traumatic injury was sustained by a Latino, controlling for demographics, injury-related factors, and Latino representation in the underlying labor force. RESULTS: We found a 5% mean annual increase in the odds that a comparable work-related traumatic injury was sustained by a Latino (P = 0.007). Falls in industrial/mine/quarry locations were the strongest contributor to increasing disparity. CONCLUSIONS: Latinos bear an increasingly disproportionate burden of occupational injuries and are less likely to have health insurance coverage aside from workers' compensation.

The impact of regulatory enforcement and consultation visits on workers' compensation claims incidence rates and costs, 1999-2008.

BACKGROUND: Studies of regulatory effectiveness have shown mixed evidence of impact of inspections on injury rates. We examine changes in workers compensation claims rates and costs for Washington employers having either an inspection, with or without citation, or a voluntary consultation activity. METHOD: We merge 10 years of enforcement and consultation activity with workers compensation records at the individual workplace level for stable firms with a single business location and at least 10 full-time employees. The change in claims incidence rates (CIRs) was estimated, controlling for workplace claims rate history, size, and industry. Separate analyses were performed for non-musculoskeletal and musculoskeletal (MSD) CIRs, claims costs and for enforcement activities with citation and without citation. RESULTS: Enforcement activities are associated with a significant reduction in CIRs and costs. Similar results may also be attributable to consultations. Inspections were associated with a 4% decline in time-loss claims rates relative to uninspected workplaces. The effect strengthens when MSD claims are excluded. Citations for non-compliance are associated with a 20% decline in non-MSD CIRs relative to uninspected workplaces. There is also some evidence for a reduction in MSD claims rates beginning in the second year following inspection. Enforcement and consultation activity is associated with substantial decreases in claims costs. CONCLUSIONS: Enforcement activities make a significant contribution to reducing CIRs and costs. Similar results following consultations may also exist. Inspections with citations are more effective than those without. Claims rates for non-MSD injuries, related to hazards covered by specific standards, are more affected in the year following the visit, while those for MSDs take longer to begin falling.

Identification of work-related injuries in a State Trauma Registry.

OBJECTIVE: Many state trauma registries contain work-related information but are underutilized for occupational injury research/surveillance. We assessed three methods of identifying work-related injuries in the Washington State Trauma Registry (WTR). METHODS: State-designated trauma facilities report traumatic injuries meeting specific inclusion criteria to the WTR. The WTR reports from 1998 to 2008 were linked to workers' compensation claims to generate sensitivity estimates. RESULTS: The sensitivity of the WTR work-related indicator was 87%, varying significantly by injury mechanism/location. Sensitivity was 89% for payer and 60% for an indicator based on International Classification of Diseases-9th Revision-Clinical Modification external cause codes. CONCLUSIONS: The WTR work-related indicator is highly sensitive and may identify injuries that occur in the course of exempt/excluded employment, are not reported to workers' compensation, and/or are work-related using definitions that go beyond WC coverage. Judicious use of external cause codes may identify additional work-related injuries.

Occupational health and safety surveillance and research using workers' compensation data.

OBJECTIVE: Examine uses of US workers' compensation (WC) data for occupational safety and health purposes. METHODS: This article is a summary of the proceedings from an invitational workshop held in September 2009 to discuss the use of WC data for occupational safety and health prevention purposes. RESULTS: Workers' compensation data systems, although limited in many ways, contain information such as medical treatments, their costs and outcomes, and disability causes that are unavailable from national occupational surveillance sources. CONCLUSIONS: Despite their limitations, WC records are collected in a manner consistent with many occupational health and safety surveillance needs. Reports are available on the use of WC data for surveillance and research purposes such as estimating the frequency, magnitude, severity, and cost of compensated injuries. Inconsistencies in WC data can limit generalization of research results.

The persistent gap in health-care coverage between low- and high-income workers in Washington State: BRFSS, 2003-2007.

OBJECTIVES: We examined the disparities in health-care coverage between low- and high-income workers in Washington State (WA) to provide support for possible policy decisions for uninsured workers. METHODS: We examined data from the WA Behavioral Risk Factor Surveillance System 2003-2007 and compared workers aged 18-64 years of low income (annual household income <$35,000) and high income (annual household income ≥$35,000) on proportions and sources of health-care coverage. We conducted multivariable logistic regression analyses on factors that were associated with the uninsured. RESULTS: Of the 54,536 survey respondents who were working-age adults in WA, 13,922 (25.5%) were low-income workers. The proportions of uninsured were 38.2% for low-income workers and 6.3% for high-income workers. While employment-based health benefits remained a dominant source of health insurance coverage, they covered only 40.2% of low-income workers relative to 81.5% of high-income workers. Besides income, workers were more likely to be uninsured if they were younger; male; Hispanic; less educated; not married; current smokers; self-employed; or employed in agriculture/forestry/fisheries, construction, and retail. More low-income workers (28.7%) reported cost as an issue in paying for health services than did their high-income counterparts (6.7%). CONCLUSION: A persistent gap in health-care coverage exists between low- and high-income workers. The identified characteristics of these workers can be used to implement policies to expand health insurance coverage.

Medical care surrounding work-related back injury claims among Washington State Union Carpenters, 1989-2003.

OBJECTIVE: We describe medical care received through workers' compensation (WC) and union-provided insurance surrounding work-related back injuries and examine relationships between care provided and time off work among a large cohort of carpenters. METHODS AND PARTICIPANTS: Union records identified a cohort of 20,642 carpenters working in Washington State from 1989-2003 and their private health insurance claims. These data were linked to workers' compensation files from this state-run program including records of medical care. RESULTS: Over 74,000 WC medical encounters resulted from 2959 work-related back injuries. Eleven percent received private care for musculoskeletal back pain within 90 days of work-related injury; this proportion increased with increasing lost days. Delay to physical therapy was more prevalent among those out of work longest. The proportion of claimants with care from both systems and from private utilization only increased after the first 90 days and, for the subset with at least one paid lost work day, after return to work. CONCLUSIONS: Examination of medical care through both systems versus solely in workers' compensation provides a more complete understanding of back injury care while also demonstrating complexity. Differences in outcomes based upon treatment shortly after injury are worthy of further exploration.

Burden of work-related knee disorders in Washington State, 1999 to 2007.

OBJECTIVE: To describe the burden of knee work-related musculoskeletal disorders (WMSDs). METHODS: Knee WMSDs were identified using Washington State Fund workers' compensation data from 1999 to 2007 and analyzed by cost, industry, occupation, and claims incidence rates. RESULTS: Knee WMSDs accounted for 7% of WMSD claims and 10% of WMSD costs. The rate of decline in claims incidence rates for knee WMSDs was similar to the rate of decline for all other WMSDs. Industries at highest risk for knee WMSDs included construction and building contractors. Occupations of concern included carpenters and truck drivers in men and nursing aides and housekeepers in women. CONCLUSIONS: Between 1999 and 2007, Washington State Fund knee WMSDs were widespread and associated with a large cost. Identification of specific occupational knee WMSD risk factors in high-risk industries is needed to guide prevention efforts.