Opioid-related mortality after occupational injury in Washington State: accounting for preinjury opioid use.

OBJECTIVES: To estimate the impact of occupational injury and illness on opioid-related mortality while accounting for confounding by preinjury opioid use. METHODS: We employed a retrospective cohort study design using Washington State workers' compensation data for 1994-2000 injuries linked to US Social Security Administration earnings and mortality data and National Death Index (NDI) cause of death data from 1994 to 2018. We categorised injuries as lost-time versus medical-only, where the former involved more than 3 days off work or permanent disability. We determined death status and cause of death from NDI records. We modelled separate Fine and Gray subdistribution hazard ratios (sHRs) and 95% CIs for injured men and women for opioid-related and all drug-related mortality through 2018. We used quantitative bias analysis to account for unmeasured confounding by preinjury opioid use. RESULTS: The hazard of opioid-related mortality was elevated for workers with lost-time relative to medical-only injuries: sHR for men: 1.53, 95% CI 1.41 to 1.66; for women: 1.31, 95% CI 1.16 to 1.48. Accounting for preinjury opioid use, effect sizes were reduced but remained elevated: sHR for men was 1.43, 95% simulation interval (SI) 1.20 to 1.69; for women: 1.27, 95% SI 1.10 to 1.45. CONCLUSIONS: Occupational injuries and illnesses severe enough to require more than 3 days off work are associated with an increase in the hazard of opioid-related mortality. The estimated increase is reduced when we account for preinjury opioid use, but it remains substantial. Reducing work-related injuries and postinjury opioid prescribing and improving employment and income security may decrease opioid-related mortality.

Adding injury to insult: Unfair treatment at work and occupational injury among hospital patient-care workers.

BACKGROUND: Hospital patient-care workers have high occupational injury rates. While physical hazards within hospital work environments are established determinants of injury, social exposures may also contribute. This study examined how reports of unfair treatment at work, a dimension of work-related experiences of discrimination, were associated with injury among hospital-based patient-care workers. METHODS: We used data from the Boston Hospital Workers Health Study, a longitudinal cohort of nurses and nursing assistants at two Boston-area hospitals. In 2018, we conducted a worker survey asking about three types of unfair treatment at work and occupational injuries during the past year. We used mixed-effects logistic regression models to evaluate associations between specific types, total load, and high-frequency exposure of unfair treatment with injury, adjusting for age, gender, race and ethnicity, job title, and unit type. RESULTS: Among 1001 respondents, 21% reported being humiliated in front of others at work, 28% reported being watched more closely than other workers, and 47% reported having to work twice as hard as others for the same treatment. For each type of unfair treatment, we observed a monotonic relationship with occupational injury wherein increasing frequency of exposure was associated with increased odds of injury. We also observed monotonic relationships between total load and high-frequency exposure to unfair treatment and odds of injury. CONCLUSIONS: Work-related unfair treatment is associated with injury among hospital workers. Programs and policies that focus on preventing unfair treatment may lessen injury burden in hospital workers.

Increased all-cause mortality following occupational injury: a comparison of two states.

OBJECTIVES: To measure the impact of lost-time occupational injuries on all-cause mortality in Washington State and, using the same data elements and study design, to determine whether the estimated impact was similar to previous estimates for New Mexico. METHODS: We linked injuries in the Washington workers' compensation system with Social Security Administration data on earnings and mortality. We estimated Cox survival models of mortality for women and men with lost-time compared with medical-only injuries, adjusting for age, pre-injury earnings and industry. We used quantitative bias analysis to account for confounding by pre-injury smoking and obesity. RESULTS: The estimated mortality HR was 1.24 for women (95% CI 1.21 to 1.28) and 1.22 for men (95% CI 1.20 to 1.24). After adjusting for unmeasured pre-injury smoking and obesity, the estimated HR for women was 1.10, 95% simulation interval (SI) 1.00 to 1.21; for men, it was 1.15, 95% SI 1.04 to 1.27. CONCLUSIONS: All-cause mortality for Washington workers with lost-time injuries was higher than for those with medical-only injuries. Estimated HRs for Washington were consistent with those previously estimated for New Mexico, a less populous state with lower median wages and a different workers' compensation insurance mechanism. This suggests that the relationship between workplace injury and long-term mortality may be generalisable to other US states. These findings support greater efforts to enhance safety and to investigate factors that improve postinjury employment opportunities and long-term health. This association should be examined in additional locations, with different study conditions, or using additional data on pre-injury risk factors.

Impact of workplace injury on opioid dependence, abuse, illicit use and overdose: a 36-month retrospective study of insurance claims.

OBJECTIVES: To examine the impact of workplace injury on opioid dependence, abuse and overdose (opioid-related morbidity) and if severity of injury increases the hazard of these health effects. METHODS: We used MarketScan databases to follow injured and propensity score matched non-injured workers, both without prior opioid-related diagnoses. Using a Cox proportional hazard model, we examined the impact of workplace injury on opioid-related morbidity. RESULTS: The hazard of opioid-related morbidity for injured workers was 1.79 times than that of matched non-injured workers (95% CI 1.89 to 3.60). For medical-only and lost-time injured workers, it was respectively 1.54 (95% CI 1.02 to 2.32) and 2.91 (95% CI 1.75 to 4.84) times that of non-injured workers. CONCLUSIONS: Reducing workplace injury or severity of workplace injury, as well as efforts to ensure appropriate opioid prescribing for injured workers, may help to reduce the societal costs of opioid use.

Paradoxical Impact of a Patient-Handling Intervention on Injury Rate Disparity Among Hospital Workers.

OBJECTIVES: To test whether a comprehensive safe patient-handling intervention, which successfully reduced overall injury rates among hospital workers in a prior study, was differentially effective for higher-wage workers (nurses) versus low-wage workers (patient care associates [PCAs]). METHODS: Data were from a cohort of nurses and PCAs at 2 large hospitals in Boston, Massachusetts. One hospital received the intervention in 2013; the other did not. Using longitudinal survey data from 2012 and 2014 plus longitudinal administrative injury and payroll data, we tested for socioeconomic differences in changes in self-reported safe patient-handling practices, and for socioeconomic differences in changes in injury rates using administrative data. RESULTS: After the intervention, improvements in self-reported patient-handling practices were equivalent for PCAs and for nurses. However, in administrative data, lifting and exertion injuries decreased among nurses (rate ratio [RR] = 0.64; 95% confidence interval [CI] = 0.41, 1.00) but not PCAs (RR = 1.10; 95% CI = 0.74,1.63; P for occupation × intervention interaction = 0.02). CONCLUSIONS: Although the population-level injury rate decreased after the intervention, most improvements were among higher-wage workers, widening the socioeconomic gap in injury and exemplifying the inequality paradox. Results have implications for public health intervention development, implementation, and analysis.

Suicide and drug-related mortality following occupational injury.

BACKGROUND: Drug overdoses and suicides have been rising since 2000 and are major contributors to a 3-year decline in US life expectancy. Studies suggest that injured workers have elevated rates of depression and opioid use, but no studies have measured excess mortality related to these risks. MATERIALS AND METHODS: We linked New Mexico workers' compensation data for 100 806 workers injured in 1994 through 2000 with Social Security Administration earnings and mortality data through 2013 and National Death Index cause of death data. We then estimated the association between receiving lost-time workers' compensation benefits and mortality hazard ratios (HRs) and 95% confidence intervals (CIs) based on Fine and Gray cause-specific subdistribution hazards for common causes of death and for drug-related, suicide, and alcohol-related mortality. RESULTS: There was almost a 3-fold increase in combined drug-related and suicide mortality hazard among women (HR = 2.63, 95% CI = 1.91-3.64) and a substantial increase among men (HR = 1.42, 95% CI = 1.13-1.79). Circulatory disease mortality hazard was elevated for men (HR = 1.25, 95% CI = 1.05-1.50). CONCLUSION: Workplace injuries severe enough to require more than a week off work may impair workers' long-term health and well-being. Drug-related deaths and suicides may be important contributors to the long-term excess mortality of injured workers. Improved workplace conditions, improved pain treatment, better treatment of substance use disorders, and treatment of postinjury depression may substantially reduce mortality consequent to workplace injuries.

Preventive care utilization: Association with individual- and workgroup-level policy and practice perceptions.

Preventive medical care may reduce downstream medical costs and reduce population burden of disease. However, although social, demographic, and geographic determinants of preventive care have been studied, there is little information about how the workplace affects preventive care utilization. This study examines how four types of organizational policies and practices (OPPs) are associated with individual workers' preventive care utilization. We used data collected in 2012 from 838 hospital patient care workers, grouped in 84 patient care units at two hospitals in Boston. Via survey, we assessed individuals' perceptions of four types of OPPs on their work units. We linked the survey data to a database containing detailed information on medical expenditures. Using multilevel models, we tested whether individual-level perceptions, workgroup-average perceptions, and their combination were associated with individual workers' preventive care utilization (measured by number of preventive care encounters over a two-year period). Adjusting for worker characteristics, higher individual-level perceptions of workplace flexibility were associated with greater preventive care utilization. Higher average unit-level perceptions of people-oriented culture, ergonomic practices, and flexibility were associated with greater preventive care utilization. Overall, we find that workplace policies and practices supporting flexibility, ergonomics, and people-oriented culture are associated with positive preventive care-seeking behavior among workers, with some policies and practices operating at the individual level and some at the group level. Improving the work environment could impact employers' health-related expenditures and improve workers' health-related quality of life.

The relationship between organizational policies and practices and work limitations among hospital patient care workers.

OBJECTIVE: We examined relationships between organizational policies and practices (OPPs) (safety practices, ergonomic practices, and people-oriented culture) and work limitations in a sample of hospital workers. METHODS: We used the 6-item Work Limitations Questionnaire (WLQ) to assess workers' perceptions of health-related work limitations. Self-reported OPPs and the WLQ were collected from workers in Boston, Massachusetts (n = 1277). We conducted random-intercept multi-level logistic regression models for each OPP using stepwise selection of covariates. RESULTS: As the unit-average ergonomic practice score increased by one, the odds of a worker reporting work limitations decreased by approximately 39% (P-value = 0.018), adjusted for job title, age, and body mass index. A similar relationship existed for people-oriented culture (P-value = 0.038). The association between safety practices and work limitations was similar, but not statistically significant. CONCLUSIONS: This study demonstrated the importance of workplace OPPs. OPPs that promote positive and supportive environments and that foster improvements in ergonomics may help reduce work limitations.

Lifting and exertion injuries decrease after implementation of an integrated hospital-wide safe patient handling and mobilisation programme.

OBJECTIVE: With increasing emphasis on early and frequent mobilisation of patients in acute care, safe patient handling and mobilisation practices need to be integrated into these quality initiatives. We completed a programme evaluation of a safe patient handling and mobilisation programme within the context of a hospital-wide patient care improvement initiative that utilised a systems approach and integrated safe patient equipment and practices into patient care plans. METHODS: Baseline and 12-month follow-up surveys of 1832 direct patient care workers assessed work practices and self-reported pain while an integrated employee payroll and injury database provided recordable injury rates collected concurrently at 2 hospitals: the study hospital with the programme and a comparison hospital. RESULTS: Safe and unsafe patient handling practice scales at the study hospital improved significantly (p<0.0001 and p=0.0031, respectively), with no differences observed at the comparison hospital. We observed significant decreases in recordable neck and shoulder (Relative Risk (RR)=0.68, 95% CI 0.46 to 1.00), lifting and exertion (RR=0.73, 95% CI 0.60 to 0.89) and pain and inflammation (RR=0.78, 95% CI 0.62 to 1.00) injury rates at the study hospital. Changes in rates at the comparison hospital were not statistically significant. CONCLUSIONS: Within the context of a patient mobilisation initiative, a safe patient handling and mobilisation programme was associated with improved work practices and a reduction in recordable worker injuries. This study demonstrates the potential impact of utilising a systems approach based on recommended best practices, including integration of these practices into the patient's plan for care.

The impact of non-fatal workplace injuries and illnesses on mortality.

BACKGROUND: Little research has examined the relationship between non-fatal workplace injuries and illnesses, and long-term mortality. METHODS: We linked non-fatal injury cases reported to the New Mexico workers' compensation system for 1994-2000 with Social Security Administration data on individual earnings and mortality through 2014. We then derived sex-specific Kaplan-Meier curves to show time to death for workers with lost-time injuries (n = 36,377) and comparison workers (n = 70,951). We fit multivariable Cox survival models to estimate the hazard ratio separately for male and female workers with lost-time injuries. RESULTS: The estimated hazard ratio for lost-time injuries is 1.24 for women and 1.21 for men. Ninety-five percent confidence intervals were 1.15, 1.35 and 1.15, 1.27, respectively. CONCLUSION: Lost-time occupational injuries are associated with a substantially elevated mortality hazard. This implies an important formerly unmeasured cost of these injuries and a further reason to focus on preventing them. Am. J. Ind. Med. 59:1061-1069, 2016. © 2016 Wiley Periodicals, Inc.

Understanding the hospital sharps injury reporting pathway.

BACKGROUND: Patient-care workers are frequently exposed to sharps injuries, which can involve the risk of serious illness. Underreporting of these injuries can compromise prevention efforts. METHODS: We linked survey responses of 1,572 non-physician patient-care workers with the Occupational Health Services (OHS) database at two academic hospitals. We determined whether survey respondents who said they had sharps injuries indicated that they had reported them and whether reported injuries were recorded in the OHS database. RESULTS: Respondents said that they reported 62 of 78 sharps injuries occurring over a 12-month period. Only 28 appeared in the OHS data. Safety practices were positively associated with respondents' saying they reported sharps injuries but not with whether reported injuries appeared in the OHS data. CONCLUSIONS: Administrators should consider creating reporting mechanisms that are simpler and more direct. Administrators and researchers should attempt to understand how incidents might be lost before they are recorded.

Association between perceived inadequate staffing and musculoskeletal pain among hospital patient care workers.

OBJECTIVE: To examine association between perceived inadequate staffing and musculoskeletal pain and to evaluate the role of work-related psychosocial and physical work factors in the association among hospital patient care workers. METHODS: A cross-sectional study was conducted among 1,572 patient care workers in two academic hospitals. Perceived inadequate staffing was measured using the "staffing adequacy subscale" of Nursing Work Index, which is a continuous scale that averages estimates of staffing adequacy by workers in the same units. Musculoskeletal pain (i.e., neck/shoulder, arm, low back, lower extremity, any musculoskeletal pain, and the number of area in pain) in the past 3 months was assessed using a self-reported Nordic questionnaire. Multilevel logistic regression was applied to examine associations between perceived inadequate staffing and musculoskeletal pain, considering clustering among the workers in the same units. RESULTS: We found significant associations of perceived inadequate staffing with back pain (OR 1.50, 95 % CI 1.06, 2.14) and the number of body area in pain (OR 1.42, 95 % CI 1.01, 2.00) after adjusting for confounders including work characteristics (job title, having a second job or not, day shift or not, and worked hours per week). When we additionally adjusted for physical work factors (i.e., use of a lifting device, and the amount of the time for each of five physical activities on the job), only the association between perceived inadequate staffing and back pain remained significant (OR 1.50, 95 % CI 1.03, 2.19), whereas none of the associations was significant for all of musculoskeletal pains including back pain (OR 0.96, 95 % CI 0.66, 1.41) when we additionally adjusted for work-related psychosocial factors (i.e., job demands, job control, supervisor support, and co-worker support) instead of physical work factors. CONCLUSIONS: Perceived inadequate staffing may be associated with higher prevalence of back pain, and work-related psychosocial factor may play an important role in the potential pathway linking staffing level to back pain among hospital workers.

Capture-recapture estimates of the undercount of workplace injuries and illnesses: sensitivity analysis.

BACKGROUND: In recent years, capture-recapture methods have been applied to state Survey of Occupational Injuries and Illnesses (SOII) and workers' compensation data, but uncertainties arise because of population differences between the two sources, likely source dependence, and concerns about the accuracy of case linkage. METHODS: We linked SOII and workers' compensation records for California and used capture-recapture methods to estimate the proportion of injuries and illnesses involving at least 4 days away from work captured by each source. We then did a sensitivity analysis. RESULTS: Assuming source independence, estimates of the proportion of injuries and illnesses involving at least 4 days away from work captured by the SOII varied from 42.4% to 49.0%, while workers' compensation estimates were between 76.9% and 77.6%. Re-estimating SOII capture rates assuming source dependence (OR = 3) reduced capture estimates substantially. CONCLUSIONS: Estimated capture rates remained low after changing several of the underlying assumptions. Positive source dependence had the greatest impact.

Use of multiple data sources for surveillance of work-related amputations in Massachusetts, comparison with official estimates and implications for national surveillance.

BACKGROUND: Accurate surveillance of work-related injuries is needed at national and state levels. We used multiple sources for surveillance of work-related amputations, compared findings with Survey of Occupational Injuries and Illnesses (SOII) estimates, and assessed generalizability to national surveillance. METHODS: Three data sources were used to enumerate work-related amputations in Massachusetts, 2007-2008. SOII eligible amputations were compared with SOII estimates. RESULTS: 787 amputations were enumerated, 52% ascertained through hospital records only, exceeding the SOII estimate (n = 210). The estimated SOII undercount was 48% (95% CI: 36-61%). Additional amputations were reported in SOII as other injuries, accounting for about half the undercount. Proportionately more SOII estimated than multisource cases were in manufacturing and fewer in smaller establishments. CONCLUSION: Multisource surveillance enhanced our ability to document work-related amputations in Massachusetts. While not feasible to implement for work-related conditions nationwide, it is useful in states. Better understanding of potential biases in SOII is needed.

Worker assessments of organizational practices and psychosocial work environment are associated with musculoskeletal injuries in hospital patient care workers.

BACKGROUND: Hospital patient care (PC) workers have high rates of workplace injuries, particularly musculoskeletal injuries. Despite a wide spectrum of documented health hazards, little is known about the association between psychosocial factors at work and OSHA-recordable musculoskeletal injuries. METHODS: PC-workers (n = 1,572, 79%) completed surveys assessing a number of organizational, psychosocial and psychological variables. Associations between the survey responses and injury records were tested using bivariate and multivariate analyses. RESULTS: A 5% of the PC-workers had at least one OSHA-recordable musculoskeletal injury over the year, and the injuries were significantly associated with: organizational factors (lower people-oriented culture), psychosocial factors (lower supervisor support), and structural factors (job title: being a patient care assistant). CONCLUSIONS: The results show support for a multifactorial understanding of musculoskeletal injuries in hospital PC-workers. An increased focus on the various dimensions associated with injury reports, particularly the organizational and psychosocial factors, could contribute to more efficient interventions and programs.

Can Better Leadership Reduce Nursing Home Staff Turnover?

OBJECTIVES: To assess whether a measure of leadership support for worker safety, health, and well-being predicts staff turnover in nursing homes after controlling for other factors. DESIGN: This paper uses administrative payroll data to measure facility-level turnover and uses a survey measure of nursing home leadership commitment to workers. In addition, we use data from Medicare to measure various nursing home characteristics. SETTING AND PARTICIPANTS: Nursing homes with at least 30 beds serving adults in California, Ohio, and Massachusetts were invited to participate in the survey. The analysis sample included 495 nursing homes. METHODS: We used a multivariable ordinary least squares model with turnover rate as the dependent variable. We used an indicator for nursing homes who scored above the median on the measure of leadership that supports worker safety, health, and well-being. Control variables include bed count (deciles), ownership (corporate/noncorporate × for-profit/not-for-profit), percent of residents on Medicaid, state, being in a nonmetropolitan county, and total nurse staffing per patient day in the 2 quarters before the survey. RESULTS: The unadjusted turnover rate was lower for those nursing homes that scored higher on leadership commitment to worker safety, health, and well-being. After controlling for additional variables, greater leadership commitment was still associated with lower turnover but with some attenuation. CONCLUSIONS AND IMPLICATIONS: We find that nursing homes with leadership that communicated and demonstrated commitment to worker safety, health, and well-being had relatively fewer nurses leave during the study period, with turnover rates approximately 10% lower than homes without. These findings suggest that leadership may be a valuable tool for reducing staff turnover.

Predicting COVID-19 Cases in Nursing Homes of California and Ohio: Does the Work Environment Matter?

OBJECTIVE: The cross-sectional study evaluates if the pre-pandemic work environments in nursing homes predict COVID-19 cases among residents and staff, accounting for other factors. METHOD: Leveraging data from a survey of California and Ohio nursing homes (n = 340), we examined if Workplace Integrated Safety and Health domains - Leadership, Participation, and Comprehensive and Collaborative strategies predicted cumulative COVID-19 cases among nursing home residents and staff. RESULTS: In Ohio, a 1-unit increase in Leadership score was associated with 2 fewer staff cases and 4 fewer resident cases. A 1-unit increase in Comprehensive and Collaborative Strategies score in California showed an average marginal effect of approximately 1 less staff case and 2 fewer resident cases. CONCLUSION: These findings suggest that leadership commitment and inter-department collaboration to prioritize worker safety, may have protected against COVID-19 cases in nursing homes.

Who do you ask? predicting injury rates from survey responses.

BACKGROUND: Few studies have addressed whether using manager or worker perceptions of safety policies and practices alone predict reported injury rates less accurately than using both. OBJECTIVE: This study provides an example and describes a method that can be used to address this issue with survey instruments designed to measure safety climate, policies, or practices. METHODS: Using multilevel logistic regression, we estimated the relationship between worker and manager perceptions of a given exposure and the odds of worker injury during the post-survey year for three safety scales. We tested whether surveying both workers and managers provides additional predictive value compared with surveying just one group. RESULTS: Injury in the year following the survey was significantly associated with worker scores on two of the three scales. Manager responses were not significantly associated with injury and did not significantly improve injury rate prediction when added to a model with only worker survey responses. CONCLUSIONS: The capacity of manager-only or worker-only perceptions of safety policies and practices to predict worker injuries should be established before choosing to survey just one or the other. The approach and findings in this paper can be applied to other survey instruments and in other settings to help make this choice.

Association between work-family conflict and musculoskeletal pain among hospital patient care workers.

BACKGROUND: A growing body of evidence suggests that work-family conflict is an important risk factor for workers' health and well-being. The goal of this study is to examine association between work-family conflict and musculoskeletal pain among hospital patient care workers. METHODS: We analyzed a cross-sectional survey of 1,119 hospital patient care workers in 105 units in two urban, academic hospitals. Work-family conflict was measured by 5-item Work-Family Conflict Scale questionnaire. Multilevel logistic regression was applied to examine associations between work-family conflict and self-reported musculoskeletal pain in the past 3 months, adjusting for covariates including work-related psychosocial factors and physical work factors. RESULTS: In fully adjusted models, high work-family conflict was strongly associated with neck or shoulder pain (OR: 2.34, 95% CI: 1.64-3.34), arm pain (OR: 2.79, 95% CI: 1.64-4.75), lower extremity pain (OR: 2.20, 95% CI: 1.54-3.15) and any musculoskeletal pain (OR: 2.45, 95% CI: 1.56-3.85), and a number of body areas in pain (OR: 2.47, 95% CI: 1.82-3.36) in the past 3 months. The association with low back pain was attenuated and became non-significant after adjusting for covariates. CONCLUSIONS: Given the consistent associations between work-family conflict and self-reported musculoskeletal pains, the results suggest that work-family conflict could be an important domain for health promotion and workplace policy development among hospital patient care workers.