Developing A Conceptual Framework for Early Intervention Vocational Rehabilitation for People Following Spinal Cord Injury.

PURPOSE: Early intervention vocational rehabilitation (EIVR) can improve return to work (RTW) outcomes for people with spinal cord injury (SCI). However, mechanisms explaining how and why EIVR works are not well understood. This study aims to develop a conceptual framework describing key mechanisms of EIVR intervention effect following SCI. METHODS: We synthesised data from a realist literature review with data from interviews of people with SCI (n = 30), a survey of people with SCI who had received EIVR (n = 37), a focus group of EIVR providers and a focus group of community vocational providers. We first synthesised the literature review and interviews to develop an initial programme theory describing the contexts in which mechanisms are activated to produce EIVR outcomes. Then we used data from the survey and focus groups to further refine the EIVR programme theory. Finally, a conceptual framework was developed to support knowledge dissemination. RESULTS: By ensuring consistent messaging across the multi-disciplinary team, EIVR programmes establish and maintain hope that work is possible following injury. Conversations about work allow individuals to determine the priority of work following injury. These conversations can also improve self-efficacy by providing individualized support to envisage pathways toward RTW goals and maintain worker identity. The synthesised study findings highlight the contexts and resources required to trigger activation of these mechanisms. CONCLUSIONS: EIVR key mechanisms of effect are not specific to SCI as a health condition, therefore enabling this framework to be applied to other populations who face similar impairments and return to work barriers.

Understanding longer-term disability outcomes for Maori and non-Maori after hospitalisation for injury: results from a longitudinal cohort study.

OBJECTIVES: The objectives are to (1) describe disability outcomes at 24 months after injury and (2) identify factors contributing to disability outcomes at 24 months after injury, for Maori and non-Maori who have been hospitalised for injury. STUDY DESIGN: This is a prospective cohort study. METHODS: Prospective Outcomes of Injury Study participants were injured New Zealanders aged 18-64 years and recruited from New Zealand's no-fault injury insurer, the Accident Compensation Corporation's entitlement claims register. Data about a number of pre-injury, injury-related and early post-injury characteristics were collected from interviews held at 3 and 24 months after injury. Disability was measured using the World Health Organization Disability Assessment Schedule (WHODAS). Modified Poisson regression modelling was used to estimate relative risks (RRs) of disability for Maori and non-Maori who were hospitalised for injury. RESULTS: Analyses were restricted to 375 Maori and 1824 non-Maori participants for whom complete data were available. Of these, 105 (28%) Maori and 446 (24%) non-Maori were hospitalised for their injury. Of these hospitalised groups, 26% of Maori and 10% of non-Maori were experiencing disability (WHODAS ≥10) at 24 months after injury. Maori who were hospitalised for injury and who were not working for pay before their injury (RR = 2.7; 95% confidence interval [CI] 1.4-4.9), who were experiencing disability before their injury (RR = 3.1; 95% CI 1.6-5.8) or who reported trouble accessing healthcare services for their injury (RR = 2.6; 95% CI 1.3-5.2) were independently at increased risk of disability 24 months after injury. Non-Maori who were hospitalised for injury and who had inadequate household income before injury (RR = 2.4; 95% CI 1.4-4.1), less than the secondary school qualifications (RR = 2.0; 95% CI 1.1-3.8), were not working for pay before injury (RR = 2.8; 95% CI 1.5-5.1), were experiencing disability before their injury (RR = 3.0; 95% CI 1.7-5.2), had ≥2 chronic conditions (RR = 3.5; 95% CI 2.0-6.4) or had body mass index ≥30 kg/m2/undisclosed (RR = 2.4; 95% CI 1.3-4.4) were at increased risk of disability 24 months after injury. CONCLUSIONS: Variables predicting disability 24 months after injury for Maori, also predict disability 24 months after injury for non-Maori, with one notable exception-trouble accessing healthcare services. Our findings show that having access to healthcare services for injury plays an important role after injury and must be focussed on to ensure that the burden of poor injury-related outcomes and injury-related inequities are reduced and ultimately eliminated.

Musculoskeletal disorders among nurses compared with two other occupational groups.

BACKGROUND: There is a high incidence of low back pain (LBP) among nurses. However, few longitudinal studies have investigated musculoskeletal disorders (MSDs) at other anatomical sites in nurses. AIMS: To describe the cumulative incidence and persistence/recurrence of MSDs of the low back, neck, shoulder, elbow, wrist/hand and knee among New Zealand nurses, to investigate the impact of MSDs on work and functional tasks and to compare findings for nurses with those in postal workers and office workers. METHODS: Participants completed a postal survey at baseline and again 1 year later. Information was collected about MSDs in the previous 1 month and 12 months and about the ability to attend work, undertake work duties and perform functional tasks. RESULTS: Among nurses, the low back was the site with the highest cumulative incidence and highest prevalence of persistent/recurrent, work-disabling and functional-task-disabling pain. Work-disabling LBP was more prevalent among nurses and postal workers than office workers (P < 0.001). Nurses had a substantial prevalence of work-disabling shoulder pain (10%) and functional-task-disabling knee (19%) and wrist/hand pain (16%). With the exception of the elbow, each occupational group had a high prevalence of persistent/recurrent MSDs at all anatomical sites. CONCLUSIONS: LBP continues to have a substantial impact among nurses. Other less commonly considered MSDs, such as shoulder, wrist/hand and knee pain, also made work or functional tasks difficult, suggesting that primary and secondary prevention efforts should consider MSDs at other anatomical sites as well as the low back.

Socioeconomic outcomes following spinal cord injury and the role of no-fault compensation: longitudinal study.

STUDY DESIGN: Longitudinal cohort study. OBJECTIVES: To estimate socioeconomic and work outcomes over 2 and a half years following spinal cord injury (SCI), and to compare those in receipt of compensation (Accident Compensation Corporation, ACC) and those not. SETTING: People admitted to the two spinal units in 2007-2009 in New Zealand, where there is a unique no-fault compensation scheme for injury. METHODS: Interviews were conducted at ∼6, 18 and 30 months after SCI and data collected on pre-SCI and post-SCI health and socioeconomic characteristics. Poisson regression, quantile regression and a linear mixed model regression were used to compare differences in outcomes. RESULTS: Of the 162 eligible people, 118 (73%) participated and 91(77%) were followed to 30 months; 79% received ACC. Median personal income, self-reported standard of living and household income adequacy all fell slightly to 18 months and then stabilized at 30 months. At that time, 49% had returned to paid work. Among those not eligible for ACC, income fell to less than half the ACC group (P<0.006 after adjustment), and return to work was lower (29% versus 54%). CONCLUSION: The findings that most people retained their economic status and that return to work was relatively high appear to be due to the proportion entitled to the ACC no-fault compensation scheme for injury; with earnings-related compensation, a focus on rehabilitation to work and non-means-tested support services. This situation should mitigate against the downward spiral into poverty and further ill-health.

Long-Term Disability Outcomes for Migrants (and Non-migrants) 12 Years Post-injury: Results from the Prospective Outcomes of Injury Study in New Zealand.

To understand, and identify predictors of, long-term post-injury (i.e. 12 years post-injury) disability outcomes for migrants and non-migrants. This 12-year longitudinal study followed participants with entitlement claim injuries registered with New Zealand's universal no-fault injury insurer between 2007 and 2009. Information was collected about migrant status, other sociodemographic, health and disability characteristics, and injury characteristics. Disability outcome information was collected 12 years later. Of 1543 people interviewed 12 years post-injury, 1497 had disability and migrant status data available; 20% were migrants (n = 301). Migrants reporting inadequate pre-injury household income or those who perceived their injury as a threat to life at the time of injury were more likely to experience disability 12 years post-injury (aRR 2.08; 95% CI 1.09-4.03, aRR 2.93; 95%CI 1.17-6.69, respectively). Hospitalised injured migrants were significantly less likely to have long-term disability (aRR 0.18; 95%CI 0.04-0.55) than those not hospitalised. We found sociodemographic and injury-related characteristics were independently associated with long-term disability among migrants. We highlight that some characteristics, ascertained early in the injury pathway, predict risk of long-term disability. Early post-injury interventions focused on improving disability outcomes for migrants may also have long-term impacts.

Participation in paid and unpaid work one year after injury and the impact of subsequent injuries for Maori: Results from a longitudinal cohort study in New Zealand.

INTRODUCTION: Indigenous populations experience greater injury burdens than non-indigenous groups. This paper investigated, for injured Maori (New Zealand's indigenous population): 1) participation in paid and unpaid work 12 months after injury, 2) whether subsequent injuries are predictive of reduced participation, and 3) if particular characteristics of subsequent injuries predict reduced participation. METHODS: The Subsequent Injury Study utilised data from the earlier Prospective Outcomes of Injury Study, a study of 2856 injured New Zealanders (including 566 Maori; 20%) who had an Accident Compensation Corporation (ACC; New Zealand's no-fault injury insurer) entitlement claim (sentinel injury). Data about subsequent injuries reported to ACC and hospital discharge data for injuries resulting in hospitalisation were also utilised. Multivariable models were used to examine if certain aspects of subsequent injury predicted either of two outcomes - reduced participation in paid, and unpaid work 12 months after a sentinel injury. RESULTS: Eligible participants were identified from the 405 Maori participants interviewed at 12 months. Thirty-two percent sustained at least one ACC subsequent injury, and 16% reported reduced participation in unpaid work. Of the eligible participants working for pay at the time of their sentinel injury, 35% reported reduced participation in paid work. Although the relationship between sustaining a subsequent injury (or not) and reduced participation in paid work was unclear (aRR 1.4, 95%CI 0.9,2.3), particular subsequent injury characteristics were identified as being independently predictive: subsequent injury resulting from an assault (aRR 2.4, 95%CI 1.2,4.9), a subsequent injury involving an entitlement claim (aRR 2.0, 95%CI 1.1,3.4), sustaining more than one subsequent injury (aRR 2.0, 95%CI 1.1,3.6), and only non-work-related subsequent injuries (aRR 1.6, 95%CI 1.0,2.7). CONCLUSIONS: Reduced participation in paid work is prevalent for Maori after an ACC entitlement claim injury. Particular characteristics of subsequent injuries after such an event impacts on participation in paid work 12 months after the sentinel injury, but the picture is less clear for unpaid work. Understanding the changes in paid and unpaid work, and the predictive characteristics of subsequent injuries for injured Maori, is important for future injury prevention strategies and supporting return to work rehabilitation programmes, specifically for Maori.

Prospective outcomes of injury study.

BACKGROUND: In New Zealand (NZ), 20% of adults report a disability, of which one-third is caused by injury. No prospective epidemiological studies of predictors of disability following all-cause injury among New Zealanders have been undertaken. Internationally, studies have focused on a limited range of predictors or specific injuries. Although these studies provide useful insights, applicability to NZ is limited given the importance of NZ's unique macro-social factors, such as NZ's no-fault accident compensation and rehabilitation scheme, the Accident Compensation Corporation (ACC). OBJECTIVES: (1) To quantitatively determine the injury, rehabilitation, personal, social and economic factors leading to disability outcomes following injury in NZ. (2) To qualitatively explore experiences and perceptions of injury-related outcomes in face-to-face interviews with 15 Maori and 15 other New Zealanders, 6 and 12 months after injury. SETTING: Four geographical regions within NZ. DESIGN: Prospective cohort study with telephone interviews 1, 4 and 12 months after injury. PARTICIPANTS: 2500 people (including 460 Maori), aged 18-64 years, randomly selected from ACC's entitlement claims register (people likely to be off work for at least 1 week or equivalent). DATA: Telephone interviews, electronic hospital and ACC injury data. Exposures include demographic, social, economic, work-related, health status, participation and/or environmental factors. OUTCOME MEASURES: Primary: disability (including WHODAS II) and health-related quality of life (including EQ-5D). Secondary: participation (paid and unpaid activities), life satisfaction and costs. ANALYSIS: Separate regression models will be developed for each of the outcomes. Repeated measures outcomes will be modelled using general estimating equation models and generalised linear mixed models.

Prospective evaluation of the effects of prostatectomy on symptoms and quality of life.

AIMS: To evaluate prospectively urinary symptoms and quality of life before and after prostate surgery, among men who had been on a waiting list for elective transurethral prostate resection (TURP). METHODS: Face-to-face interviews with 47 men before and after prostate surgery using the urinary symptom specific American Urological Association Urinary Symptom Index (AUA-7), the Short Form 36 Health Survey (SF-36), and questions relating to the effects of urinary symptoms on men's lives and acceptable waiting times for surgery. RESULTS: The mean AUA-7 score before surgery for all participants was 22.2 (range 5-34) and after surgery improved to a mean of 7.3 (range 1-28). Men with severe urinary symptoms before surgery experienced the greatest improvement in symptoms after surgery, compared with the mild/moderate symptom group. Significant improvements occurred in three of the eight SF-36 dimensions following surgery. Acceptable waiting times for surgery differed according to the severity of mens' urinary symptoms. CONCLUSIONS: Efforts to develop methods for prioritisation of access to surgery are supported. Men with mild or moderate symptoms may reasonably delay surgery, with the expectation that, if they develop more severe symptoms, surgery will be helpful. Because of the risks as well as the benefits of prostate surgery, the use of illustrative vignettes may be useful for clinicians advising patients.

Solving the surgical waiting list problem? New Zealand's 'booking system'.

This article discusses the development and implementation of New Zealand's booking system for publicly funded non-urgent surgical and medical procedures. The 'booking system' emerged out of New Zealand's core services debate and the government's desire to remove waiting lists. It was targeted for implementation by mid-1998. However, the booking system remains in an unsatisfactory state and a variety of problems have plagued its introduction. These include a lack of national consistency in the priority access criteria, failure to pilot the system and a shortfall in the levels of funding available to treat the numbers of patients whose priority criteria 'scores' deem them clinically eligible for surgery. The article discusses endeavours to address these problems. In conclusion, based on the New Zealand experience, the article provides lessons for policy-makers interested in introducing surgical booking systems.

Waiting for elective surgery: effects on health-related quality of life.

OBJECTIVE: To describe the experiences of people required to wait for admission to a New Zealand regional hospital to receive elective surgery. DESIGN: Cross-sectional. SETTING: Eligible people were invited to participate in a face-to-face interview with one of us in their own home or in a private office at the University of Otago. STUDY PARTICIPANTS: The study population comprised all people on the waiting list for prostatectomy or hip or knee joint replacement. Of those who were eligible and contacted, 89% of men (n=102) on the prostatectomy waiting list and 92%. of people (n = 47) on the hip/knee joint replacement waiting list were interviewed. Main outcome measures. Participants completed the SF-36 health survey to measure general health-related quality of life and condition-specific instruments to measure the severity of each participant's condition. Participants were also asked questions concerning acceptable waiting times. RESULTS: The majority of participants reported severe symptoms and significantly poorer health-related quality of life on most dimensions than a general sample of the New Zealand population. Neither general quality of life nor condition-specific health appeared to worsen with the duration of wait, but this may have been an effect of the study design. People with more severe symptoms desire surgery more quickly than people with less severe symptoms. The lengthy wait for surgery experienced by many participants represents a burden in terms of living with the unrelieved severe symptoms and poor health-related quality of life.