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

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

Examining the Association of Billed Advance Care Planning With End-of-Life Hospital Admissions Among Advanced Cancer Patients in Hospice.

BACKGROUND: Advance care planning (ACP), or the consideration and communication of care preferences for the end-of-life (EOL), is a critical process for improving quality of care for patients with advanced cancer. The incorporation of billed service codes for ACP allows for new inquiries on the association between systematic ACP and improved EOL outcomes. OBJECTIVE: Using the IBM MarketScan® Database, we conducted a retrospective medical claims analysis for patients with an advanced cancer diagnosis and referral to hospice between January 2016 and December 2017. We evaluated the association between billed ACP services and EOL hospital admissions in the final 30 days of life. DESIGN: This is a cross-sectional retrospective cohort study. PARTICIPANTS: A total of 3,705 patients met the study criteria. MAIN MEASURES: ACP was measured via the presence of a billed ACP encounter (codes 99497 and 99498) prior to the last 30 days of life; hospital admissions included a dichotomous indicator for inpatient admission in the final 30 days of life. KEY RESULTS: Controlling for key covariates, patients who received billed ACP were less likely to experience inpatient hospital admissions in the final 30 days of life compared to those not receiving billed ACP (OR: 0.34; p < 0.001). CONCLUSION: The receipt of a billed ACP encounter is associated with reduced EOL hospital admissions in a population of patients with advanced cancer on hospice care. Strategies for consistent, anticipatory delivery of billable ACP services prior to hospice referral may prevent potentially undesired late-life hospital admissions.

Preventing Adolescent and Young Adult Suicide: Do States With Greater Mental Health Treatment Capacity Have Lower Suicide Rates?

PURPOSE: Youth suicide is increasing at a significant rate and is the second leading cause of death for adolescents. There is an urgent public health need to address the youth suicide. The objective of this study is to determine whether adolescents and young adults residing in states with greater mental health treatment capacity exhibited lower suicide rates than states with less treatment capacity. METHODS: We conducted a state-level analysis of mental health treatment capacity and suicide outcomes for adolescents and young adults aged 10-24 spanning 2002-2017 using data from Centers for Disease Control and Prevention, U.S. Bureau of Labor Statistics, Federal Bureau of Investigation, and other sources. Multivariable linear fixed-effects regression models tested the relationships among mental health treatment capacity and the total suicide, firearm suicide, and nonfirearm suicide rates per 100,000 persons aged 10-24. RESULTS: We found a statistically significant inverse relationship between nonfirearm suicide and mental health treatment capacity (p = .015). On average, a 10% increase in a state's mental health workforce capacity was associated with a 1.35% relative reduction in the nonfirearm suicide rate for persons aged 10-24. There was no significant relationship between mental health treatment capacity and firearm suicide. CONCLUSIONS: Greater mental health treatment appears to have a protective effect of modest magnitude against nonfirearm suicide among adolescents and young adults. Our findings underscore the importance of state-level efforts to improve mental health interventions and promote mental health awareness. However, firearm regulations may provide greater protective effects against this most lethal method of firearm suicide.

Changes in early high-risk opioid prescribing practices after policy interventions in Washington State.

OBJECTIVE: To test associations between several opioid prescribing policy interventions and changes in early (acute/subacute) high-risk opioid prescribing practices. DATA SOURCES: Population-based workers' compensation pharmacy billing and claims data, Washington State Department of Labor and Industries (January 2008-June 2015). STUDY DESIGN: We used interrupted time series analysis to test associations between three policy intervention timepoints and monthly proportions of population-based measures of high-risk, low-risk, and any workers' compensation-related opioid prescribing. We also tested associations between the policy intervention timepoints and five high-risk opioid prescribing indicators among workers prescribed any opioids within 3 months after injury: (a) >7 cumulative (not necessarily consecutive) days' supply of opioids during the acute phase, (b) high-dose opioids, (c) concurrent sedatives, (d) chronic opioids, and (e) a composite high-risk opioid prescribing indicator. PRINCIPAL FINDINGS: Within 3 months after injury, 9 percent of workers were exposed to high-risk and 12 percent to low-risk workers' compensation-related opioid prescribing; 79 percent filled no workers' compensation-related opioid prescription. Among workers prescribed any early (acute/subacute) opioids, the indicator for >7 days' supply of opioids during the acute phase was present for 30 percent, high-dose opioids for 18 percent, concurrent sedatives for 3 percent, and chronic opioids for 2 percent. Beyond a general shift toward more infrequent and lower-risk workers' compensation-related opioid prescribing, each policy intervention timepoint was significantly associated with reductions in specific acute/subacute high-risk opioid prescribing indicators; each of the four specific high-risk opioid prescribing indicators had significant reductions associated with at least one policy. CONCLUSIONS: Several state-level opioid prescribing policies were significantly associated with safer workers' compensation-related opioid prescribing practices during the first 3 months after injury (acute/subacute phase), which should in turn reduce transition to chronic opioids and associated negative health outcomes.

Early High-Risk Opioid Prescribing Practices and Long-Term Disability Among Injured Workers in Washington State, 2002 to 2013.

OBJECTIVE: To estimate associations between early high-risk opioid prescribing practices and long-term work-related disability. METHODS: Washington State Fund injured workers with at least one opioid prescription filled within 6 weeks after injury (2002 to 2013) were included (N = 83,150). Associations between early high-risk opioid prescribing (longer duration, higher dosage, concurrent sedatives), and time lost from work, total permanent disability, and a surrogate measure for Social Security disability benefits were tested. Measures of early hospitalization, body part, and nature of injury were included to address confounding by indication concerns, along with sensitivity analyses controlling for injury severity. RESULTS: In adjusted logistic models, early high-risk opioid prescribing was associated with roughly three times the odds of each outcome. CONCLUSION: Exposure to high-risk opioid prescribing within 90 days of injury was significantly and substantially associated with long-term temporary and permanent disability.

The Firearm Suicide Crisis: Physicians Can Make a Difference.

Firearm suicide receives relatively little public attention in the United States, however, the United States is in the midst of a firearm suicide crisis. Most suicides are completed using a firearm. The age-adjusted firearm suicide rate increased 22.6% from 2005 to 2017, and globally the US firearm suicide rate is 8 times higher than the average firearm suicide rate of 22 other developed countries. The debate over how to solve the firearm suicide epidemic tends to focus on reducing the firearm supply or increasing access to behavioral health treatment. Ineffectual federal firearm control policies and inadequate behavioral health treatment access has heightened the need for primary care physicians to play a more meaningful role in firearm suicide prevention. We offer suggestions for how individual physicians and the collective medical community can take action to reduce mortality arising from firearm suicide and firearm deaths.

Behavioral Health Care And Firearm Suicide: Do States With Greater Treatment Capacity Have Lower Suicide Rates?

Firearms account for most self-harm deaths, and many more Americans kill themselves with a firearm each year than are murdered with one. Mental illness is an important risk factor for firearm suicide. While the literature focuses on firearm safety, little is understood about how the supply of behavioral health treatment services can reduce firearm suicide. We evaluated whether states with greater behavioral health treatment capacity have lower firearm suicide rates, examining variation across the United States and over time. The mean adjusted firearm suicide rate rose from 6.74 per 100,000 people in 2005 to 7.89 per 100,000 in 2015-a 17.1 percent increase. We found a significant independent inverse relationship between greater behavioral health treatment capacity and the firearm suicide rate. We show that across all states, on average, a 10.0 percent relative increase in behavioral health workers per state was associated with a modest 1.2 percent relative reduction in the adjusted firearm suicide rate. Given this finding, we discuss whether firearm control initiatives might offer a greater protective effect for reducing firearm suicide, compared to the protective effect of increasing behavioral health treatment capacity.

Identifying Problematic Substance Use in a National Sample of Adolescents Using Frequency Questions.

BACKGROUND: Brief substance use screening questions for tobacco, alcohol, cannabis, and other drugs need further validation in adolescents. In particular, optimal age-specific screening cut-points are not known, and no study has been large enough to evaluate screening questions for noncannabis illicit drug use. METHODS: Adolescent respondents to an annual national household survey were included (2008 to 2014; n = 169,986). Days of tobacco use in the past month, and days of alcohol, cannabis, other illicit drug use in the past year, were assessed as brief screens for tobacco dependence and DSM-IV alcohol (AUD), cannabis (CUD), and other illicit drug use disorders (DUD). Areas under receiver operating characteristics curves (AUCs), sensitivity and specificity were estimated separately by age group (12-15-, 16-17-, and 18-20-year-olds) and cut-points that maximized combined values of sensitivity and specificity were considered optimal. RESULTS: The prevalence of tobacco dependence, AUD, CUD, and DUD was 5.8%, 7.1%, 4.5%, and 2.0%, respectively. AUCs ranged 0.84 to 0.99. The optimal cut-points for screening for tobacco dependence and DUDs was the same for all age groups: ≥1 day. The optimal cut-points for alcohol and cannabis varied by age: ≥3 days for 12-15-year-olds and ≥12 days for older adolescents. CONCLUSIONS: Brief measures of past-year use, or past-month use for tobacco, accurately identified adolescents with problematic substance use. However, health systems should use age-specific screening cut-points for alcohol and cannabis to optimize screening performance.

Effectiveness of Medicare cost-sharing elimination for Cancer screening on utilization.

BACKGROUND: The Patient Protection and Affordable Care Act (ACA) eliminated the cost-sharing requirement for several preventive cancer screenings. This study examined the cancer screening utilization of mammogram, Pap smear and colonoscopy in Medicare fee-for-service (FFS) under the ACA. METHODS: The primary data were the 2007-2013 Medicare Current Beneficiary Survey linked to FFS claims. The effect of the cost-sharing removal on the probability of receiving a preventive cancer screening test was estimated using a logistic regression, separately for each screening test, adjusting for the complex survey design. The model was also separately estimated for different socioeconomic and race/ethnic groups. The study sample included beneficiaries with Part B coverage for the entire calendar year, excluding beneficiaries in Medicaid or Medicare Advantage plans. Beneficiaries with a claims-documented or self-reported history of targeted cancers, who were likely to have diagnostic tests or have surveillance screenings were excluded. The screening measures were constructed separately following Medicare coverage and U.S. Preventive Services Task Force (USPSTF) recommendations. We measured the screening utilization outcome drawing from claims data, as well as using the self-reported survey data. RESULTS: After the cost-sharing removal policy, we found no statistically significant difference in a beneficiary's probability of receiving a colonoscopy (transition period: OR = 1.08, 95% CI = 0.90-1.29; post-policy period: OR = 1.08, 95% CI = 0.83-1.42), a mammogram (transition period: OR = 1.03, 95% CI = 0.91-1.17; post-policy period: OR = 1.07, 95% CI = 0.88-1.30), or a biennial Pap smear (transition period: OR = 0.87, 95% CI = 0.69-1.09; post-policy period: OR = 0.72, 95% CI = 0.51-1.03) in claims-based measures following Medicare coverage. Similarly, we found null effects of the policy change on utilization of colonoscopy among enrollees 50-75 years old, biennial mammograms by women 50-74, and triennial Pap smear tests among women 21-65 in claims-based measures according to USPSTF. The findings from survey-based measures were consistent with the estimates from claims-based measures, except that the use of Pap smear declined since 2011. Further, the policy change did not increase utilization in patients with disadvantaged socioeconomic characteristics. Yet the disparate patterns in adjusted screening rates by socioeconomic status and race/ethnicity persisted over time. CONCLUSIONS: Removing out-of-pocket costs for screenings did not provide enough incentives to increase the screening rates among Medicare beneficiaries.

Innovations in Occupational Health Care Delivery Can Prevent Entry into Permanent Disability: 8-Year Follow-up of the Washington State Centers for Occupational Health and Education.

BACKGROUND: Long-term work disability is known to have an adverse effect on the nation's labor force participation rate. To reduce long-term work disability, the Washington State Department of Labor and Industries established a quality improvement initiative that created 2 pilot Centers of Occupational Health and Education (COHE). OBJECTIVES: To document the level of work disability in a sample of injured workers with musculoskeletal injuries and to examine (8-y) work disability outcomes associated with the COHE health care model. RESEARCH DESIGN: Prospective nonrandomized intervention study with nonequivalent comparison group using difference-in-difference regression models. SUBJECTS: Intervention group represents 18,790 workers with musculoskeletal injuries treated by COHE providers. Comparison group represents 20,992 workers with similar injuries treated within the COHE catchment area by non-COHE providers. MEASURES: Long-term disability outcomes include: (1) on disability 5 years after injury; (2) received a state pension for total permanent disability; (3) received total disability income support through the Social Security Disability Insurance program; or (4) a combined measure including any one of the 3 prior measures. RESULTS: COHE patients had a 30% reduction in the risk of experiencing long-term work disability (odds ratio=0.70, P=0.02). The disability rate (disability days per 1000 persons) over the 8-year follow-up for the intervention and comparison groups, respectively, was 49,476 disability days and 75,832 disability days. CONCLUSIONS: Preventing long-term work disability is possible by reorganizing the delivery of occupational health care to support effective secondary prevention in the first 3 months following injury. Such interventions may have promising beneficial effects on reversing the nation's progressively worsening labor force participation rate.

Mental Health and Substance Use Care Among Young Adults Before and After Affordable Care Act (ACA) Implementation: A Rural and Urban Comparison.

PURPOSE: Rural young adults experience greater unmet need for mental health (MH) and alcohol or drug (AOD) treatment and lower health insurance coverage than urban residents. It is unknown whether Affordable Care Act (ACA) reforms in 2010 (dependent coverage extended to age 26) or 2014 (Medicaid expansion) closed rural/urban gaps in insurance and treatment. The present study compared changes in rates of health insurance, MH treatment, and AOD treatment for rural and urban young adults over a period of ACA reforms. METHODS: Young adult participants (18-25 years) in the National Survey on Drug Use and Health (2008-2014) with past-year psychological distress or AOD abuse were included. Difference-in-differences logistic regression models estimated rural/urban differences in insurance, MH, and AOD treatment pre- versus post-ACA reforms. Analyses adjusted for gender, race, marital status, and health status. RESULTS: Among 39,482 young adults with psychological distress or AOD, adjusted insurance rates increased from 72.0% to 81.9% (2008-2014), but a significant rural/urban difference (5.1%) remained in 2014 (P < .05). Among young adults with psychological distress (n = 23,470), MH treatment rates increased following 2010 reforms from 30.2% to 33.0%, but gains did not continue through 2014. Differences in MH treatment over time did not vary by rural/urban status and there were no significant changes in AOD treatment for either group. CONCLUSIONS: Although rates of insurance increased for all young adults, a significant rural/urban difference persisted in 2014. Meaningful increases in MH and AOD treatment may require targeted efforts to reduce noninsurance barriers to treatment.

Expanding vocational retraining options for injured workers: An experiment in worker choice.

BACKGROUND: An innovative self-directed vocational retraining alternative (Option 2) has been offered to eligible Washington State injured workers since 2008. OBJECTIVE: We aimed to describe: (1) how frequently Option 2 was selected and by whom, (2) the extent to which Option 2 workers used their reserved retraining funds, and (3) how worker satisfaction and employment outcomes for Option 2 workers compared with those of workers undergoing traditional vocational retraining. METHODS: Five-year cohort study involving workers' compensation data, state wage files, and two worker surveys. RESULTS: Fewer than 25% of Option 2 workers used their retraining funds. Retraining fund use was associated with better employment outcomes. Workers who were older, whose preferred language was not English, or who had lower pre-injury wages or less education, were least likely to use Option 2 retraining funds. Many workers chose Option 2 because they thought the approved traditional retraining plan was not a good fit for them. CONCLUSIONS: Self-directed retraining may benefit workers who have the ability, resources, and motivation to independently identify and complete retraining. Additional efforts may be needed to ensure that traditional retraining plans are well-suited to workers' circumstances, and to identify and remove barriers to use of reserved retraining funds.

Opioid poisonings in Washington State Medicaid: trends, dosing, and guidelines.

BACKGROUND: Opioid poisonings have increased as use of prescription opioid medications have increased. To reduce these poisonings, guidelines for chronic opioid use have been implemented. However, if opioid poisonings occur in individuals who do not have high prescribed doses and who are not chronic opioid users, the current guidelines may need revision. OBJECTIVES: To examine changes in rates of methadone and other opioid poisonings after implementation of the WA State Opioid Guideline in 2007 and to examine the prescription history before poisonings. METHODS: The study sample consisted of individuals who had at least 1 paid claim for an opioid prescription in the Medicaid fee-for-service system between April 2006 and December 2010 and had an emergency department or inpatient hospital claim for an opioid poisoning. RESULTS: Methadone poisonings occurred at 10 times the rate of other prescription opioid poisonings and increased between 2006 and 2010. Rates of other prescription opioid poisonings appeared to level off after implementation of the WA opioid guideline in 2007. Among individuals with nonmethadone opioid poisonings, only 44% had chronic opioid use, 17% had prescribed doses in the week before the poisoning >120 mg/d morphine-equivalent dose (MED), 28% had doses <50 mg/d MED, and 48% had concurrent sedative prescriptions. CONCLUSIONS: It may be prudent to revise guidelines to address opioid poisonings occurring at relatively low prescribed doses and with acute and intermittent opioid use. Research is needed to establish the best strategies to prevent opioid poisonings.

Workers' compensation: poor quality health care and the growing disability problem in the United States.

The proportion of working age citizens permanently removed from the workforce has dramatically increased over the past 30 years, straining both Federal and State disability systems designed as a safety net to protect them. Almost one-third of these rapidly emerging disabilities are related to musculoskeletal disorders, and three of the top five diagnoses associated with the longest Years Lived with Disability are back, neck and other musculoskeletal disorders. The failure of Federal and state workers' compensation systems to provide effective health care to treat non-catastrophic injuries has been largely overlooked as a principal source of permanent disablement and corresponding reduced labor force participation. Innovations in workers' compensation health care delivery, and in use of evidence-based coverage methods such as prospective utilization review, are effective secondary prevention efforts that, if more widely adopted, could substantially prevent avoidable disability and provide more financial stability for disability safety net programs.

Using O*NET to estimate the association between work exposures and chronic diseases.

BACKGROUND: A standardized process using data from the Occupational Information Network (O*NET) is applied to estimate the association between long-term aggregated occupational exposure and the risk of contracting chronic diseases later in life. We demonstrate this process by analyzing relationships between O*NET physical work demand ratings and arthritis onset over a 32-year period. METHODS: The National Longitudinal Survey of Youth provided job histories and chronic disease data. Five O*NET job descriptors were used as surrogate measures of physical work demands. Logistic regression measured the association between those demands and arthritis occurrence. RESULTS: The risk of arthritis was significantly associated with handling and moving objects, kneeling, crouching, and crawling, bending and twisting, working in a cramped or awkward posture, and performing general physical activities. CONCLUSION: This study demonstrates the utility of using O*NET job descriptors to estimate the aggregated long-term risks for osteoarthritis and other chronic diseases when no actual exposure data is available.

A novel method for estimating the effects of job conditions on asthma and chronic lung disease.

OBJECTIVE: This study uses 32 years of longitudinal job history to analyze the long-term effect of exposure to specific workplace conditions on the risk of contracting asthma or chronic lung disease later in life. Our approach allows for the estimation of occupational respiratory risks even in the absence of direct environmental monitoring. METHODS: We employ a novel methodology utilizing data from the National Longitudinal Survey of Youth 1979 (NLSY79), and ratings of job exposures from the Occupational Information Network (O*NET), which are based on 70 years of empirical data compiled by the U.S. Department of Labor. A series of multivariable logistic regression analyses are performed to determine how long-term exposure to a particular occupational O*NET indicator (e.g., working in an extremely hot or cold environment) is related to asthma and COPD risk. RESULTS: The risk of contracting COPD was significantly associated with long-term work in very hot or cold temperatures (OR = 1.50, CI: 1.07-2.10), performing physically demanding activities (OR = 1.65, CI:1.20-2.28), working outdoors exposed to weather (OR = 1.45, CI:1.06-1.99), and workplace exposure to contaminants (OR = 1.42, CI:1.05-1.96). In general, the effects of exposure were greater for COPD than for asthma. With respect to contracting asthma, only exposure to work in very hot or cold temperatures (OR = 1.35, CI:1.08-1.70) and performing physically demanding activities (OR = 1.23, CI:1.00-1.52) were statistically significant. CONCLUSIONS: Use of O*NET job descriptors as surrogate measures of workplace exposures can provide a useful way of analyzing the risk of occupationally-related respiratory disease in situations where direct exposure measurement is not feasible.

Vocational rehabilitation program evaluation: comparison group challenges and the role of unmeasured return-to-work expectations.

PURPOSE: Despite the importance and cost of workers' compensation (WC)-based vocational rehabilitation (VR) programs, outcome evaluations are rare, in part due to the scarcity of suitable comparison groups. The aims of this study were to assess (1) the adequacy of a commonly recommended internal comparison group, i.e., workers who were eligible for but did not receive services, and (2) return-to-work (RTW) expectations as a potential source of bias. METHODS: In this prospective cohort study, we used WC claims data and worker-reported RTW expectations to compare workers who received vocational retraining services to eligible workers who did not receive such services. Workers were surveyed after retraining eligibility determination, prior to the initiation of retraining activities. VR progress and RTW wage outcomes were followed for 3 years. The magnitude of confounding contributed by RTW expectations and other covariates was quantified. RESULTS: Workers who were somewhat or very certain they would RTW had significantly better outcomes. RTW expectations played a strong confounding role, reducing the retraining plan effect estimate by about 23 %, while education and physical capacity each changed the effect estimate by <5 %. CONCLUSIONS: RTW expectations predicted long-term RTW outcomes and can play a strong confounding role if unmeasured. We found that the internal comparison group approach, commonly recommended for VR program evaluation, is inappropriate for WC-based VR evaluations. Ultimately, there is no simple solution to the challenge of identifying a comparison group; however, measurement of RTW expectations, an easily-measured multi-dimensional construct, may be a useful addition to the VR evaluation toolbox.

Improving vocational rehabilitation services for injured workers in Washington State.

Workers who incur permanent impairments or have ongoing medical restrictions due to injuries or illnesses sustained at work may require support from vocational rehabilitation programs in order to return to work. Vocational rehabilitation programs implemented within workers' compensation settings are costly, and effective service delivery has proven challenging. The Vocational Improvement Project, a 5.5-year pilot program beginning in 2008, introduced major changes to the Washington State workers' compensation-based vocational rehabilitation program. In the evaluation of this pilot program, set within a large complex system characterized by competing stakeholder interests, we assessed effects on system efficiency and employment outcomes for injured workers. While descriptive in nature, this evaluation provided evidence that several of the intended outcomes were attained, including: (1) fewer repeat referrals, (2) fewer delays, (3) increased choice for workers, and (4) establishment of statewide partnerships to improve worker outcomes. There remains substantial room for further improvement. Retraining plan completion rates remain under 60% and only half of workers earned any wages within two years of completing their retraining plan. Ongoing communication with stakeholders was critical to the successful conduct and policy impact of this evaluation, which culminated in a 3-year extension of the pilot program through June 2016.

Injured workers' assessment of vocational rehabilitation services before and after retraining.

PURPOSE: Workers' compensation-based vocational rehabilitation (VR) programs are costly and challenging to operate effectively. This study aimed to: (1) describe injured workers' assessment of Washington State's VR system before and after vocational retraining, (2) describe the factors affecting injured worker satisfaction with VR services, and (3) gather suggestions for program improvement from injured workers. METHODS: Telephone surveys were conducted in two distinct samples: (1) 361 workers were interviewed after determination of retraining eligibility but before retraining plan development, and (2) 360 workers were interviewed after cessation of vocational services and claim closure. RESULTS: Injured workers interviewed before retraining were more often satisfied with the VR system (69 %) than were those interviewed after VR services ended (46 %). Although 55 % were initially somewhat/very certain they would return to work (RTW) after retraining, only 21 % had RTW 3-6 months after claim closure. Poor health, poor functional ability, and multiple retraining attempts were significantly associated with dissatisfaction. Suggestions for program improvement fell most frequently into the following areas: (1) more training choices, more worker input into the retraining goal, and/or a better fit of the retraining goal with the workers' experience and abilities (25 %); (2) listen to, respect, and/or understand the worker with regard to their interests, goals, and limitations (17 %); and (3) more support with job placement, work re-entry skills, and RTW in general (9 %). CONCLUSIONS: There is substantial room for improvement in worker satisfaction with VR. Injured workers' feedback may facilitate identification of opportunities to improve the VR process and RTW outcomes.

How do coverage policies influence practice patterns, safety, and cost of initial lumbar fusion surgery? A population-based comparison of workers' compensation systems.

BACKGROUND CONTEXT: In response to increasing use of lumbar fusion for improving back pain, despite unclear efficacy, particularly among injured workers, some insurers have developed limited coverage policies. Washington State's workers' compensation (WC) program requires imaging confirmation of instability and limits initial fusions to a single level. In contrast, California requires coverage if a second opinion supports surgery, allows initial multilevel fusion, and provides additional reimbursement for surgical implants. There are no studies that compare population-level effects of these policy differences on utilization, costs, and safety of lumbar fusion. PURPOSE: The purpose of this study was to compare population-level data on the use of complex fusion techniques, adverse outcomes within 3 months, and costs for two states with contrasting coverage policies. STUDY DESIGN AND SETTING: The study design was an analysis of WC patients in California and Washington using the Agency for Healthcare Research and Quality's State Inpatient Databases, 2008-2009. PATIENT SAMPLE: All patients undergoing an inpatient lumbar fusion for degenerative disease (n=4,628) were included the patient sample. OUTCOME MEASURE(S): Outcome measures included repeat lumbar spine surgery, all-cause readmission, life-threatening complications, wound problems, device complications, and costs. METHODS: Log-binomial regressions compared 3-month complications and costs between states, adjusting for patient characteristics. RESULTS: Overall rate of lumbar fusion operations through WC programs was 47% higher in California than in Washington. California WC patients were more likely than those in Washington to undergo fusion for controversial indications, such as nonspecific back pain (28% versus 21%) and disc herniation (37% versus 21%), as opposed to spinal stenosis (6% versus 15%), and spondylolisthesis (25% versus 41%). A higher percentage of patients in California received circumferential procedures (26% versus 5%), fusion of three or more levels (10% versus 5%), and bone morphogenetic protein (50% versus 31%). California had higher adjusted risk for reoperation (relative risk [RR] 2.28; 95% confidence interval [CI], 2.27-2.29), wound problems (RR 2.64; 95% CI, 2.62-2.65), device complications (RR 2.49; 95% CI, 2.38-2.61), and life-threatening complications (RR 1.31; 95% CI, 1.31-1.31). Hospital costs for the index procedure were greater in California ($49,430) than in Washington ($40,114). CONCLUSIONS: Broader lumbar fusion coverage policy was associated with greater use of lumbar fusion, use of more invasive operations, more reoperations, higher rates of complications, and greater inpatient costs.