Trends in disability duration and cost of workers' compensation low back pain claims (1988-1996)

Previously published epidemiologic studies of low back pain (LBP) have reported that the prevalence of low back disability has increased dramatically. These studies based their findings on either the number of disability claims filed, the disability duration, or both. This information was from countries other than the United States or from the US Social Security Disability Insurance data, with findings reported only to the early 1980s. More recent studies of US workers' compensation LBP claims reported a decrease in the incidence rate from the late 1980s to the mid-1990s. No studies have been found that report on the trends of disability duration for workers' compensation LBP claims. This study examined recent trends in the length of disability (LOD) for LBP claims and associated costs, using a large sample of claims from the privately insured US workers' compensation market. LOD and cost information were derived for injuries from 1988, 1990, 1992, 1994, and 1996. For each year, the distributions of LOD and cost were skewed, with the small percentage of claims that lasted more than one year (4.6%-8.8%, depending on the year) accounting for a large percentage of the total disability days (77.6%-90.1%) and cost (64.9%-84.7%). From 1988 to 1996, the average LOD decreased 60.9%, from 156 days to 61 days. The probability of being on disability for a long period of time has decreased over the years. Over the study period, the average cost of a claim decreased 41.4%, while the median cost increased 19.7%. The most influential change in the LOD and cost distributions was a reduction in expensive claims with a long disability duration. The evolution of LOD and cost is also detailed for different disability durations for the study period.     

Preserving workers' compensation benefits in a managed health care environment

Managed care techniques are increasingly being applied in the workers' compensation setting. Many workers, labor representatives and public health advocates fear that the introduction of managed care into workers' compensation may reflect a broader employer-driven campaign to erode benefits, tighten eligibility criteria, and weaken employees' control over health care and compensation issues. The potential threats to workers can be mitigated by involving them in the design of the workers' compensation health plan and selection of provider organization, assuring access to appropriate specialists and diagnostic testing, minimizing delays, increasing accountability through contract provisions and government oversight, and enhancing communications through the use of ombudsmen and alternative dispute resolution approaches. Additional outcomes studies assessing the long-term impact of managed care in workers' compensation are needed.     

Healthcare utilization and referral patterns in the initial management of new-onset, uncomplicated, low back workers' compensation disability claims

Most episodes of low back pain are considered non-specific in nature, with the vast majority resolving within 2 weeks and almost all resolving within 6 weeks regardless of the medical intervention. Recently published clinical guidelines have clearly delineated a limited set of circumstances that would indicate the need for specialist referral. The purpose of this study was to describe the healthcare utilization and physician referral patterns for new-onset, uncomplicated, low back workers' compensation disability cases randomly selected from a large insurance carrier data source. The provision of care in urgent care centers and emergency departments for both initial and main sources of care occurred more frequently than was probably indicated. For this selected group of uncomplicated low back pain cases, specialist care was provided more commonly than would be expected or indicated (36% of the sample was seen by a surgeon, while only 2% received surgery). In addition, referral to specialists (other than occupational medicine specialists) was often made sooner than would be expected or indicated, with a median of 13 days for such referrals. Such overutilization of resources can reasonably be expected to increase overall medical costs.     

Uses of workers' compensation data in epidemiology research

Contrary to general opinion, workers' compensation data can be helpful in epidemiologic research. Dr. Goldsmith assesses several studies based on data culled from workers' compensation or disability programs and explains how valuable information was derived.     

Recognition of psychologists in workers' compensation law.

Reviews the workers' compensation laws with reference to the recognition of psychologists as diagnosticians of mental injuries and treatment providers for workers with work-related mental injuries. It is shown that with the exception of California, Florida, Hawaii, and the federal system, psychological services are not explicitly recognized as available to, nor are psychologists explicitly recognized as diagnosticians or treatment providers for, the mentally injured worker. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of prevention in workers' compensation managed care arrangements

Managed care's emphasis on restricting costs may interfere with its ability to assume a prevention orientation. The authors present models, derived from group health and workers' compensation, of successful incorporation of prevention into managed care arrangements.     

Variation in bone mineral density between different anatomical sites in a normal local population

Bone mineral density (BMD) measured using dual energy X-ray absorptiometry (DXA) can be expressed in terms of standard deviations, above or below mean young adult T-scores and above or below age-matched Z-scores. The differences between the left neck of the femur (LN), right neck of the femur (RN) and lumbar spine (L2-L4) were statistically significant, irrespective of whether expressed as T-scores or Z-scores. Therefore skeletal status assessment should involve as many sites as practically possible. Considering the low radiation dose and short scanning time, it is suggested that at least the two femurs and lumbar spine BMD be used in routine osteoporosis risk assessment.     

Awareness of disability and long-term outcome after traumatic brain injury.

The degree of long-term (7.41 yrs postinjury) impairment of disability awareness was quantified in 63 adults (aged 18–45 yrs) with closed-head injuries as the difference between self-ratings and staff ratings on the Scales of Independent Behavior. Other measures included the Wechsler Adult Intelligence Scale--Revised (WAIS--R), the Wechsler Memory Test—Revised, the Wisconsin Card Sorting Test, and ratings of actual functional status based on classifications in vocational and independent living level. Impaired awareness and its relationship to actual level of present vocational and residential status, maladaptive behaviors, attention and freedom from distractibility, and a measure of frontal system functioning was examined. Impaired awareness was significantly associated with lower vocational and residential status, maladaptive behavior, greater distractibility, and increased perseveration. Impaired awareness is directly proportional to duration of posttraumatic amnesia and general memory. Impaired awareness of disability appears to be a consequence of a general cognitive impairment rather than a specific deficit. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Toward a neuropsychological model of functional disability after mild traumatic brain injury.

Discusses investigations into the nature, causes, predictors, and treatment of functional disability after minor traumatic brain injury (TBI). Distinctions among minor head injury, mild traumatic brain injury, postconcussion syndrome, and posttraumatic stress disorder (PTSD) are clarified, and methodological and information-processing issues in minor TBI are identified. Four stages of clinical research related to minor TBI are described: identification of functional scenarios (1983–1987), development of educational materials (1985–1986), ongoing research (1988–1992), and clinical applications (1992 and continuing). Finally, a neuropsychological model of functional disability after minor TBI is presented, with implications for assessment and treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Managed care in workers' compensation: analysis of cost drivers and vendor selection

1. Managed care for employee benefits provides a model of cost containment for workers' compensation; however, significant differences must be understood. 2. Purchasers of managed care services must perform an internal assessment to determine the cost drivers for workers' compensation. Managed care does not address all cost drivers. 3. A model for evaluating managed care vendors places them on a continuum of risk, similar to insurance risk, where a variety of cost containment strategies may be used together. 4. By reviewing seven key aspects of a managed care vendor, a purchaser can rate the vendor's ability to meet their needs.     

The functions and consensus motifs of nine types of peptide segments that form different types of nucleotide-binding sites

From an analysis of current data on 16 protein structures with defined nucleotide-binding sites consensus motifs were determined for the peptide segments that form such nucleotide-binding sites. This was done by using the actual residues shown to contact ligands in the different protein structures, plus an additional 50 sequences for various kinases. Three peptide segments are commonly required to form the binding site for ATP or GTP. Binding motif Kinase-1a is found in almost all sequences examined, and functions in binding the phosphates of the ligand. Variant versions, comparable to Kinase-1a, are found in a subset of proteins and appear to be related to unique functions of those enzymes. Motif Kinase-2 contains the conserved aspartate that coordinates the metal ion on Mg-ATP. Motif Kinase-3 occurs in at least four versions, and functions in binding the purine base or the pentose. Two protein structures show ATP-binding at a separate regulatory site, formed by the motifs Regulatory-1 and Regulatory-2. Structures for adenylate kinase and guanylate kinase show three different sequence motifs that form the binding site for a nucleoside monophosphate (NMP). NMP-1 and NMP-2 bind to the pentose and phosphate of the bound ligand. NMP-1 is found in almost all the kinases that phosphorylate AMP, CMP, GMP, dTMP, or UMP. NMP-3a is found in kinases for AMP, GMP, and UMP, while NMP-3b binds only GMP. For the binding of NTPs, three distinct types of nucleotide-binding fold structures have been described. Each structure is associated with a particular function (e.g. transfer of the gamma-phosphate, or of the adenylate to an acceptor) and also with a particular spatial arrangement of the three Kinase segments evident in the linear sequence for the protein.     

Suggested guidelines for rating cardiac disability in workers' compensation. Medical and Chiropractic Advisory Committee to the Administrative Director of the California Division of Industrial Accidents

Cardiac disability ratings in workers' compensation cases currently lack any consistent scientific basis, with varying medical evidence used by different examiners in the same case. Opinions about the extent of disability may differ with the same patient, delaying resolution and the delivery of benefits. We describe guidelines for determining cardiac impairment and suggest a schedule for rating disability based on evidence. Our experience is in California, but arriving at equitable ratings for disability purposes is a nationwide challenge. Exercise stress testing provides the best reproducible data to test the heart's ability to do work. When exercise stress testing is not possible or adequate, alternative or supplemental testing is necessary. Certain conditions, such as hypertension, arrhythmias, coronary artery spasm, and a history of coronary artery operations or myocardial infarction, may affect "cardiac disability" but may not necessarily be reflected in exercise testing.     

Carpal tunnel surgery outcomes in workers: effect of workers' compensation status

One hundred thirteen workers' compensation and 53 non-workers' compensation patients who had undergone open carpal tunnel release were queried about job status and the presence or absence of residual symptoms of numbness, pain, or nocturnal awakening an average of 42 months postoperatively. Thirty-nine non-workers' compensation subjects were at their original jobs as compared to only 53 workers' compensation subjects. Seventeen of the workers' compensation subjects were unemployed versus two non-workers' compensation subjects. These differences were significant. Of patients changing jobs, 39 workers' compensation subjects and 2 non-workers' compensation subjects attributed their job change to symptoms of carpal tunnel syndrome. Residual symptoms were significantly more common in workers' compensation compared to non-workers' compensation subjects, with 92 of the former and 26 of the latter subjects reporting some residual symptoms.     

Control of workers' compensation claims and costs in the U.S. Army

The Army Medical Department has been implementing initiatives to reduce workers' compensation claims and costs since 1983. After years of an upward trend, reductions in both costs and claims were reported for 1995 and 1996. To assess efforts at managing workers' medical care and compensation in the Army, we reviewed Department of Defense and Department of the Army documents and studied data on claims and costs. We found several programs that were launched to control claims and associated costs. None of these programs adequately addressed the absence of real-time financial incentives for reducing compensation costs, a lack of acceptable workers' compensation data collection and data management systems, and a lack of emphasis on medical case management. To sustain this trend of decreased costs and claims, the Army must focus on (1) incentives, (2) data management systems, and (3) a comprehensive plan for medically managing workers' compensation claims and costs.     

Development of a scoring system to assess disability in an Italian elderly population. Evaluation of a disability questionnaire

Patients with idiopathic and symptomatic restless legs syndrome (RLS) suffer from "dyskinesia while awake" or "daytime myoclonus" when at rest preceded by sensory symptoms. In order to characterise the RLS either as reflex movement or as voluntary movement we measured movement-related cortical potentials in 5 idiopathic and 8 uraemic RLS patients. Movements from both legs were polygraphically recorded concomitantly with cortical activity 2000 msec before to 500 msec after onset of EMG activity. These data were compared with a voluntary simulation of each patient's movement pattern and with 5 age-matched controls performing dorsiflexion of the right, left and both feet. Cortical activity preceding daytime myoclonus was absent in RLS patients whereas self-initiated leg movements in patients elicited onset times (1180-1380 msec) and amplitudes of Bereitschaftspotential (readiness potential) not significantly different from readiness potentials in control subjects (P > 0.05). Lack of movement-related potentials in myoclonus and/or dyskinesias during daytime in RLS patients is compatible with an involuntary mechanism of induction and points towards a subcortical or spinal origin of RLS.     

Effects of different types of anticholinesterase agents on in vivo hippocampal population spikes in rats

Laparoscopic oophoropexy may prevent recurrent (repeat torsion of the same ovary) or sequential (subsequent torsion of the contralateral ovary) ovarian torsion. Two adolescent girls with sequential ovarian torsion underwent laparoscopic plication of utero-ovarian ligaments. Neither patient has had recurrence in the 6. 5 and 2 years, respectively, since surgery. Sequential ovarian torsion has been described,1-8 and in almost every instance the authors raised the question of whether or not oophoropexy should have been done at the time of the initial episode of torsion. In virtually every instance the second ovary was removed and the patient rendered menopausal. In two patients with sequential ovarian torsion the ovary was saved and oophoropexy performed laparoscopically in an effort to prevent recurrence.     

Postoperative plasma concentrations of procalcitonin after different types of surgery

Transforming growth factor (TGF)-beta 1 is an important cytokine involved in the pathobiology of tissue fibrosis through its stimulation of the production of, and inhibition of the degradation of, extracellular matrix proteins. We examined the clinical usefulness of plasma TGF-beta 1 concentration as a marker of fibrogenesis in patients with chronic viral hepatitis. Thirty-five patients, 11 with minimal chronic hepatitis, 14 with mild chronic hepatitis and 10 with moderate chronic hepatitis and 20 healthy subjects were studied. Transforming growth factor-beta 1 concentrations in platelet-poor plasma were measured with a TGF-beta 1 enzyme-linked immunosorbent assay system kit after acid-ethanol extraction. Plasma TGF-beta 1 levels were significantly elevated in patients with mild and moderate chronic hepatitis, but not in those with minimal chronic hepatitis, compared with the levels in the controls. Plasma TGF-beta 1 levels were increased in parallel with the histological degree of necroinflammation and of liver fibrosis. Plasma TGF-beta 1 levels were positively correlated with blood levels of procollagen type III N-peptide, and 7S fragment and central triple-helix of type IV collagen. These results suggest that plasma TGF-beta 1 level is a useful marker in assessing the situation of liver active fibrogenesis in patients with chronic viral hepatitis.     

Assessing disability after head injury: improved use of the Glasgow Outcome Scale

OBJECTIVE: The objective of this study was to assess somatic and inherited androgen receptor gene mutations in families with only one affected individual. METHODS: Molecular genetic analysis of the androgen receptor gene in DNA derived from blood leukocytes from 30 families with single-strand conformation analysis, direct sequencing, and restriction fragment analysis was performed. RESULTS: In 22 families the mothers and all investigated grandmothers were heterozygous carriers. However, within the sisters and aunts, both heterozygous carriers and noncarriers were present. In eight families a de novo mutation was characterized. In three of these patients indication for somatic mosaicism was found. CONCLUSIONS: De novo mutations occur at a high rate within the androgen receptor gene (8 of 30 = 26.7%); a high proportion (3 of 8) arise after the zygote stage. Thus only direct analysis of the underlying mutation of the androgen receptor gene in the proband and his or her family can provide the basis for genetic counseling.