Is workers' compensation a comorbidity - if so what do we do about it?

Inferior outcomes and higher complication rates after shoulder arthroplasty in workers’compensation patients

These authors compared the complication rates and clinical outcomes after shoulder arthroplasty in workers' compensation (WC) patients and control non-WC patients.
They queried their institutional shoulder arthroplasty database for patients with minimum 2-year follow-up who underwent total shoulder arthroplasty, reverse total shoulder arthroplasty, or hemiarthroplasty. 45 WC patients were age and sex matched with 45 non-WC patients and retrospectively evaluated for complication rates, patient-reported outcomes, and range of motion.

The WC group had twice as high rate of prior surgery (82% vs 38%).

The WC group had an eight times higher reoperation rate (16% vs 2%) 

The WC group had three times the rate of persistent pain at final follow-up (33% vs 11%). 

The WC group had half the improvement for the SST (from 3.2 to 5.8) in comparison to the non WC group  (4.3 to 9.7).

On multivariate regression controlling for other variables including number of prior surgical procedures, WC status remained associated with lower improvements in the Simple Shoulder Test  scores, as well as a higher reoperation rate and a higher rate of persistent pain.

Comment: This article demonstrates that patients with workers' compensation insurance are at greater risk for adverse outcomes after shoulder arthroplasty.

From these data it appears that the value of shoulder arthroplasty (improvement measured against cost, reoperations and complications) is less for patients on WC insurance. It appears that WC gets less return on its investment in shoulder arthroplasty than other forms of insurance. This study did not assess the success rate of returning patients to work for patients on WC and those not on WC; if shoulder arthroplasty were successful in getting a substantial number of patients back to work, this fact might tip the value equation.

A number of questions arise:

(1) Should these results influence the decision of WC to fund shoulder arthroplasty? 

(2) Should these results influence the surgeon's decision to perform shoulder arthroplasty on WC funded patients? 

(3) When a patient has chronic osteoarthritis with work-related aggravation, to what degree should WC insurance be fiscally responsible for the total cost of shoulder arthroplasty? 

(4) Does WC insurance coverage of time off work disincent patients from "getting better"?

We do not know for sure how to answer these questions, but we must think about them in each case.

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Shoulders with job-related injuries and worker's compensation

A concerning thing about many occupational disorders is the ‘grab bag’ of imprecise terms that have been applied to them, such as “Complaints of the Arms, Neck and Shoulders (CANS)”, “Work-related upper extremity musculoskeletal disorders (WRUEMSDS)”, “Occupational shoulder disorders (OSDS)”, “Repetitive Motion Disorder (RMD)”, and “Impingement Syndrome”- these are conditions that do not have either robust diagnostic criteria or specific treatment for a defined anatomic entity. They leave shoulder surgeons in a very subjective and imprecise position. A well respected shoulder surgeon once told me that he always gets MRI’s on patients with work-related claims ‘to prove there’s nothing wrong’. The problem is that we rarely see a normal MRI reading on anyone over the age of 25 – everyone has some ‘findings’. As a result, we often see injured workers that have had acromioplasties, acromioclavicular resections, biceps tenodeses, SLAP repairs and Bankart repairs performed on patients in the absence of supporting evidence from the history and physical exam– the results are predictable.

Occupational disorders usually share some important features. They are thought to be caused by the patient’s job. They keep the patient from doing his or her job properly. They result in health care costs and loss of earnings for the patient. And they bring forth the question of the patient’s entitlement to reimbursement and compensation. For these reasons, occupational disorders create an undeniable conflict between (a) the desire of the patient to emphasize the magnitude of the shoulder disability in order to maximize the support they receive from the employer’s insurance and (b) the desire of the employer and the employer’s insurance to minimize their coverage for time off work, medical expenses and long term disability. The shoulder surgeon is often placed in middle of this conflict and asked to make time-consuming, imponderable, non-medical determinations, such as the “percent of permanent partial impairment” or defining when the patient is ‘fixed and stable” or what percent of the problem was “pre-existing” or whether the problem would have come on in the “absence of the patient’s employment”. While the physician is rarely an expert in making these determinations, each decision carries a major impact for the patient and the employer. Patients may feel threatened that the doctor will ‘cut them off’ resulting in a termination of the disability payments that they depend on for family support. This may drive patients to have surgical procedures as a demonstration of the severity of the problem. Employers often want the injured worker back only if there are ‘no restrictions,’ which is usually a challenge in that we can rarely restore an injured shoulder to normal. Physicians are asked to ‘approve’ various job modifications without detailed knowledge of what the modified job really entails.

In terms of the outcome of treatment, it has been repeatedly demonstrated that workman’s compensation is an important co-morbidity. Patients insured for on-the-job injuries have poorer outcomes than patients with other types of insurance coverage. Another fact must be recognized: if a patient is out of work for a year, the chances of going back to work are slim.

While all of these considerations may disincline surgeons from taking on injured workers, these individuals deserve the same thoughtful care we strive to deliver to all our patients. Our practice is to split the issues into (a) the job and (b) the shoulder. We are up front that no cuff surgery is likely to get a dockworker or carpenter back 100%. Before considering any surgery, we make sure that the Labor and Industries or Worker’s Compensation insurance is formally notified that the injury is likely to prevent full resumption of the pre-injury job – without or with treatment. We encourage the parties to begin the process of vocational rehabilitation, again before any interventional treatment. Once the vocational issues are resolved (‘this individual will not be able to return to work requiring overhead use of the arm’), we can devote our attention to defining expectations of treatment and trying our best to match these expectations with a realistic presentation of the outcomes we have achieved for patients having similar pathology.

Patients and surgeons faced with job related injuries face challenges that are not encountered in the management of conditions unrelated to work. These differences need to be carefully considered in planning their evaluation and management.

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