This technical report presents the methods and results of a study of the physician's role in the return-to-work (RTW) process of injured workers who have sustained disabling low back injuries in the California workers' compensation system. RTW is a complex and multifactorial process, influenced by the nature and severity of injury, medical treatment and rehabilitation, the claims and litigation process, worksite variables, employer policies, and economic variables. Although physicians play a key role in the RTW process, virtually nothing is known about their beliefs and attitudes regarding RTW, which factors influence physicians' RTW determinations, or the impact of physician variables on RTW outcomes. Worker's compensation claim and bill review data were obtained from a larger workers' compensation insurer in California to sample patients based on medical diagnosis and indemnity benefit payments, and their primary treating physicians based on frequency of doctor visits. Several injury and job factors were significantly associated with duration of work disability even after adjustment for potential confounders. Results showed that duration of disability increases during all disability phases with the time spent bending and lifting or pushing or pulling heavy objects at work, high psychological job demands, low supervisor support, shorter pre-injury employment, older age, and more severe back injury. The effect of injury severity decayed over time. During the subacute/chronic phases, duration of work disability increased with low job control, high job strain, and low control over work and rest schedules. Unexpectedly, history of a previous injury was unrelated to duration of disability during the acute phase, and associated with shorter disability during the subacute/chronic disability phases. Job dissatisfaction, low coworker support, exposure to whole body vibration, and prolonged sitting or standing were not related to duration of disability. This report documents attitudes and beliefs regarding RTW and work restriction among physicians, including medical, chiropractic, and osteopathic doctors who treat workers' compensation patients with low back pain, the most frequent and costly industrial injury. Physician attitudes and beliefs showed large variations between and within provider groups characterized by type of license or specialty. These wide variations reflect the lack of scientific evidence or even consensus regarding the management of disability due to low back pain. More research is needed to develop evidence-based guidelines regarding disability management, RTW determinations, and work restrictions. The rare consensus among physicians, for example regarding the usefulness of modified work programs, reflects an emerging understanding of the broader social dimensions of the return-to-work process in which the success of the physician in facilitating RTW depends on matching contribution of other agents in the RTW process. The analyses of the surveys show significant effects of physical and psychosocial job conditions both as independent barriers to RTW and as possible cofounders of the physician's impact on RTW outcomes. However, prospective studies are needed to confirm this finding. Work in progress assesses the effects of physicians factors on RTW outcomes taking these job factors and demographic and injury characteristics into account.
Niklas Krause, M.d., Ph.D., M.P.H., Project Director, Public Health Institute, Berkeley, CA 95704