Biomedical subjects

Deborah Fulton-Kehoe

Publications and source records attributed to Deborah Fulton-Kehoe.

18 recordsLinked to original sources

PubMed2007

Prognostic factors of long-term disability in a workers' compensation system.

OBJECTIVE: We identified predictive factors of long-term disability in new workers' compensation claims to guide secondary prevention research and target interventions for high-risk claims. METHODS: Workers with 4 or more days of work disability resulting from workplace injuries were followed for approximately 6 years in a population-based retrospective inception cohort study of 81,077 workers. RESULTS: Predictors of long-term disability included delay between injury and first medical treatment, older age, construction industry, logging occupation, longer time from medical treatment to claim filing, back injury, smaller firm size, female gender, higher unemployment rate, and having dependents. We used logistic and quantile regression to investigate predictors of disability. These models produced consistent information regarding predictors. CONCLUSION: These factors can be used to identify jobs or workers at increased risk for long-term disability that warrant prevention intervention.

Adult↗

PubMed2006

Lumbar fusion outcomes in Washington State workers' compensation.

STUDY DESIGN: Retrospective population-based cohort study. OBJECTIVE: To evaluate the influence of lumbar intervertebral fusion devices on clinical and disability outcomes among Washington State compensated workers with chronic back pain. SUMMARY OF BACKGROUND DATA: The efficacy of lumbar fusion for chronic low back pain remains controversial. Recent randomized controlled trials have shown results of fusion to be equivalent to those of structured exercise and cognitive intervention. Lumbar fusion rates, however, continue to increase nationally, fueled, in part, by introduction of new fusion devices, including intervertebral cages in 1996. It is not known whether these newer devices have improved outcomes, and particularly in compensated workers. METHODS: In this population-based retrospective cohort study, we identified Washington State injured workers who underwent lumbar fusion between 1994 and 2001 from Washington State Workers' Compensation system administrative database. All the data for this study were obtained from either the claims or medical bill payment databases. Multiple logistic regression analyses were used to examine the association between the surgical technique (interbody cages and/or instrumentation) and the risk of disability, reoperation, and complications following lumbar fusion. RESULTS: Among the 1,950 eligible subjects, fusions with cages increased from 3.6% in 1996 to 58.1% in 2001. Overall disability rate at 2 years after fusion was 63.9%, reoperation rate 22.1%, and rate for other complications 11.8%. Use of cages or instrumentation was associated with increased complication risk compared with bone-only fusions without improving disability or reoperation rates. Legal, work-related, and psychologic factors predicted worse disability. Discography and multilevel fusions predicted greater reoperation risk. Degenerative disc disease and concurrent decompression procedures predicted lower reoperation risk. CONCLUSIONS: Use of intervertebral fusion devices rose rapidly after their introduction in 1996. This increased use was associated with an increased complication risk without improving disability or reoperation rates.

Cohort Studies↗

PubMed2006

Worker recovery expectations and fear-avoidance predict work disability in a population-based workers' compensation back pain sample.

STUDY DESIGN: Prospective, population-based cohort study. OBJECTIVES: To examine whether worker demographic, pain, disability, and psychosocial variables, assessed soon after work-related back pain disability onset, predict 6-month work disability. SUMMARY OF BACKGROUND DATA: Greater age, pain, and physical disability, and certain psychosocial characteristics may be risk factors for prolonged back pain-related work disability, although many studies have been small, findings have been inconsistent, and some psychosocial variables have not been examined prospectively. METHODS: Workers (N = 1,068) completed telephone interviews assessing demographic, pain, disability, and psychosocial variables 18 days (median) after submitting Workers' Compensation back pain disability claims. Administrative measures of work disability 6 months after claim submission were obtained. RESULTS: At 6 months, 196 workers (18.4%) were receiving work disability compensation. Age, race, education, and baseline pain and disability were significant predictors of 6-month disability. Adjusting for baseline demographics, pain, disability, and other psychosocial variables, high work fear-avoidance (odds ratio, 4.6; 95% confidence interval, 1.6-13.7) and very low recovery expectations (odds ratio, 3.1, 95% confidence interval, 1.5-6.5) were significant independent predictors. CONCLUSIONS: Among individuals with acute work-related back pain, high pain and disability, low recovery expectations, and fears that work may increase pain or cause harm are risk factors for chronic work disability.

Adolescent↗

PubMed2006

Factors associated with early opioid prescription among workers with low back injuries.

UNLABELLED: Prescription of opioids for nonmalignant musculoskeletal pain has increased substantially in recent years, but there is little information on the incidence of, or factors associated with, such prescription for work-related back pain. In a prospective cohort study (N = 1,067), we examined associations between worker sociodemographic and other characteristics and opioid prescription within six weeks of the first medical visit for workers' compensation claims for work loss due to back injury. We examined administrative, pharmacy, and worker-reported data. In bivariate logistic regression models, Hispanics were less likely than non-Hispanic whites to receive opioid prescriptions, and very high body mass index, daily tobacco use, greater pain and physical disability, pain radiating below the knee, injury severity categorizations (from medical records) of major sprain and radiculopathy, and worse mental health were associated with opioid prescription. Adjusting for demographics, pain intensity, and physical disability, opiate prescription was significantly associated with daily tobacco use, pain radiating below the knee, and injury severity categories (major sprain and radiculopathy). Knowledge of worker characteristics associated with early opioid prescription may be useful in future studies of the role of early pain treatment in influencing subsequent course of pain and disability among workers with back injuries. PERSPECTIVE: Little is known about patient characteristics that may influence physicians' decisions concerning prescription of opioids for acute back pain. Not surprisingly, workers with more severe back injuries are more likely to be prescribed opioids, but reasons for prescription disparities based on ethnicity and tobacco use warrant further study.

Adult↗

PubMed2005

Opioid dosing trends and mortality in Washington State workers' compensation, 1996-2002.

BACKGROUND: The use of opioids for chronic non-cancer pain has increased in the United States since state laws were relaxed in the late 1990s. These policy changes occurred despite scanty scientific evidence that chronic use of opioids was safe and effective. METHODS: We examined opiate prescriptions and dosing patterns (from computerized databases, 1996 to 2002), and accidental poisoning deaths attributable to opioid use (from death certificates, 1995 to 2002), in the Washington State workers' compensation system. RESULTS: Opioid prescriptions increased only modestly between 1996 and 2002. However, prescriptions for the most potent opioids (Schedule II), as a percentage of all scheduled opioid prescriptions (II, III, and IV), increased from 19.3% in 1996 to 37.2% in 2002. Among long-acting opioids, the average daily morphine equivalent dose increased by 50%, to 132 mg/day. Thirty-two deaths were definitely or probably related to accidental overdose of opioids. The majority of deaths involved men (84%) and smokers (69%). CONCLUSIONS: The reasons for escalating doses of the most potent opioids are unknown, but it is possible that tolerance or opioid-induced abnormal pain sensitivity may be occurring in some workers who use opioids for chronic pain. Opioid-related deaths in this population may be preventable through use of prudent guidelines regarding opioid use for chronic pain.

Accidents↗

PubMed2005

Work-related carpal tunnel syndrome in Washington State workers' compensation: temporal trends, clinical practices, and disability.

BACKGROUND: Work-related carpal tunnel syndrome (CTS) is a leading cause of disability. There is a need for information about temporal trends, clinical practices, and treatment outcomes. METHODS: A population based, retrospective cohort study of Washington State workers' compensation claims for CTS was initiated focusing on claims filed during 1990-1994, followed through 2000 (n = 16,710). RESULTS: Half of the claims were filed for conditions other than CTS, but were eventually identified to be or include CTS. The first CTS diagnosis occurred more than 3 months after claim filing in 20% of claims. The longer that the CTS diagnosis occurred after claim filing, the more likely that CTS was accompanied by other problems, and disability tended to be longer. CONCLUSIONS: Making an accurate diagnosis of CTS and initiating appropriate actions earlier than might otherwise occur could reduce the disability and costs in a large fraction of claims that are ultimately determined to involve CTS.

Carpal Tunnel Syndrome↗

PubMed2005

Use of the AAEM guidelines in electrodiagnosis of ulnar neuropathy at the elbow.

OBJECTIVE: The goal of this study was to determine if practice patterns in Washington State were altered by the development and publication of the American Association of Electrodiagnostic Medicine practice parameter for electrodiagnosis of ulnar neuropathy at the elbow. DESIGN: Medical records from 350 workers' compensation patients who underwent surgery for ulnar neuropathy at the elbow in Washington State were reviewed for the consistency of the electrodiagnosticians' report and the practice parameter. Statistical analysis (chi2 or Fischer's exact test) compared prepublication and postpublication patterns of test use. RESULTS: Thirty-one percent of the 153 studies (n = 47) were not consistent with American Association of Electrodiagnostic Medicine guidelines before its publication vs. 34% of the 138 studies (n = 47) after publication. This was not a statistically significant change (P = 0.63). CONCLUSION: Evaluation of the usefulness and dissemination of the guidelines is warranted. The practice parameter may need to be simplified and educational efforts extended to improve provider use of new guidelines.

Adult↗

PubMed2004

Prediction of chronic disability in work-related musculoskeletal disorders: a prospective, population-based study.

BACKGROUND: Disability associated with work-related musculoskeletal disorders is an increasingly serious societal problem. Although most injured workers return quickly to work, a substantial number do not. The costs of chronic disability to the injured worker, his or her family, employers, and society are enormous. A means of accurate early identification of injured workers at risk for chronic disability could enable these individuals to be targeted for early intervention to promote return to work and normal functioning. The purpose of this study is to develop statistical models that accurately predict chronic work disability from data obtained from administrative databases and worker interviews soon after a work injury. Based on these models, we will develop a brief instrument that could be administered in medical or workers' compensation settings to screen injured workers for chronic disability risk. METHODS: This is a population-based, prospective study. The study population consists of workers who file claims for work-related back injuries or carpal tunnel syndrome (CTS) in Washington State. The Washington State Department of Labor and Industries claims database is reviewed weekly to identify workers with new claims for work-related back injuries and CTS, and these workers are telephoned and invited to participate. Workers who enroll complete a computer-assisted telephone interview at baseline and one year later. The baseline interview assesses sociodemographic, employment-related, biomedical/health care, legal, and psychosocial risk factors. The follow-up interview assesses pain, disability, and work status. The primary outcome is duration of work disability over the year after claim submission, as assessed by administrative data. Secondary outcomes include work disability status at one year, as assessed by both self-report and work disability compensation status (administrative records). A sample size of 1,800 workers with back injuries and 1,200 with CTS will provide adequate statistical power (0.96 for low back and 0.85 for CTS) to predict disability with an alpha of.05 (two-sided) and a hazard ratio of 1.2. Proportional hazards regression models will be constructed to determine the best combination of predictors of work disability duration at one year. Regression models will also be developed for the secondary outcomes.

Activities of Daily Living↗

PubMed2004

The association between pain and disability.

A clearer understanding of how pain intensity relates to disability could have important implications for pain treatment goals and definitions of treatment success. The objectives of this study were to determine the optimal pain intensity rating (0-10 scale) cutpoints for discriminating disability levels among individuals with work-related carpal tunnel syndrome (CTS) and low back (LB) injuries, whether these cutpoints differed for these conditions and for different disability measures, and whether the relationship between pain intensity and disability was linear in each injury group. Approximately 3 weeks after filing work injury claims, 2183 workers (1059 CTS; 1124 LB) who still had pain completed pain and disability measures. In the LB group, pain intensity rating categories of 1-4, 5-6, and 7-10 optimally discriminated disability levels for all four disability measures examined. In the CTS group, no pain intensity rating categorization scheme proved superior across all disability measures. For all disability measures examined, the relationship between pain intensity and disability level was linear in the CTS group, but nonlinear in the LB group. Among study participants with work-related back injuries, when pain level was 1-4, a decrease in pain of more than 1-point corresponded to clinically meaningful improvement in functioning, but when pain was rated as 5-10, a 2-point decrease was necessary for clinically meaningful improvement in functioning. The findings indicate that classifying numerical pain ratings into categories corresponding to levels of disability may be useful in establishing treatment goals, but that classification schemes must be validated separately for different pain conditions.

Adult↗

PubMed2004

Improving quality through identifying inappropriate care: the use of guideline-based utilization review protocols in the Washington State Workers' Compensation System.

Utilization review (UR) is widely instituted to ensure that medical treatment is clinically necessary and appropriate. UR programs have been criticized for their failure to promote quality and for relying on proprietary review criteria that are rarely subject to external, independent evaluation or validation. In fashioning its UR program for workers' compensation, the Washington State Department of Labor and Industries sought to address these shortcomings. Working collaboratively with the state medical association, the Department of Labor and Industries developed treatment guidelines and then used these guidelines to formulate review criteria for UR. From 1993 through 1998, 100,005 UR reviews were conducted, half of which used the guideline-based review criteria. We analyzed these reviews to examine the patterns of denied requests. The overall denial rate for the guideline-based reviews was 7.3%. The highest denial rates were for thoracic outlet syndrome surgery (19.1%) and lumbar fusion (17.7%). The use of guideline-based UR protocols may improve the effectiveness of UR as a tool to identify potentially inappropriate care.

Adult↗

PubMed2004

Use of attorneys and appeal filing in the Washington State workers' compensation program: does patient satisfaction matter?

LEARNING OBJECTIVES: Specify the frequency with which injured workers in Washington State's compensation system retained an attorney or filed an appeal, and the personal and job-related correlates of these actions. Analyze the relationship between workers' legal actions and their satisfaction in two domains: how well the claim was managed administratively, and how well the worker and claim manager communicated with one another. Characterize the relationship between retaining an attorney and long-term disability. ABSTRACT: Little is known about how often injured workers retain attorneys or file appeals in the workers' compensation system. We conducted a population-based study to examine the frequency of attorney retention and appeal filing in the Washington State workers' compensation program and the factors related to this event. Data for the study were provided by a survey conducted on 804 injured workers who were interviewed an average of 159 days after claim receipt. Attorney retention and appeal filing were examined up to 28 months later. Seven percent of the workers either retained an attorney or filed an appeal. Workers who were less satisfied with claims administration procedures were more likely to retain an attorney or file an appeal (P<0.05). The average length of time from claim receipt to attorney retention (368 days) suggests that retaining an attorney is a correlate rather than a predictor of long-term disability.

Adolescent↗

PubMed2004

Multidisciplinary pain center outcomes in Washington State Workers' Compensation.

We conducted this study to evaluate the clinical and disability status of injured workers 4.6 years after undergoing multidisciplinary pain center evaluation, comparing subjects who received treatment to subjects who were evaluated only. Three hundred injured workers were selected for a telephone survey; 150 had received pain center treatment and 150 had been evaluated but not treated. The survey included the SF-12, and questions about subjects' pain intensity and current work status. A workers' compensation database indicated the disability status of subjects. The response rate was 50%. In multivariate analyses, treated and evaluated-only subjects did not differ significantly in disability status, pain intensity, SF-12 scores, or current work status. At 4.6 years follow up, there was no evidence that pain center treatment affects either disability status or clinical status of injured workers.

Accidents, Occupational↗

PubMed2004

A communitywide intervention to improve outcomes and reduce disability among injured workers in Washington State.

One pressing challenge facing the U.S. health care system is the development of effective policies and clinical management strategies to address deficiencies in health care quality. In collaboration with researchers at the University of Washington, the Washington State Department of Labor and Industries has created a communitywide delivery system intervention to improve health outcomes and reduce disability among injured workers. This intervention is currently being tested in two sites in western and eastern Washington. So far, it appears to be possible to engage physicians and health care institutions in quality improvement initiatives and to form effective public-private partnerships for this purpose. Furthermore, collaborating with university researchers may help enhance the scientific rigor of the quality improvement initiative and create more opportunities for a successful evaluation.

Accidents, Occupational↗

PubMed2004

Patient satisfaction, treatment experience, and disability outcomes in a population-based cohort of injured workers in Washington State: implications for quality improvement.

OBJECTIVE: To determine what aspects of patient satisfaction are most important in explaining the variance in patients' overall treatment experience and to evaluate the relationship between treatment experience and subsequent outcomes. DATA SOURCES AND SETTING: Data from a population-based survey of 804 randomly selected injured workers in Washington State filing a workers' compensation claim between November 1999 and February 2000 were combined with insurance claims data indicating whether survey respondents were receiving disability compensation payments for being out of work at 6 or 12 months after claim filing. STUDY DESIGN: We conducted a two-step analysis. In the first step, we tested a multiple linear regression model to assess the relationship of satisfaction measures to patients' overall treatment experience. In the second step, we used logistic regression to assess the relationship of treatment experience to subsequent outcomes. PRINCIPAL FINDINGS: Among injured workers who had ongoing follow-up care after their initial treatment (n = 681), satisfaction with interpersonal and technical aspects of care and with care coordination was strongly and positively associated with overall treatment experience (p < 0.001). As a group, the satisfaction measures explained 38 percent of the variance in treatment experience after controlling for demographics, satisfaction with medical care prior to injury, job satisfaction, type of injury, and provider type. Injured workers who reported less-favorable treatment experience were 3.54 times as likely (95 percent confidence interval, 1.20-10.95, p = .021) to be receiving time-loss compensation for inability to work due to injury 6 or 12 months after filing a claim, compared to patients whose treatment experience was more positive.

Aged↗

PubMed2004

Policy-relevant research: when does it matter?

Evidence-based medicine is most meaningful to policy makers when research questions are clearly informed by strategic health policy questions. In Washington State workers' compensation, key structural characteristics allow for the conduct of effective policy-relevant research. These include clear authority and a stable funding stream, a formal relationship between a policy agency and a University, development of appropriate research capacity, development of research questions related to strategic goals, and a robust data source. The research conducted relies on computerized medical bills and work disability records, medical records, structured telephone surveys to collect data on pain, functional status, quality of life, and computerized data on employment status. The types of policy-relevant research include identification of factors leading to preventable disability, outcomes research of specific procedures, technology assessment, and "real-time" research that addresses rapidly emerging questions. Health policy changes implemented from research have been substantial in Washington State workers' compensation, including: 1) noncoverage or partial coverage decisions for emerging technologies not proven to be of value to injured workers, 2) formal treatment guidelines and utilization review criteria for invasive, expensive, or marginally effective procedures, 3) disability prevention efforts, and 4) relatively rapid changes in policy as emerging patterns suggest harmful outcomes from existing treatments (e.g., schedule II opioids). Key structural characteristics must be in place to conduct policy-relevant research effectively. The workers' compensation system in Washington State is a single-payer system with other unique properties that have allowed the emergence of these structural characteristics and the conduct of research linked to the strategic goals of policy makers.

Adult↗

PubMed2003

Comparison of the Roland-Morris Disability Questionnaire and generic health status measures: a population-based study of workers' compensation back injury claimants.

STUDY DESIGN: Workers' compensation back injury claimants completed baseline and follow-up telephone interviews in a prospective population-based cohort study. OBJECTIVE: To compare the Roland-Morris Disability Questionnaire (RDQ) to widely used generic health status measures in a sample of workers with recent work-related back injuries in terms of validity, reliability, responsiveness to change, and floor and ceiling effects. SUMMARY OF BACKGROUND DATA: Little research has directly compared the validity and responsiveness of the RDQ to that of the Short-Form 12 or Short-Form 36 health status measures among individuals with back pain. Furthermore, there is little information concerning the validity, reliability, and responsiveness of the RDQ as a measure of functional outcomes for workers with back injuries. METHODS: Approximately 8 weeks (median) after filing low back injury claims, 309 workers completed the RDQ, Short-Form 12, and Short-Form 36 scales and gave information about their work status in computer-assisted telephone interviews. An average of 5 months later, 284 workers (91.9%) completed the measures again. RESULTS: The RDQ demonstrated excellent internal consistency and validity through correlations with other measures of physical functioning, ability to discriminate between those working and those not working, and much more responsiveness to change than the Short-Form 12 and Short-Form 36 scales. However, 15% of the sample did not answer one or more RDQ items. CONCLUSIONS: The RDQ is a valid measure of physical disability among workers with back injuries. Its greater responsiveness to change suggests its superiority to the Short-Form 12 and Short-Form 36 as an outcome measure in this population.

Adolescent↗

PubMed2002

Increased reporting of occupational hearing loss: workers' compensation in Washington State, 1984-1998.

BACKGROUND: Workers' compensation claims for hearing loss increased two-fold during 1984-1991 in Washington State. METHODS: This population-based descriptive study examined 27,019 claims filed during 1984-1998 and accepted for hearing loss, in the workers' compensation jurisdiction that covers nearly all non-federal workers in Washington State. RESULTS: The number of claims increased 12-fold during 1984-1998. The annual incidence reached 2.6/1,000 workers statewide, and 70/1,000 in the most impacted industry. The increase involved all ages over 35 years, especially claimants over 65 years. Only 4% of providers accounted for 66% of claims. Most claimants (90%) received permanent partial disability compensation. In 1998, identifiable costs exceeded $57 million dollars. CONCLUSIONS: The striking increase in claims is probably largely due to reporting phenomena unrelated to current work circumstances. However, occupational hearing loss is probably much more common than usually recognized, and contemporary workers may still face substantial risk for hearing loss.

Adolescent↗

PubMed2002

The effects of a medical care utilization review program on back and neck injury claims.

A number of quality-based evaluation and treatment protocols have been developed and marketed for the management of work-related musculoskeletal problems. Yet, little is known about their effectiveness in improving patient outcomes. We evaluated one such approach adopted by the Department of Labor and Industries, which insures approximately two-thirds of the non-federal workforce in Washington State. The outcomes of back and neck injury claims (primarily sprains and strains) filed in the 2 months after the program was fully operational were compared with two comparable groups of claims from the same base population filed before the program's availability. There were no statistically significant differences between groups in the number of days of work loss, medical costs, and permanent partial disability awards granted during the 2 years after injury. The quality-based program used as an adjunct to claims management failed to improve outcomes.

Absenteeism↗