The impact of seeking financial compensation on injury recovery following motor vehicle related orthopaedic trauma

Abstract

Introduction There is substantial evidence of an association between seeking financial compensation and poor injury recovery and Return to Work (RTW). The causal nature of this relationship remains complex and imprecise. Many compensation related measures are generic and do not encompass the complexity of scheme design or the socio-political environment in which they operate. This is particularly relevant in Australia where all states and territories provide access to financial compensation following motor vehicle related trauma. In addition, motor vehicle related trauma is a significant contributor to the burden of injury and work disability. Early identification of predictors (including compensation related factors) is essential for developing efficacious interventions and purposeful scheme policy and design to facilitate injury recovery and RTW. Accordingly, the overarching aim of this thesis is to explore the impact of seeking financial compensation on injury recovery following motor vehicle related orthopaedic trauma. Initially, Chapter 1 provides the background and historical context of how compensation schemes were thought to influence physical and psychological health. It includes an overview of the current burden of injury, and relevant scheme design. Given the background to this relatively new field of research, mixed methods were employed across three areas: a systematic review (Chapter 2); qualitative studies (Chapters 3 and 4); and an inception cohort study (Chapters 5-7). Methods and results In Chapter 2, the aim of the systematic review is to identify associations between specific compensation related factorsand health outcomes following musculoskeletal injury from prognostic and/or intervention studies. Searches were conducted using electronic medical journal databases. Selection criteria included: prognostic factors associated with validated health outcomes; six or more months follow up; and multivariate statistical analysis. Twenty nine articles were assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to determine evidence levels. The results are mixed. There is strong evidence of an association between compensation status and poorer psychological function; and legal representation and poorer physical function. There is moderate evidence of an association between compensation status and poorer physical function; and legal representation and poorer psychological function. There is limited evidence of an association between compensation status and increased pain. No studies reported positive associations between compensation status and a health or functional outcome. In Chapters 3 and 4, qualitative methods are used to examine the impact of seeking financial compensation with greater granularity. The aims are: firstly, to explore the factors that influence recovery from serious injuries, particularly differences between people with compensable and non-compensable injuries; and secondly, to understand people’s perceptions and experiences of the claims process after sustaining mild-moderate compensable injuries, and to explore ways to assist and improve those experiences. The first eight focus groups (34 attendees, 21 compensable) were conducted two to seven years post injury within the trauma service of a University Teaching Hospital. The second five focus groups (32 attendees) were conducted one year post injury within a single Compulsory Third Party (CTP) personal injury scheme. All were audio-recorded and transcribed. The methodology was based on a grounded theory approach using thematic analysis and constant comparison to generate coding categories for themes. Data saturation was reached. Analyst triangulation was used to ensure credibility of results. Key themes for the first series are: astrong sense of entitlement and injustice; a difficult claims and settlement process; an inability to move on with life during the claims process, an extreme dislike of medico-legal assessments; the necessity of legal representation to assist with the claims process; and a perceived lack of trust about having to prove an injury or disability (Chapter 3). Key themes for the second series are: complexity of the claims process; requirement of legal representation; injury recovery expectations; importance of timely healthcare decision making; and improvements for injury recovery. To assist with injury recovery, access to objective information about the claims process using online technology and social media was considered paramount (Chapter 4). In Chapters 5-7, an inception cohort study was conducted following moderate-severe injuries. The aims are: firstly, to investigate the predictors of seeking financial compensation, namely making a claim and seeking legal representation at six months (Chapter 5); secondly, to determine the predictors (including compensation related factors) of time to RTW (Chapter 6); and thirdly, to investigate the influence of seeking financial compensation (i.e. making a claim) on injury recovery. Admitted patients were recruited prospectively from two trauma hospitals with upper and/or lower extremity fractures following a motor vehicle crash. Baseline data were collected within two weeks of injury, follow up data at six, 12 and 24 months (by written questionnaire). Additional demographic and injury-related information was retrieved from hospital databases. Main outcomes were: time to RTW (number of days); Short Form-36 Version 2.0 (SF36v2), Physical/Mental Component Scores (PCS/MCS); Post Traumatic Stress Disorder (PTSD) Checklist Civilian Version (PCL-C); and Global Rating of Change (GRC) scale. Analysis involved: descriptive statistics for baseline characteristics; comparison of compensable and non-compensable participants with Analysis of Variance (ANOVA) and chi-squared tests; for predictors, logistic regression, Cox proportional hazards regression models, and linear mixed models were used. There were 452 participants. Baseline characteristics showed: mean age 40 years; 75% male; 74% working pre-injury; 30% in excellent pre-injury health; 56% sustained serious injuries (Injury Severity Score [ISS] 9-15); 61% had a low-middle range household income; 35% self-reported at-fault in the crash; and 61% made a claim at six months. Participant follow up data was available at six, 12 and 24 months for 301(67%), 271(60%), and 230(51%) respectively. Results showed that there are no significant differences in pre-injury or baseline health status between those who made a claim and those who did not, but these measures largely related to physical health. As an outcome, seeking financial compensation at six months is associated with a higher pre-injury Body Mass Index (BMI) rather than injury-related factors, and seeking legal representation at six months is solely related to socio-economic factors (Chapter 5). For those working pre-injury (n=334, 74%), a longer time to RTW is associated with greater injury severity and lower occupational skill levels; while a shorter time to RTW is associated with recovery expectations for usual activities within 90 days, full-time pre-injury work hours, and very good self-assessed pre-injury health status. Legal representation (analysed at six months only) is not associated with time to RTW (Chapter 6). As a predictor, seeking financial compensation is associated with poor injury recovery, mainly for mental health status (MCS) and PTSD (PCL-C). However, the differences are of marginal clinical significance. Irrespective of compensation status, the majority have poor injury recovery on all measures over time, especially for mental health (Chapter 7). Conclusions In summary, these results contribute to existing evidence that seeking financial compensation is associated with poor injury recovery, particularly mental health status. The causal nature of the relationship remains complex but it is posited that part of the explanation lies in scheme policy and design including legislative framework. Background pre-injury factors, namely pre-existing physical and mental health status, psychosocial and socioeconomic factors also play a role. There are opportunities to trial interventions that could improve injury recovery and/or decrease work disability. Collectively, these include screening for risk factors of poor recovery and/or RTW, access to early appropriate treatment and rehabilitation, and vocational rehabilitation for those most vulnerable. None of these are novel but they can be problematic to implement in a compensable environment.Reducing the adversarial aspects of the claims process is important and could possibly alleviate the need to seek legal representation. Some initiatives are likely to require legislative change but others could be implemented with moderate resources. Ongoing mixed methods and interdisciplinary research with an emphasis on modifiable factors is recommended.