Association between compensation status and outcomes in spine surgery: a meta-analysis of 31 studies

doi:10.1016/j.spinee.2015.09.033

The Spine Journal

Volume 15, Issue 12, 1 December 2015, Pages 2564-2573

https://doi.org/10.1016/j.spinee.2015.09.033 Get rights and content

Abstract

Background Context

Numerous studies have demonstrated poorer outcomes in patients with Workers' compensation (WC) when compared with those without WC following treatment of various of health conditions, including spine disorders. It is thus important to consider compensation status when assessing treatment outcomes in spine surgery. However, reported strengths of association have varied significantly (1.31–7.22).

Purpose

The objective of this study was to evaluate the association of unsatisfactory outcomes on compensation status in spine surgery patients.

Study Design/Setting

A meta-analysis was performed.

Patient Sample

Patient sample is not applicable in this study.

Outcome Measure

Demographics, type of surgery, country, follow-up time, patient satisfaction, return to work and non-union events were the outcome measures.

Methods

Both prospective and retrospective studies that compared outcomes between compensated and non-compensated patients in spine surgery were included. Two independent investigators extracted outcome data. The meta-analysis was performed using Revman software. Random effects model was used to calculate risk ratio (RR, 95% confidence interval [CI]) for dichotomous variables.

Results

Thirty-one studies (13 prospective; 18 retrospective) with a total of 3,567 patients were included in the analysis. Follow-up time varied from 4 months to 10 years. Twelve studies involved only decompression; the rest were fusion. Overall RR of an unsatisfactory outcome was 2.12 [1.74, 2.58; p<.001] in patients with WC when compared with those without WC after surgery. The RR ofan unsatisfactory outcome in patients with WC, compared with those without, was 2.09 [1.38, 3.17]; p<.01 among studies from Europe and Australia, and 2.14 [1.48, 2.60]; p<.01 among US studies. The RR of decompression-only procedures was 2.53 [1.85, 3.47]; p<.01,and 1.79 [1.45, 2.21]; p<.01 for fusion. Forty-three percent (209 of 491) of patients with WC did not return to work versus 17% (214 of 1250) of those without WC (RR 2.07 [1.43, 2.98]; p<.001). Twenty-five percent (74 of 292) and 13.5% (39 of 287) of patients had non-union in the compensated and non-compensated groups, respectively. This was not statistically significant (RR 1.33 [0.92, 1.91]; p=.07).

Conclusions

Workers' compensation patients have a two-fold increased risk of an unsatisfactory outcome compared with non-compensated patients after surgery. This association was consistent when studies were grouped by country or procedure. Compensation status must be considered in all surgical intervention studies.

Introduction

Patients with workers' compensation (WC) have been reported to have significantly more frequent unsatisfactory outcomes than those without it, in various disorders. Although the etiology of this association is not fully known, researchers have suggested various possible contributing factors like psychosocial secondary gains (eg, pecuniary awards that stem from civil litigation), higher severity of injury work environment, smoking status, and body mass index [1], [2], [3], [4], [5], [6]. Twenty percent of all work-related injuries are back injuries [7], [8], and the influence of financial compensation is still a controversial issue in the treatment of low back pain [7]. Within the setting of spine surgery, numerous studies have reported that the impact of compensation status on outcomes is important [1], [9], [10], [11], [12]. This highlights the importance of considering compensation status when evaluating outcomes of all intervention studies in spine. Furthermore, reported strength of this association has widely varied from 1.31 [13] to 7.22 [14] among published studies. In the evolving environment of health-care economics and cost-efficacy, this association may be an important influence when it comes to economic and clinical decision making [9]. The purpose of this meta-analysis was to consolidate all studies, both prospective and retrospective, to determine the strength of association of compensation status on unsatisfactory outcomes in spine surgery. In addition, an analysis was performed to determine how the impact of compensation status changes based on study design, country of origin, and procedure type.

Section snippets

Materials and methods

The meta-analysis was performed according to PRISMA statement for quality reporting of systematic reviews and meta-analyses [15].

Study selection

Our search resulted in a total of 7,899 potential citations. After screening by title, abstract, and entire article, 31 studies (13 prospective and 18 retrospective) were identified which met all inclusion criteria and had usable data [1], [2], [4], [6], [7], [8], [10], [11], [12], [13], [14], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37]. There were 3,567 spine surgery patients among included studies, with 2,067

Discussion

The reported association of WC status on the outcomes of spinal surgery has varied widely among several studies [13], [14]. The wide range of values makes it challenging for clinicians and researchers to assess the impact of compensation status on clinical outcomes. This meta-analysis compiles data from both retrospective and prospective studies to quantifiable risk of unsatisfactory outcome in decompression-only procedures and decompression in fusion surgery. The recent time frame (past 20

Conclusions

There is a two-fold increase of an unsatisfactory outcome in compensated patients when compared with non-compensated patients in spine surgery. Further research investigating the possible etiology of this association is necessary.

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Disparities in postoperative complications and perioperative events based on insurance status following elective spine surgery: A systematic review and meta-analysis
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Increasing evidence demonstrates disparities among patients with differing insurance statuses in the field of spine surgery. However, no pooled analyses have performed a robust review characterizing differences in postoperative outcomes among patients with varying insurance types.
A comprehensive literature search of the PUBMED, MEDLINE(R), ERIC, and EMBASE was performed for studies comparing postoperative outcomes in patients with private insurance versus government insurance. Pooled incidence rates and odds ratios were calculated for each outcome and meta-analyses were conducted for 3 perioperative events and 2 types of complications. In addition to pooled analysis, sub-analyses were performed for each outcome in specific government payer statuses.
Thirty-eight studies (5,018,165 total patients) were included. Compared with patients with private insurance, patients with government insurance experienced greater risk of 90-day re-admission (OR 1.84, p<.0001), non-routine discharge (OR 4.40, p<.0001), extended LOS (OR 1.82, p<.0001), any postoperative complication (OR 1.61, p<.0001), and any medical complication (OR 1.93, p<.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared with non-Medicare patients. Compared with Medicaid patients, Medicare patients were only more likely to experience non-routine discharge (OR 2.68, p=.0007).
Patients with government insurance experience greater likelihood of morbidity across several perioperative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based discrimination. Based on these results, it is clear that directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care.
Preoperative risk factors for nonsatisfaction after lumbar interbody fusion
2024, Brain and Spine
Low back pain (LBP) is a common cause of impaired quality of life and disability and studies regarding surgical management of patients with LBP show a high variation in patient-reported success rate.
To find valuable preoperative clinical risk factors and variables associated with a non-satisfactory patient-reported outcome following surgery.
The Danish surgical spine database (DaneSpine) was used to collect eight years of pre- and postoperative data on patients undergoing single-level fusions with either posterior- (PLIF) or transforaminal lumbar interbody fusions (TLIF). The primary outcome was patient nonsatisfaction. We collected data on European Quality of Life–5 Dimensions (EQ-5D), visual analogue scale (VAS), Oswestry Disability Index (ODI) score, pain intensity, duration of back pain, previous discectomy, and expectations regarding return to work after surgery at 2-year follow-up.
The cohort included 453 patients of which 19% reported treatment nonsatisfaction. The nonsatisfaction group demonstrated higher preoperative VAS scores for back pain (75 ± 19 vs. 68 ± 21, p = 0.006) and leg pain (65 ± 25 vs. 58 ± 28, p = 0.004). The preoperative EQ-5D score was significantly lower in the nonsatisfaction group (0.203 + 0.262 vs. 0.291 ± 0.312, p = 0.016). There was no statistical significance between patient nonsatisfaction and preoperative ODI score, age, body mass index, duration of back pain or expectations regarding return to work after surgery.
Low preoperative EQ-5D scores and high VAS leg and back pain scores were statistically significant with patient nonsatisfaction following surgery and may prove to be valuable tools in the preoperative screening and alignment of patient expectations.
Workers’ Compensation Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement Syndrome Experience Worse Mid-Term Outcomes but Similar Return-to-Work: A Propensity-Matched Analysis at 5-Year Follow-Up
2023, Arthroscopy - Journal of Arthroscopic and Related Surgery
To investigate mid-term patient-reported outcomes (PROs) and return-to-work for workers’ compensation (WC) patients undergoing primary hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) versus propensity-matched, non-WC controls and to determine whether achievement rates of minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) differ between these populations.
A retrospective cohort study was conducted on WC patients who underwent primary HA for FAIS from 2012 to 2017. WC and non-WC patients were propensity matched on a 1:4 basis by sex, age, and body mass index (BMI). PROs were compared preoperatively and at 5 years postoperatively, employing the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales, modified Harris Hip Score (mHHS), 12-item international Hip Outcome Tool (iHOT-12), and visual analog scales (VAS) for pain and satisfaction. MCID and PASS were calculated using published thresholds for these measures. Preoperative and postoperative radiographs and the presence and timing of return to unrestricted work were evaluated.
Forty-three WC patients were successfully matched to 172 non-WC controls and followed for 64.2 ± 7.7 months. WC patients demonstrated lower preoperative scores for all measures (P ≤ .031) and worse HOS-ADL, HOS-SS, and VAS pain scores at 5-year follow-up (P ≤ .021). There were no differences in MCID achievement rates or magnitude of change between preoperative and 5-year postoperative PROs (P ≥ .093); however, WC patients achieved PASS at lower rates for HOS-ADL and HOS-SS (P ≤ .009). 76.7% of WC and 84.3% of non-WC patients returned to work without restrictions (P = .302) at 7.4 ± 4.4 versus 5.0 ± 3.8 months, respectively (P < .001).
WC patients undergoing HA for FAIS report worse preoperative pain and function than non-WC patients and experience worse pain, function, and PASS achievement at 5-year follow-up. However, they demonstrate similar MCID achievement and magnitude improvement between preoperative and 5-year postoperative PROs, and return to work without restrictions at a similar rate to non-WC patients, although they may take longer to do so.
Level III, retrospective cohort study.
Influence of Prolonged Duration of Symptoms Before MIS-TLIF in a Workers' Compensation Population
2023, World Neurosurgery
We assessed the potential effect of the preoperative symptom duration on patient-reported outcomes (PROs) for workers’ compensation (WC) patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).
WC patients who had undergone primary, elective MIS-TLIF with recorded symptoms duration data available were included. Two cohorts were generated: those with a shorter (lesser) duration (LD; symptom duration <1 year) and those with a prolonged duration (PD; symptom duration >1 year). PROs were collected preoperatively and at several follow-up points for ≤1 year postoperatively. The PROs were compared within and between the 2 cohorts. The achievement rates of minimum clinically important differences were also compared between the 2 cohorts.
A total of 145 patients were included, with 76 in the PD cohort and 69 in the LD cohort. The LD cohort demonstrated improvement in the patient-reported outcomes measurement information system for physical function (PROMIS-PF) at 6 months and 1 year postoperatively, Oswestry disability index (ODI) at 12 weeks and 6 months postoperatively, visual analog scale (VAS) score for back pain at 6 weeks, 12 weeks, and 6 months postoperatively, and VAS score for leg pain at all postoperative points (P ≤ 0.015 for all). The PD cohort demonstrated improvement in the PROMIS-PF at 12 weeks and 6 months postoperatively, ODI at 6 weeks, 12 weeks, and 6 months postoperatively, and VAS score for back pain and leg pain at all postoperative periods (P ≤ 0.007 for all). All the preoperative PROs were superior for the LD cohort (P < 0.001 for all). The LD cohort reported better PROMIS-PF at 6 months and 1 year and ODI at 1 year postoperatively (P ≤ 0.037 for all). The PD cohort was more likely to achieve a minimum clinically important difference in ODI at 6 and 12 weeks postoperatively, VAS score for back pain at 6 weeks postoperatively, and VAS score for leg pain at 6 weeks and 1 year postoperatively and overall (P ≤ 0.036 for all).
Independently of the preoperative symptom duration, WC patients demonstrated improvement in physical function and pain after MIS-TLIF. Patients with a longer symptom duration reported inferior function and pain preoperatively and were more likely to demonstrate clinically significant improvements in disability and pain postoperatively.
Obesity and Workers’ Compensation in the Setting of Minimally Invasive Lumbar Decompression
2022, World Neurosurgery
Citation Excerpt :
Gum et al. evaluated numeric rating scale for back and leg pain, SF-36 PCS, and ODI and noted that WC was associated with poor clinical outcomes following lumbar fusion.30 Another meta-analysis by Cheriyan et al. found that WC status corresponded to an increased relative risk of 2.53 compared with non-WC counterparts for unsatisfactory outcomes following decompression surgery.31 The relationship between obesity and WC has also been studied.
To investigate the influence of body mass index (BMI) on perioperative outcomes, postoperative patient-reported outcome measures (PROMs), and minimal clinically important difference (MCID) achievement among workers’ compensation (WC) claimants undergoing minimally invasive lumbar decompression (MIS-LD).
WC patients diagnosed with herniated nucleus pulposus undergoing single-level MIS-LD were identified. Patients were divided into 3 groups: Non-obese (<30 kg/m²), Obese I (≥30 and <35 kg/m²), and Obese II/III (≥35 kg/m²). PROMs were collected preoperatively and at 6 weeks, 12 weeks, 6 months, 1 year, and 2 years postoperatively. The predictive influence of BMI grouping on mean PROM scores was computed using simple linear regression. To compare PROMs between groups, post hoc pairwise comparisons of adjusted means were utilized. MCID achievement was compared between groups with χ² analysis.
A total of 81 patients were in the Non-obese cohort, and 43 and 45 in the Obese I and Obese II/III cohorts, respectively. Visual analog scale (VAS) leg, Oswestry Disability Index (ODI), and 12-Item Short Form Physical Composite Score (SF-12 PCS) were worse in the Obese I cohort at 12 weeks, and SF-12 PCS was lower in the Obese I vs. Obese II/III subgroup analysis (P ≤ 0.045, all). MCID achievement rates for ODI were higher for the Non-obese group at 12 weeks and overall (P ≤ 0.049, both). MCID attainment for VAS back was higher among the Non-obese cohort at 6-weeks (P = 0.022).
Patients with higher levels of obesity were more likely to experience longer length of stay and delayed discharge following MIS-LD. Increasing BMI was generally not a significant predictor of postoperative pain, disability, or physical health PROMs at most timepoints. MCID achievement rates for disability relief were significantly higher for non-obese patients.
Workers’ Compensation Status and Outcomes Following Lumbar Surgery
2022, World Neurosurgery
Citation Excerpt :
Furthermore, many patients in these studies did not return to work within the follow-up period. More recent literature has confirmed these findings, noting that WC patients tend to have lower return-to-work rates and higher revision and complication rates.13-15 Additionally, previous research has demonstrated that WC patients who undergo lumbar fusion, especially patients who wait at least 1 year after injury to undergo surgical treatment, have even worse outcomes.16,17
To determine the influence of preoperative workers’ compensation (WC) status on patient-reported outcome measures following lumbar decompression with or without fusion.
All patients undergoing lumbar decompression with or without fusion at a single academic institution between 2013 and 2017 were identified. Patients were split into groups based on WC status: no workers’ compensation (NWC), WC), or retired. Intragroup analysis used paired t tests. Outcomes between groups were compared using Kruskal-Wallis H test. Multiple linear regression analysis determined if WC status was a predictor of change in patient-reported outcome measures. Subgroup analysis was conducted for WC patients who returned to work.
Of 571 included patients, 242 (43.4%) had NWC, 83 (14.5%) had WC, and 246 (43.1%) were retired. Comparing within groups, WC patients showed significant improvement in Short Form-12 Health Survey Physical Component Score, Oswestry Disability Index, visual analog scale (VAS) back pain, and VAS leg pain (all P < 0.001) after surgery. However, WC patients improved less than NWC or retired patients in Short Form-12 Health Survey Physical Component Score (P = 0.010), VAS back pain (P = 0.028), and VAS leg pain (P = 0.015). WC was an independent predictor of decreased improvement in Short Form-12 Health Survey Physical Component Score (β = −4.31, P = 0.001), VAS back pain (β = 0.90, P = 0.034), and VAS leg pain (β = 1.50, P = 0.002) on multivariate analysis. WC patients who did not return to work was an independent predictor of decreased improvement in VAS back pain (β = 1.39, P = 0.016) and VAS leg pain (β = 2.11, P = 0.001).
WC patients improve less than NWC patients. However, WC patients who return to work have similar VAS back and neck pain improvements as NWC patients.

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: FDA device/drug status: Not applicable.

: Author disclosures: TC: Nothing to disclose. BH: Nothing to disclose. JC: Nothing to disclose. VL: Stock Ownership: Nemaris INC (20% Share holder); Speaking and/or Teaching Arrangements: Medtronic (B, Paid directly to author), DePuy Spine (C, Paid directly to author), Medicrea (B, Paid directly to author); Grants: SRS (D, Paid directly to institution/employer), NIH (D, Paid directly to institution/employer), DePuy (H, Received through ISSGF, Paid directly to institution/employer), outside the submitted work. JMS: Nothing to disclose. JAB: Nothing to disclose. TJE: Royalties: K2M (F, Paid directly to author); Stock Ownership: Fastenetix (F, Paid directly to author); Speaking and/or Teaching Arrangements: K2M (C); Trips/Travel: K2M (B); Research Support (Investigator Salary, Staff/Materials): Paradigm Spine (F, Paid directly to institution/employer), Fridolin (E, Paid directly to institution/employer); Fellowship Support: OREF (E, Paid directly to institution/employer), OMEGA (E, Paid directly to institution/employer), AOSpine (E, Paid directly to institution/employer), outside the submitted work. JAG: Royalties: NuVasive (C); Stock Ownership: NuVasive (<1%); Consulting: NuVasive (A), Medtronic (B); Board of Directors: ISASS (None); Research Support (Staff and/or Materials): AxioMed (Amount not disclosed, Paid directly to institution/employer); Fellowship Support: OREF (Amount not disclosed, Paid directly to institution/employer).

: The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

: The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

: No funding was received for this study.

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Review ArticleAssociation between compensation status and outcomes in spine surgery: a meta-analysis of 31 studies

Abstract

Background Context

Purpose

Study Design/Setting

Patient Sample

Outcome Measure

Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Study selection

Discussion

Conclusions

Spine J

Int J Surg

J Hand Surg [Am]

J Shoulder Elbow Surg

Arthroscopy

J Clin Neurosci

Clinical outcomes after posterolateral lumbar fusion in workers' compensation patients: a case-control study

Spine

The impact of workers' compensation on outcomes of surgical and nonoperative therapy for patients with a lumbar disc herniation: SPORT

Spine

The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica

Spine

A comparison of perioperative costs and outcomes in patients with and without workers' compensation claims treated with minimally invasive or open transforaminal lumbar interbody fusion

Spine

Lumbar spine surgery in the obese patient

J Spinal Disord

Patient-oriented outcomes from low back surgery: a community-based study

Spine

Is occupational low back pain on the rise?

Spine

Association between compensation status and outcome after surgery: a meta-analysis

JAMA

Results of elective lumbar discectomy for patients involved in the workers' compensation system

J Spinal Disord

Patient selection for lumbar discectomy with a revised objective rating system

Clin Orthop Relat Res

Is type of compensation a predictor of outcome after lumbar fusion?

Spine

Treatment of symptomatic anterior cervical nonunion using the Rogers interspinous wiring technique

Am J Orthop (Belle Mead NJ)

Comparison of instrumented anterior interbody fusion with instrumented circumferential lumbar fusion

Eur Spine J

Evidence partners: methodological resources

Prospective multiple outcomes study of outpatient lumbar microdiscectomy: should 75 to 80% success rates be the norm?

J Neurosurg

Long-term disability and return to work among patients who have a herniated lumbar disc: the effect of disability compensation

J Bone Joint Surg Am

Review Article
Association between compensation status and outcomes in spine surgery: a meta-analysis of 31 studies