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Universal No-fault Compensation is Associated With Improved Return to Work Rates in Spine Fusion

Manson, Jonathan F. MB ChB, FRACS; Landham, Priyan R. MD, FRCS (Tr & Orth); Cunningham, John E. BSc (Hons), MBBS, MClinEpi, FRACS, FAOrthA; Montgomery, Alexander S. Dipl Orth Eng, FRCS (Tr & Orth); Don, Angus S. MB ChB, FRACS; Robertson, Peter A. MD, FRACS

doi: 10.1097/BRS.0000000000001096
Health Services Research

Study Design. Retrospective cohort study and systematic literature review.

Objective. To examine the influence of “universal no-fault compensation” upon return-to-work rates in patients undergoing lumbar spinal fusion, and then to make comparison with workers' compensation (WC) and non-workers' compensation (non-WC) claimants.

Summary of Background Data. Compensation has an adverse influence upon outcomes and return to work in lumbar spinal fusion. It is unclear whether this is due to the compensation per se, or due to the features of WC including its adversarial environment, delayed resolution of claims, and need for disability enhancement to promote compensation. The New Zealand Accident Compensation Corporation (ACC) is a universal no-fault system offering early treatment and salary reimbursement. Given the differing features of these compensation systems, comparison of return-to-work rates may give insight into the differing outcomes for the two compensation systems.

Methods. From a cohort of 428 patients undergoing lumbar spinal fusion, 178 patients covered by ACC system underwent a structured interview to determine pre-injury, pre-surgical, and post-surgical work status. A systematic literature review was performed relating to lumbar spine fusion, return to work, and WC.

Results. The return-to-work rate for the ACC patients in work at the time of their injury was 81%. The systematic review of 21 studies including 2519 subjects revealed a return-to-work rate of 40% for WC patients, and 74% for non-WC patients (P < 0.001). There was a significantly greater return-to-work rate for ACC patients than WC patients (P < 0.001), but no difference between ACC and non-WC patients.

Conclusion. The return-to-work rates for a universal no-fault compensation system are higher than those under WC cover, and are compatible with non-WC cases. This suggests that the features of WC may contribute to the inferior return-to-work rates.

Level of Evidence: 3

Patients undergoing lumbar spinal fusion under a universal no-fault compensation system attained 81% return to work. Systematic literature review reveals return-to-work rates of 40% for workers' compensation, and 74% for nonworkers' compensation. The adversarial environment, delayed resolution, and incentives for prolonged disability may reduce return-to-work rates.

*Department of Orthopaedic Surgery, Whangarei Hospital, Whangarei, New Zealand

Department of Orthopaedic Surgery, Auckland City Hospital, Auckland, New Zealand

Department of Orthopaedic Surgery, Royal Melbourne Hospital, Melbourne, Australia; and

§Department of Orthopaedic Surgery, St Bartholomew's and The Royal London Hospital, London, UK.

Address correspondence and reprint requests to Peter A. Robertson, MD, FRACS, The Orthopaedic Clinic, Mercy Specialist Centre, 100 Mountain Road, Epsom 1023, Auckland, New Zealand; E-mail:

Acknowledgment date: July 12, 2014. First revision date: April 1, 2015. Second revision date: May 7, 2015. Acceptance date: June 4, 2015.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, consultancy, employment, grants, patents, royalties, payment for lectures.

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