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The Influence of No Fault Compensation on Functional Outcomes After Lumbar Spine Fusion

Montgomery, Alexander Sheriff, Dipl Orth Eng, MRCS, FRCS (Tr and Orth)*; Cunningham, John Edward, BSc (Hons), MBBS, MClinEpi, FRACS, FAOrthA; Robertson, Peter Alexander, MD, FRACS

doi: 10.1097/BRS.0000000000000966
Literature Review

Study Design. Prospective cohort study and systematic literature review.

Objective. To compare the functional outcomes for lumbar spinal fusion in both compensation and noncompensation patients in an environment of universal no fault compensation and then to compare these outcomes with those in worker's compensation and nonworkers compensation cohorts from other countries.

Summary of Background Data. Compensation has an adverse effect on outcomes in spine fusion possibly based on adversarial environment, delayed resolution of claims and care, and increased compensation associated with prolonged disability. It is unclear whether a universal no fault compensation system would provide different outcomes for these patients. New Zealand's Accident Compensation Corporation (ACC) provides universal no fault compensation for personal injury secondary to accident and offers an opportunity to compare results with differing provision of compensation.

Methods. A total of 169 patients undergoing lumbar spinal fusion were assessed preoperatively, at 1 year, and at long-term follow-up out to 14 years, using functional outcome measures and health-related quality-of-life measures. Comparison was made between those covered and not covered by ACC for 3 distinct diagnostic categories. A systematic literature review comparing outcomes in Worker's Compensation and non-Compensation cohorts was also performed.

Results. The functional outcomes for both ACC and non-ACC cohorts were similar, with significant and comparable improvements over the first year that were then sustained out to long-term follow-up for both cohorts. At long-term follow-up, the health-related quality-of-life measures were the same between the 2 cohorts.

The literature review revealed a marked difference in outcomes between worker's compensation and non–worker's compensation cohorts with a near universal inferior outcome for the compensation group.

Conclusion. The similarities in outcomes of patients undergoing lumbar spine fusion under New Zealand's universal no fault compensation system, when compared with the dramatically inferior outcomes for these patients under other worker's compensation systems, suggest that the system of compensation has a major influence on patient outcomes, and that change of compensation to a universal no fault system is beneficial for patients undergoing lumbar fusion surgery.

Level of Evidence: 2

There is no difference in outcomes for lumbar spine fusion patients between compensated and non-compensated patients in a system that provides universal no fault coverage. This is dramatically different to the worker's compensation population from adversarial systems suggesting that the type of compensation profoundly affects outcomes for these patients.

*St Bartholomews Hospital and The Royal London Hospital, London, England

The Royal Melbourne Hospital and the Epworth Richmond, Melbourne, Australia; and

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

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

Acknowledgment date: June 4, 2014. Revision date: December 4, 2014. Acceptance date: February 23, 2015.

The device(s)/drug(s) is/are FDA approved or approved by corresponding national agency for this indication.

No funds were received in support of this work.

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

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