Objective: To evaluate a program to reduce musculoskeletal disability-related absenteeism at a North American manufacturing facility.
Study Design: Staged communication and educational interventions targeting physicians to improve care of musculoskeletal conditions and reduce related absenteeism.
Methods: The program was implemented in three 1-year stages. The first stage required physicians to complete assessment forms for employees claiming disability because of musculoskeletal injuries. The second stage added physician education programs focusing on current clinical guidelines. The third stage incorporated local physician education about the facility's onsite physical therapy program. Annual number of work-related injuries, days lost per injury and per scheduled full-time-equivalent (FTE) employee, lightduty days per injury, average annual indemnity per FTE, indemnity per injury, medical costs per FTE, and medical costs per injury were examined to determine the program's effectiveness.
Results: Overall productivity improved by a mean of 12.5 days per injured employee. Mean days lost per work-related injury decreased from 35.1 to 27.6. Number of light-duty days increased from 6.1 to 11.1 per work-related injury. Mean annual indemnity per work-related injury decreased from $9327 to $4493; mean annual medical costs per work-related injury decreased from $4848 to $2679. The annual incidence of musculoskeletal injuries declined by up to 50%.
Conclusions: This intervention was associated with reduced musculoskeletal disability-related absenteeism and increased productivity. The program reduced medical costs per work-related injury and improved the company's communications and relationship with local physicians.
(Am J Manag Care. 2006;12:SP27-SP32)
Disability-related absences cost major corporations billions of dollars annually. On a typical day, 3% to 6% of any given workforce is likely to be absent as a result of unscheduled issues or disability claims. In 2004, American industries reported approximately 4 257 300 cases of nonfatal injuries and illnesses.1 Of these cases, about 1 259 300 involved lost workdays, 525 390 related to musculoskeletal injuries (eg, sprains, strains, muscle tears), and 282 240 involving back injuries.
The causes, nature, treatment, and prevention of work-related musculoskeletal injuries were investigated in a North American facility with an unusually large number of musculoskeletal disability claims, lost workdays, and surgical referrals. Based on its findings, the company developed a 3-stage communication and educational intervention targeted at community physicians and employees. The program aimed to improve care received by injured employees and to reduce disability-related absenteeism, and was implemented in three 1- year stages. In this article, we describe the changes in related clinical and financial outcomes.
International Truck and Engine Corporation (referred to hereafter as International) is the nation's largest manufacturer of medium-and heavy-duty trucks, school buses, and diesel engines, with facilities in more than 40 major locations. The company employs mostly blue-collar, hourly employees involved in manufacturing operations. International provides free outpatient medical services and support for employees through plant staff. In addition to traditional corporate managers, department and plant staff includes physicians, physical therapists, nurses, and case managers.
In late 2001, approximately 25% (≥200) of International's musculoskeletal disability claims, accounting for 65% of total workers' compensation costs company-wide, were coming from the Springfield, Ohio, manufacturing facility. At that time, Ohio state workers' compensation laws allowed employees to seek care at International or select their own treating physicians.
Workers' compensation records revealed that International's Springfield employees with musculoskeletal injuries were not always adequately diagnosed or treated by local primary care physicians (as determined by local orthopedic specialists). Although some employees were unnecessarily referred to orthopedic specialists, others were not referred when appropriate. Additionally, physicians frequently prescribed sedating, controlled-substance pain relievers (eg, opioids), which prevented a safe return to work and often kept employees from returning when their level of disability would have allowed a return to light duty. Company resources, including onsite physicians and physical therapists, were not being sufficiently utilized at the Springfield facility to maximize outcomes.
The literature on musculoskeletal disability management programs indicated that the incidence of workers' compensation claims often leveled off after implementation of a risk screening program that included employee education about work-related musculoskeletal pain.2 Furthermore, clinical practice guidelines for musculoskeletal injuries have been successfully applied in the workers' compensation setting.3 Thus, it was hypothesized that physician education and use of established guidelines, along with improved communications with employees, might help reduce workers' disability costs and improve the care of injured employees at the Springfield site.
In 2002, the company developed the International Musculoskeletal Disability Management (IMDM) program, administered by its Medical Services Department located within the Springfield facility. Baseline data were obtained from workers' compensation records from the first quarter of 2000 through the fourth quarter of 2001. The IMDM program was implemented in 3 stages (Figure) and comprised the following:
The Employee Status/Return to Work Report. This form (the ESRW Report) was given to all employees filing a claim for a musculoskeletal disability, and they, in turn, gave the form to their treating physician. The physician reported on the nature of the disability and current ability to perform body movements, such as bending, twisting, and repetitive hand use; safety-sensitive activities, such as operating motorized equipment; lifting and carrying; and pushing or pulling at specified weight limits, both above and below shoulder level. A new form was completed for each visit and returned to the Medical Services Department.
Evidence-based Medicine Diagnostic Training Seminars. The American Academy of Orthopedic Surgeons (AAOS) clinical guidelines4 were selected and used as the basis for more than a dozen diagnostic training seminars presented by orthopedic specialists to local primary care physicians who currently or recently treated International employees. The seminars were funded by the company and a corporate sponsor.
Job Descriptions. Treating physicians were given the employee's job description, which helped them to assess conditions wherein the employee could return to work, either on a light-duty or unrestricted basis.
Clinical Practice Guidelines. During stages 2 and 3, the AAOS practice guidelines specific to an employee's injury were given to treating physicians.
Awareness of Onsite Capabilities. Physicians were informed about International's onsite physical therapy capabilities so that they might allow injured employees to return to work earlier, knowing they would be appropriately followed and their therapy sessions could be scheduled to accommodate work shifts.
Letters to Physicians. Local physicians were encouraged to (1) complete the ESRW Report; (2) use the AAOS clinical practice guidelines; (3) use the company's onsite physical therapy services for employees with musculoskeletal conditions; and (4) prescribe appropriate medications to safeguard employees, particularly over-the-counter pain relievers, nonsteroidal anti-inflammatory drugs, or the cyclooxygenase-2 (COX-2) inhibitor celecoxib.
Determining Outcomes Related to Study Interventions
Four primary clinical end points were examined. The mean number of scheduled full-time-equivalent (FTE) employees was determined by dividing 37.5 hours per week into the total number of hours worked. The number of work-related injuries was taken from the monthly work loss injury report, and mean injury rate was determined by dividing the total number of injuries by the average number of employees during the stage. The number of days lost per work-related injury was computed by dividing the number of injuries into the total number of injury-related lost workdays. Finally, the number of days lost per scheduled FTE employee was computed as the number of lost workdays divided by the total number of scheduled FTE employees.
Four secondary-cost end points were examined. The average indemnity paid per FTE employee was computed as total facility indemnity costs divided by the total number of FTE employees. The average indemnity paid per work-related injury was computed as the total work-related indemnity cost divided by the total number of injuries. The average medical cost paid per FTE employee was calculated by dividing the total medical costs by the total number of FTE employees. The average medical cost per work-related injury (annually) was computed as total medical costs divided by the number of injuries.
Periodic updates were communicated to the plant management in Springfield and to senior company management. These updates made management aware of the need for continued adherence to the study interventions.
Average values of the clinical and financial outcome measures were compared before and after the program. Outcomes are reported as rates, so the change in total FTE employees does not affect the results, although the number of claims dropped in proportion to the decrease in FTE employees.
In 2001, the Springfield facility employed 3417 persons. The number of FTE employees at the facility decreased between 2001 and 2005 as a result of merging some operations into other locations and because a large number of employees retired. The number of employees at the study's end was 1366. The mean age of employees at the Springfield facility was 52.6 years, and mean tenure with the company was 23.2 years. Eighty-two percent of the employees at the facility were men.
Large reductions were observed in work-related injuries (75%), days lost per injury (21%), and days lost per FTE employee (50%). Overall productivity improved by an average of 12.5 days per injured employee after the program was implemented. The mean number of days lost per work-related injury decreased from 35.1 days to 27.6 days, or an improvement of 7.5 days per injury (Table 1). Furthermore, the number of light-duty days increased per work-related injury, from 6.1 to 11.1, and use of the company's onsite physical therapy facilities increased by more than 50%.
Both mean indemnity and medical costs decreased per injured employee (Table 2). The mean annual indemnity paid per work-related injury decreased by $4834 (from $9327 to $4493) and the mean annual medical costs paid per work-related injury decreased by $2169 (from $4848 to $2679). The greatest change from baseline was observed in the mean annual indemnity paid per FTE employee at the facility. Over the 3 stages of the study, this amount decreased from $590 to $178 per FTE employee.
The most commonly occurring musculoskeletal injuries at the Springfield facility both before and after the program began were to the shoulder, wrist, hand, and lower back (Table 3). After taking into account the reduction in the number of employees at the Springfield facility compared with baseline, the overall incidence of musculoskeletal injuries declined from baseline to end of study by as much as 50%. The greatest reduction occurred in the number of back injuries reported per year.
In the IMDM program, International identified shortcomings in its musculoskeletal disability management procedures and implemented solutions that were both clinically and financially effective. Although International decided to enact these procedures in 3 stages, a company wanting to duplicate this program could implement all 3 stages simultaneously or at an accelerated rate compared with this program.
In the Springfield facility, 50.9 hours go into building 1 truck. The IMDM program increased productivity by a mean of 12.5 days per injury. Based on a 37.5-hour workweek, multiplying this number by 7.5 hours per day and by the 54 employees injured during stage 3 reveals a gain of 5062 man-hours, which translates into 99 more trucks built per year. Also, given that replacement employees cost between $24.18 and $45.30 per hour, a gain of 5062 man-hours saves between $122 399 and $229 309 annually.
The large percentage of reductions in work-related injuries, days lost per injury, and days lost per FTE employee noted in this study compare favorably with disability management programs evaluated by Doheny,5 who reported a 20% reduction in the length of long-term absences, and by Skisak and colleagues,6 who reported 9% to 23% reductions in total absences, a 20% reduction in absences lasting 4 or more days, and a 28% reduction in extended absences. Because physicians in this study initially often kept employees out of work until they were fully recovered, the number of annual light-duty days increased substantially after the study interventions were implemented. This increase is likely attributable to efforts to educate physicians about injured employees' tasks, their option to return to work on a light-duty basis, and the company's onsite physical therapy facilities. Goetzel and colleagues noted that when indirect costs associated with absenteeism, such as overtime premiums and cost of replacement workers, are examined, the health and productivity cost burden increases substantially.7 However, we did not collect these data, so no comparison between prestudy and poststudy indirect costs could be made. Although preliminary information on pain medications prescribed to workers with musculoskeletal injuries during this study is anecdotal, the use of controlled substances decreased at the Springfield facility. Conversely, the use of the COX-2 inhibitor celecoxib and other nonsteroidal anti-inflammatory drugs increased.
The success of the IMDM program was related to several factors. First, International took a systems perspective, not a defective-component perspective, focusing on improving organizational factors rather than individual employee factors.8 The involvement of senior management throughout the program helped to ensure corporate responsibility for the program. Additionally, local healthcare providers were presented with a unified plan for managing musculoskeletal injuries and using in-house resources more effectively.
Program implementation appears to be associated with increased productivity and averted costs. The data collected from the ESRW Report provided ongoing feedback and established a means of accountability and evaluation of the program and its components, including return on investment. Although implementation costs (eg, physician education programs, printing of guidelines, letter mailings) for the IMDM program were minimal, the program has been successful in reducing workers' compensation costs by more than $1500 annually per FTE employee at this facility.
Goetzel and colleagues listed 10 best practices found in several successful health and productivity management plans.7 The IMDM program followed each of these practices. Its goals were aligned with those of the company, and each component was interdisciplinary, involving people from several different departments. This helped to ensure adequate input for decision making and lent broad-based support. A program "champion" (the Medical Services Department) was identified and became the driving force behind the IMDM initiative. More important, senior management was involved in the design, implementation, and evaluation of each component and was committed to the success of the program, which emphasized improvements in injured employees' care and quality of life, not just reductions in healthcare costs. Communication was consistent throughout the organization and the community of local healthcare providers. In addition to ideas from its own plan design group, the IMDM program incorporated ideas from the literature, thus benefiting from lessons learned in similar efforts.
Limitations of the Study
This was an observational study, and it is possible that the extra care and attention given to injured employees may have influenced their progress and return to full productivity. These employees may have experienced an effect similar to the Hawthorne effect, wherein the awareness of being studied changes observed behaviors. International hoped that employees would see the program as a genuine attempt to improve their welfare and job satisfaction. Their awareness of the program, however, may have influenced their behavior.6
This program was implemented in a small community, with all employees working in 1 centralized location (Springfield). In this setting, it was easier to identify most of the physicians treating musculoskeletal-injured employees of the company. Replicating the program in its entirety might not be possible in larger communities, particularly the physician training seminars.
The interpretation of results of this study is limited by lack of a control group, which could not be used because International has no other facility in Ohio. Because workers' compensation regulations vary across states, using an out-of-state facility as a control group would not have been feasible. Additionally, a control group within the Springfield facility could not be designated because of union guidelines, wherein activities must be rolled out evenly across all employees. As a result, it was not plausible to rule out the possibility that some of this study's findings were attributable to causes other than the implementation of the musculoskeletal disability management program. The program appeared to increase productivity and decrease healthcare costs, although it was not possible to determine whether any 1 part of a stage had more of an effect than other parts. Also, because the program was rolled out in 3 stages, it was not possible to determine whether the perceived improvements of each stage were in addition to the effects of previous initiatives, or if the effects of previous initiatives would have continued to result in improvement without the new processes being enacted.
Claims-based absences account for about 1 of every 2 lost workdays and for about 1 of every 5 absences.8 This study did not address other sources of absenteeism. Finally, because it often takes an extended period of time before all costs associated with a claim have been incurred and submitted for reimbursement, it is possible that not all costs associated with the most recently filed claims were captured in this analysis.
The IMDM program appears to be associated with improved clinical outcomes in employees at International's Springfield site who sustained musculoskeletal injuries. The plan also resulted in workers' compensation cost savings of more than $1500 annually per FTE employee. Additionally, the company improved its communications and relationship with local healthcare providers. Most important, this program improved the care of injured employees, reduced disability-related absenteeism, and increased productivity at this facility.
From International Truck and Engine Corporation, Warrenville, Ill (WBB, TKE, DDT, AMH, DBP) and Springfield, Ohio (RSB); Pfizer Inc, Chicago, Ill (ADS, DS); and Caremark Inc, Northbrook, Ill (DD).
This research was supported by Pfizer Inc. No International Truck and Engine Corporation employee or investigator received financial support or equity for trial participation. Physician training seminars conducted during this program were cosponsored by International Truck and Engine Corporation and Pfizer Inc.
Address correspondence to: Thomas K. Ehni, MD, MPH, Medical Director, International Truck and Engine Corporation, 10400 W North Ave, Melrose Park, IL 60160. E-mail: firstname.lastname@example.org.
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