Abstract
Objective: To investigate the effect of patient and injury characteristics on employment for working-age, adult survivors of burn injury using the multicenter Burn Model System national database. Design: Longitudinal survey. Setting: Multicenter regional burn centers. Participants: Adult burn survivors (N=967) age≥18 years with known employment status prior to injury were included in the analysis at 12 months after injury. Interventions: Not applicable. Main Outcome Measures: Employment status at 12 months after injury. Results: The analyses determined that those employed preinjury had higher odds of being employed (odds ratio [OR]=8.1; 95% confidence interval [CI], 4.9-13.1). White, non-Hispanic individuals were also more likely to be employed (OR=1.49; 95% CI, 1.0-2.1). Older individuals, females, those with longer hospitalizations, amputation during the acute hospitalization, and those with high pain interference at hospital discharge had lower odds of working after injury. Preinjury living situation, preinjury alcohol and drug misuse, number of acute operations and burn size (total body surface area, %) were not significant predictors of employment status at 12 months after burn injury. Conclusion: Preinjury employment remains the most significant predictor for postburn employment. Although past reports have focused on predictors for postburn employment, we believe that we need to seek greater understanding of modifiable risk factors for unemployment and examine issues related to work retention, performance, accommodations, and career trajectories for the working-age survivor of burn injury.
| Original language | English (US) |
|---|---|
| Pages (from-to) | S71-S85 |
| Journal | Archives of physical medicine and rehabilitation |
| Volume | 101 |
| Issue number | 1 |
| DOIs | |
| State | Published - Jan 2020 |
Keywords
- Burns
- Employment
- Rehabilitation
- Return to work
- Vocational rehabilitation
ASJC Scopus subject areas
- Physical Therapy, Sports Therapy and Rehabilitation
- Rehabilitation
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In: Archives of physical medicine and rehabilitation, Vol. 101, No. 1, 01.2020, p. S71-S85.
Research output: Contribution to journal › Article › peer-review
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TY - JOUR
T1 - Factors Affecting Employment After Burn Injury in the United States
T2 - A Burn Model System National Database Investigation
AU - Carrougher, Gretchen J.
AU - Bamer, Alyssa M.
AU - Mandell, Samuel P.
AU - Brych, Sabina
AU - Schneider, Jeffrey C.
AU - Ryan, Colleen M.
AU - Kowalske, Karen
AU - Esselman, Peter C.
AU - Gibran, Nicole S.
N1 - Funding Information: Our analyses of working-age employed and unemployed individuals with significant burn injury found some agreement with previous reports on factors significantly associated with postburn employment. Of greatest significance, those employed preinjury had higher odds of being employed at 12 months after injury. Thus, we included 2 additional analyses based on preinjury employment status for the 16 variables of interest. White race, non-Hispanic individuals were more likely to be employed at 12 months than those grouped as non-white race or Hispanic ethnicity. This finding is in agreement with a single past report that included race as one of their variables of interest and found that those of the white race were more likely to be employed. 14 Although we could not separate the non-white racial group into different subgroups due to small sample sizes (eg, black or African-American, Asian, American Indian or Alaska Native, multiracial) in our analyses, those of a non-white race or of Hispanic ethnicity may benefit from additional vocational services, especially in the first year following injury. Concerning the effect of insurance provider on postburn employment, insurance type at discharge is a significant factor in postburn employment status. Individuals who are employed are more likely to be covered by private insurance, while those without employer-based insurance are more likely to be unemployed. Our observations regarding lower 12-month employment for individuals insured by workers' compensation corroborates another report of lower return-to-work rates in this population. 15 This finding is of interest given that being employed prior to injury is the best predictor for returning to work and by definition, those covered by workers' compensation insurance were employed preburn. In a single-center report investigating a set of interventions aimed at burn-injured workers covered by Labor and Industries insurance (ie, workers' compensation for Washington State), investigators found a 93% return-to-work rate, with an average of 24 days from injury until return to work. 28 Difference in study outcomes between these studies may be due to participant characteristics as the Washington State group 28 likely represents a cohort with less severe injury. Unexpectedly, TBSA burn size did not consistently reach statistical significance for postburn employment. This finding is in opposition to other reports that have demonstrated a significant influence of total burn size 1 , 2 , 5 , 10 , 12 , 13 , 15 , 16 , 24 , 26 or full-thickness burn size 2 , 13 , 15 , 16 , 18 , 19 on postburn employment. An exception to this was the finding that for those unemployed preburn, individuals from the midsize injury group (10%-19% TBSA) were more likely to find employment than those within the other injury groups. Importantly, our reference group of small burns (<10% TBSA) for these comparisons may actually include burns to the hands, face, or feet, which might be small, but complicated and require multiple reconstructive surgeries. Burn injuries to the hands did not significantly affect employment after injury. This outcome was surprising given findings from the systematic review by Quinn et al 2 and others 10 , 12 that identified hand burn as a significant influence on work following injury. One potential reason is that our data variable for hand burn is dichotomous (yes or no) and does not include severity of injury to the hands or need for surgery to the hands. Future assessments should include a measure of severity such as unilateral vs bilateral hand burns with and without surgical intervention for wound closure as well as hand dominance. Older individuals had lower odds of working after injury. This finding is consistent with several previous reports for which there was a significant association between age and employment postburn, 2 , 12 , 28 suggesting that it may be more difficult for burn survivors to find employment or return to the workforce as they age or near retirement. When compared to the age groups outlined by the BLS, some interesting comparisons were identified. Most concerning is that BMS postburn employment rates are consistently lower for individuals age 18-54 years than the US general population. This cohort of working-age adults may need additional or focused vocational rehabilitation during the first year of their recovery. Of interest is that those in the older age group (55+y) had a higher employment rate than the US population. This difference could be explained by the overall younger age of our 55+ cohort with 81% between 55-64 years compared to 47% in the overall BLS group. Likewise, only 4.5% of our cohort was older than 75 years compared to 25% in the BLS group. Given that the US population is aging, continuing to follow this group is prudent. Furthermore, we recommend the use of the BLS age groups so that future studies can provide comparisons to the larger US population. Longer acute inpatient hospitalizations were also associated with lower likelihood of working postburn. For every 10 days of inpatient hospitalization, individuals were 14% less likely to find employment after injury at 12 months (data from the entire group analysis). This finding corroborates other reports 2 , 11 , 16 , 18 , 20 , 23 , 26 , 29 , 33 and suggests that longer hospitalization may be a surrogate for either severity of injury or a complicated psychosocial situation at hospital discharge. Women also had lower odds of being employed at 12 months after burn injury. This finding has been reported previously. 29 , 30 When the data were analyzed based on preburn employment status, this variable (female sex) was no longer significant. Nonetheless, we would suggest that researchers broaden or reconsider the meaning or definition of work, especially for those who identify as a “homemaker/caregiver” or “volunteer.” In this study, we were focused on paid employment after injury, however, it may be that returning to work within the home or returning to preinjury functional capacity may be a more appropriate definition for those who do not receive financial remuneration for their work or for those who rely on subsistence practices (eg, native Alaskans). This is an area of study that the Northwest Regional BMS ( http://burnrehab.washington.edu ) plans to investigate further. Individuals reporting high pain interference at hospital discharge consistently had lower odds of working postburn, a finding that corroborates other reports that cite pain 1 , 4 , 20 , 22 and chronic pain 18 as significant factors. The importance of this finding is that clinicians can work to modify this outcome by seeking to improve pain management during the acute hospitalization and early postdischarge recovery periods. However, with increasing focus and concern for the opioid overdose epidemic in the United States, 34 clinicians will be challenged even more as they treat postburn pain in an effort to achieve comprehensive and effective pain management. A first step is to better understand our outpatient opioid prescriptive practices and subsequent utilization by our patient population. 35 Those with a burn-related amputation also had lower odds of employment postburn. Two previous studies, including a BMS report, 21 , 30 found that amputation negatively influenced postburn employment. In this report, individuals with any level of amputation (8% of the model participants) are half as likely to be employed at 12 months after injury compared to those without an amputation. At a minimum, functional recovery for this population of people who survive burn injury warrants further study. Since 2015, the BMS has committed to collecting amputation-related data in greater detail. The BMS longitudinal database now collects information for the number and level of amputations if only the hand or foot is involved: the thumb or digits of the hand and partial or full amputation of the feet; information is collected by medical record review and not self-report. Once enough participants with these data points are enrolled, we will be able to compare outcomes based on the acute and rehabilitative care received in this cohort of survivors with potentially, greater functional limitations. With the addition of hand dominance (obtained via self-report), we will be able to study the effect of an upper extremity amputation when it affects the dominant hand with the outcome of postburn employment. Preinjury living situation (partner vs no partner) and preinjury alcohol or drug abuse by self-report were not consistently significantly associated with employment status 12 months postburn. However, in the unemployed group, having a partner preburn did not positively correlate with employment after injury. These findings are surprising given the importance that social support has on recovery 23 and a previous analysis that demonstrated a negative effect of substance abuse on work in the population of people who survived burn injury. 32 Individuals reporting a history of seeking psychological counseling or therapy before injury were half as likely to find employment as those who did not. In general, this finding is congruent with 10 other studies, 5 , 6 , 17 , 19 , 20 , 23-25 , 27 , 29 including a systematic review by Mason et al 1 that report that either a history of psychosocial issues, personality disorder, or depression after injury influenced employment postburn. Furthermore, in a 2001 BMS report, Fauerbach et al 36 suggested that a greater prevalence of psychological impairment among adult burn survivors who were unemployed before the injury may explain why preburn employment status is such a powerful determinant of postburn work outcomes. Although significant, we found that preburn counseling has limitations given how the question was asked: a dichotomous yes or no answer without defining the type of therapy or counseling received. Therefore, in 2018, the BMS National Longitudinal Study investigators added the question, “Before your burn injury, were you ever told by a doctor that you had any of the following psychological issues?” Participants choose all applicable issues: depression, bipolar disorder, anxiety, posttraumatic stress syndrome, schizophrenia or other psychotic disorder, or other (with option to write in a disorder). In addition, patient-reported outcome measures from the Patient-Reported Outcome Measure Information System (PROMIS) ( http://www.healthmeasures.net/explore-measurement-systems/promis ) concerning depression, posttraumatic stress syndrome, and anxiety were added in 2015 for completion at all follow-up time points. Most of the contributing factors significantly associated with unemployment after a burn injury cannot be modified, including age, sex, race or ethnicity, or unstable home disposition. However, pain interference and in-hospital complications represent 2 modifiable factors that may respond to different treatment strategies. If significant pain interference is recognized early and successful intervention is provided, a positive effect on postburn employment may be realized. Future studies should include this or similar variables and not be limited to pain intensity scores alone (eg, pain level or intensity measured on a 0-10 numeric rating scale). This study used a metric from the 12-Item Short Form Health Survey but others exist which are equally good or better at capturing this construct. 37 Examples include several short forms from the PROMIS item bank. PROMIS is a set of person-centered measures that evaluates and monitors health in both adults and children. These measures can be used with individuals living with any health concerns and with the general population, thus allowing for comparisons across injury populations. Likewise, inpatient complications, a focus of many health quality programs, represent another modifiable variable. As we have previously reported, patients who had complications during their hospitalization report poorer quality of life than patients who did not. 38 Therefore, efforts to reduce hospital complications might significantly shorten hospital length of stay and improve long-term outcomes and quality of life, including postburn community participation and employment. One finding of note in our study is that the BMS center providing acute care had a significant effect on employment postburn. All of the participating BMS centers provide comprehensive, multidisciplinary care and services to individuals with burn injury from the time of injury through recovery as directed by the funding agency, the National Institute on Disability, Independent Living, and Rehabilitation Research. However, site 2 was associated with greater postburn employment rates in all analyses performed, raising the possibility of differences in state, regional, or burn center-specific practices related to vocational services. This deserves further investigation and reporting. Our analysis from one of the largest multicenter longitudinal burn injury databases provides clinicians, including vocational rehabilitation counselors, with knowledge about predictors for successful community reintegration, with a focus on employment following a significant burn injury. Future studies should investigate new and innovative treatments. Investigators should consider conceptualizing employment after injury along a time continuum and should include part-time or light-duty work. As discussed by others, successful work integration may require multiple work trials or cycles of attempting to return to work. Work capacity can be affected by functional limitations from chronic pain, scar contractures, and emotional well-being, all of which may change and hopefully improve over the course of one's rehabilitation and recovery. Furthermore, for individuals injured at work compared to those without a work-related injury, worse long-term work reintegration outcomes have been reported. Schneider et al 39 suggest the need for identification of those at higher risk for work reintegration as well as a greater understanding of the barriers individuals face when they do return to work. We know little about accommodations that are needed that ultimately support a person as he or she returns to and performs at work. Stergiou-Kita and Grigorovich 6 identified 3 stages to consider for future investigations: (1) gaining employment; (2) maintaining employment; and (3) work advancement. Funding Information: Supported by a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (grant no. 90DPBU0004 and 90DPGE0004).The National Institute on Disability, Independent Living, and Rehabilitation Research is a center within the Administration for Community Living, Department of Health and Human Services. The contents of this article do not necessarily represent the policy of the National Institute on Disability, Independent Living, and Rehabilitation Research, the Administration for Community Living; the Department of Health and Human Services, and do not assume endorsement by the Federal Government. Publisher Copyright: © 2019 American Congress of Rehabilitation Medicine
PY - 2020/1
Y1 - 2020/1
N2 - Objective: To investigate the effect of patient and injury characteristics on employment for working-age, adult survivors of burn injury using the multicenter Burn Model System national database. Design: Longitudinal survey. Setting: Multicenter regional burn centers. Participants: Adult burn survivors (N=967) age≥18 years with known employment status prior to injury were included in the analysis at 12 months after injury. Interventions: Not applicable. Main Outcome Measures: Employment status at 12 months after injury. Results: The analyses determined that those employed preinjury had higher odds of being employed (odds ratio [OR]=8.1; 95% confidence interval [CI], 4.9-13.1). White, non-Hispanic individuals were also more likely to be employed (OR=1.49; 95% CI, 1.0-2.1). Older individuals, females, those with longer hospitalizations, amputation during the acute hospitalization, and those with high pain interference at hospital discharge had lower odds of working after injury. Preinjury living situation, preinjury alcohol and drug misuse, number of acute operations and burn size (total body surface area, %) were not significant predictors of employment status at 12 months after burn injury. Conclusion: Preinjury employment remains the most significant predictor for postburn employment. Although past reports have focused on predictors for postburn employment, we believe that we need to seek greater understanding of modifiable risk factors for unemployment and examine issues related to work retention, performance, accommodations, and career trajectories for the working-age survivor of burn injury.
AB - Objective: To investigate the effect of patient and injury characteristics on employment for working-age, adult survivors of burn injury using the multicenter Burn Model System national database. Design: Longitudinal survey. Setting: Multicenter regional burn centers. Participants: Adult burn survivors (N=967) age≥18 years with known employment status prior to injury were included in the analysis at 12 months after injury. Interventions: Not applicable. Main Outcome Measures: Employment status at 12 months after injury. Results: The analyses determined that those employed preinjury had higher odds of being employed (odds ratio [OR]=8.1; 95% confidence interval [CI], 4.9-13.1). White, non-Hispanic individuals were also more likely to be employed (OR=1.49; 95% CI, 1.0-2.1). Older individuals, females, those with longer hospitalizations, amputation during the acute hospitalization, and those with high pain interference at hospital discharge had lower odds of working after injury. Preinjury living situation, preinjury alcohol and drug misuse, number of acute operations and burn size (total body surface area, %) were not significant predictors of employment status at 12 months after burn injury. Conclusion: Preinjury employment remains the most significant predictor for postburn employment. Although past reports have focused on predictors for postburn employment, we believe that we need to seek greater understanding of modifiable risk factors for unemployment and examine issues related to work retention, performance, accommodations, and career trajectories for the working-age survivor of burn injury.
KW - Burns
KW - Employment
KW - Rehabilitation
KW - Return to work
KW - Vocational rehabilitation
UR - http://www.scopus.com/inward/record.url?scp=85075529519&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85075529519&partnerID=8YFLogxK
U2 - 10.1016/j.apmr.2019.09.009
DO - 10.1016/j.apmr.2019.09.009
M3 - Article
C2 - 31626744
AN - SCOPUS:85075529519
SN - 0003-9993
VL - 101
SP - S71-S85
JO - Archives of physical medicine and rehabilitation
JF - Archives of physical medicine and rehabilitation
IS - 1
ER -