CORR Insights®: Involvement in a Personal Injury Claim Is Associated With More Pain and Delayed Return to Work After Elective Nonsurgical or Surgical Treatment for Hand or Wrist Disorders: A Propensity Score–matched Comparative Study

Where Are We Now?

Before the 1990s, there was a paucity of information regarding the relationship between patient financial compensation and the outcomes of hand and wrist surgery. Starting in the 1990s, reports started to hint at a relationship between workers compensation status and worse outcome after carpal tunnel release [1, 12]. Since then, several studies, including systematic reviews and meta-analyses, identified a clear association between financial compensation and worse outcome including more pain and delayed return to normal function in not only surgery but also nonsurgical treatment of hand and wrist disorders [3-7]. Financial compensations include workers compensation, legal representation, and medical malpractice claims. Other studies also confirmed the presence of the same correlation for other injuries and in several other countries [2, 6, 8, 10, 11].

A systematic review and meta-analysis of 62 articles found that patients with workers compensation status were less likely to have more pain, less function, and delayed return to work after upper extremity surgery [6]. That study also found that certain objective evaluation measures, including grip strength and active ROM, were the least likely to be adversely associated with a patient’s workers compensation status. Another systematic review of 29 studies related to the association between financial compensation and health outcomes after musculoskeletal injury found clear evidence of an association between compensation-related factors and poorer physical and psychologic function and increased pain after injury [10].

In this issue of Clinical Orthopaedics and Related Research®, Hoogendam et al. [9] examined the records of 29,101 patients in the Netherlands who underwent nonsurgical, minor surgical, or major hand and wrist procedures. The authors found that being involved in a personal injury claim was associated with an inferior treatment outcome, with more pain and delayed return to work for patients treated nonsurgically or surgically for hand and wrist conditions. This is an important finding because of the large number of patients included and the inclusion of nonsurgically treated patients. More importantly, this study has a wider perspective because it studied patients who had personal injury claims that were unrelated to the reasons for which they were seeking treatment. Even in this subclass of patients, there was a correlation with worse outcome after treatment. Based on these discoveries, surgeons should be aware of this association when treating patients with workers compensation status or patients involved in personal injury claims. Surgeons should discuss with their patients methods to incentivize them to achieve better treatment results.

Where Do We Need To Go?

Despite the various reports documenting the association between workers compensation status and poor clinical outcome, there are still gaps in our knowledge of the different elements of this intricate association [4-7]. It is important to understand why financial compensation is associated with poor outcomes and to understand more clearly the factors that contribute to this association. We also need to better understand the factors that drive a patient’s decision to file a personal injury claim.

It is critical that treating physicians, surgeons, and therapists identify the best methods of evaluating patients who are receiving (or may expect to receive) financial compensation that depends on the injury or the result of treatment. Because objective evaluation measurements, such as grip strength, ROM, or electrodiagnostic studies, are less likely to be associated with a patient’s compensation status, these measures should be used in evaluating those patients [6]. This will allow us to gain more knowledge about the important objective parameters signifying improvement after surgical or nonsurgical treatment of upper extremity disorders.

Because there is clear evidence of inferior treatment outcomes among patients with financial compensation, we need to identify methods to improve outcomes for those patients. Studies are needed to develop and compare new, more-imaginative methods to improve the treatment outcome of those patients.

Finally, exploring the role of the treating providers in helping patients who anticipate receiving financial compensation as part of an injury settlement may be useful to clarify what providers can do to help those patients. Does establishing a better bond between the treating provider and the patient early during the treatment course have an impact on the treatment outcome? Focused research would be helpful to investigate this point. Empowering patients to take ownership of their treatment and recovery is important and should be done as early in the treatment course as possible.

How Do We Get There?

Filling the gaps in our knowledge of the association between financial compensation and poor clinical outcomes would require specific studies addressing each component of this complex association [6]. Studies should be performed early during treatment. For instance, questionnaires evaluating personality traits, psychologic makeup, and personal challenges could help identify the factors that may drive a patient to file a personal injury claim.

Because of the poor clinical treatment results in the form of persistent symptoms or lack of improvement associated with financial compensation, we should find novel ways to improve our patients’ outcomes. Forming care teams consisting of the treating physician, nurse, case manager, and hand therapist to assist in a patient’s recovery could be helpful. Comparing the clinical outcome of patients treated by the care team with those who did not have a care team would elucidate the value of such a team and in the process, it would shed some light on the factors hindering a patient’s full recovery.

Another point that deserves to be discussed is whether the addition of a psychologist to the treatment team would influence patients’ decisions to file personal injury claims and their clinical outcomes if they did so. Although conducting prospective randomized studies may be difficult and costly, a relatively large number of patients with workers compensation status treated in a major center would allow for a comparative study comparing the use of a psychologist in one group with another group in which there was no such use. Comparing the improvement of symptoms, return of function, and patient satisfaction in the two groups would be useful in identifying the different factors involved in this complex association.