title: Unremitting health-care-utilization outcomes of tertiary rehabilitation of patients with chronic musculoskeletal disorders.
abstract: BACKGROUND
  Unremitting health-care-seeking behaviors have only infrequently been addressed in the literature as an outcome of treatment for chronic disabling work-related musculoskeletal disorders. The limited research has never focused on the patient as the "driver" of health-care utilization, to our knowledge. As a result, little attention has been paid to the differences between treated patients who seek additional health care from a new provider and those who do not. The purpose of this project was to examine the demographic and socioeconomic outcome variables that characterize patients with a chronic disabling work-related musculoskeletal disorder who pursue additional health-care services from a new provider following the completion of a tertiary rehabilitation treatment program. A prospective comparison cohort design was employed to assess characteristics and outcomes of these patients, all of whom were treated with the same interdisciplinary protocol.
  
  
  METHODS
  A cohort of 1316 patients who had been consecutively treated with a rehabilitation program for functional restoration was divided into two groups on the basis of whether they had sought treatment from a new health-care provider in the year following completion of treatment. Group 0 (966 patients) did not visit a new health-care provider for treatment of their original occupational injury, and Group 1 (350 patients) visited a new provider on at least one occasion. A structured clinical interview to assess socioeconomic outcomes was carried out one year after discharge from the treatment program; this interview addressed pain, health-care utilization, work status, recurrent injury, and whether the Workers' Compensation case had been closed.
  
  
  RESULTS
  The percentage of Group-0 patients who had undergone pre-rehabilitation surgery was significantly lower than the percentage of Group-1 patients who had done so (12% compared with 21%, odds ratio = 1.9 [95% confidence interval = 1.3, 2.7]; p < 0.001). One year after treatment, 90% of the Group-0 patients had returned to work compared with only 78% of the Group-1 patients (odds ratio = 2.6 [95% confidence interval, 1.9, 3.6]; p < 0.001). Similarly, 88% of the Group-0 patients were still working at one year compared with only 62% of the patients in Group 1 (odds ratio = 4.5 [95% confidence interval, 3.3, 6.0]; p < 0.001). Whereas 96% of the Group-0 patients had resolved all related legal and/or financial disputes by one year, only 77% of the Group-1 patients had done so (odds ratio = 6.9 [95% confidence interval, 4.5, 10.5]; p < 0.001). Only a negligible percentage (0.4%) of the patients in Group 0 had undergone a new operation at the site of the original injury, whereas 12% of the Group-1 patients had done so (odds ratio = 31.0 [95% confidence interval, 11.0, 87.3]; p < 0.001). When the above outcome variables were analyzed by dividing Group 1 according to the number of visits to a new service provider, there was a trend for poorer socioeconomic outcomes to be associated with an increasing number of health-care visits.
  
  
  CONCLUSIONS
  To our knowledge, the present study represents the first large-scale examination of patients with a chronic disabling work-related musculoskeletal disorder who persist in seeking health-care following the completion of tertiary rehabilitation. The results demonstrate that about 25% of patients with a chronic disabling work-related musculoskeletal disorder pursue new health-care services after completing a course of treatment, and this subgroup accounts for a significant proportion of lost worker productivity, unremitting disability payments, and excess health-care consumption.
  
  
  METHODS
  Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.
authors.affiliation: Productive Rehabilitation Institute of Dallas for Ergonomics (PRIDE), Dallas, TX 75235, USA.
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Proctor
authors.forename: Tom G
authors.initials: TG
authors.lastname: Mayer
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Gatchel
authors.forename: Don D
authors.initials: DD
authors.lastname: McGeary
mesh_terms: D000328:Adult; D016009:Chi-Square Distribution; D002908:Chronic Disease; D003710:Demography; D006233:Persons with Disabilities / Q000523:psychology; D005260:Female; D006801:Humans; D008297:Male; D009140:Musculoskeletal Diseases / Q000523:psychology / Q000534:rehabilitation* / Q000601:surgery; D009784:Occupational Diseases / Q000523:psychology / Q000534:rehabilitation* / Q000601:surgery; D016017:Odds Ratio; D010342:Patient Acceptance of Health Care; D011446:Prospective Studies; D012959:Socioeconomic Factors; D014942:Workers' Compensation