1. Introduction
Injuries or illnesses occurring at work have a substantial impact on individuals and society [
1]. Although most injured workers can successfully recover and achieve a return to work (RTW) [
2], RTW may take a longer time for many injured workers. RTW is a complicated process and can be impacted by different factors, including physical, psychological, social, and policy-related ones. There are several stages for an injured worker to get ready for RTW [
3]. As the time that an injured worker is away from work gets longer, the likelihood of not returning to work increases [
4]. Therefore, speedy and sustained RTW is the main goal of compensable injury systems, including those in Victoria, Australia, such as WorkSafe Victoria (WSV) and Transport Accident Commission (TAC). To reach this goal, early identification of undesired outcomes [
5], such as delayed RTW, and early intervention [
6] to prevent the undesired outcomes would be beneficial.
Physiotherapists and their early intervention play an important role in occupational rehabilitation [
7] and, consequently, in reducing the post-injury cost [
8] and improving RTW [
9]. Also, the prominence of physiotherapy in treating musculoskeletal injuries is well recognized. However, the timing of the commencement of physiotherapy treatment, in other words, the time of physiotherapists’ intervention, is less clear [
10]. Therefore, WSV, in collaboration with TAC, implemented the Early Intervention Physiotherapist Framework (EIPF) in 2014. The EIPF aimed to encourage physiotherapists who were working with compensable clients to work with clients early in the treatment program in relation to their RTW. The EIPF was implemented through an online training program for physiotherapists. This Framework was designed to encourage physiotherapists to engage clients in physical therapies early in the Occupational Rehabilitation (OR) process, with the aim of decreasing time to RTW and improving RTW sustainability. Once the program was successfully completed and a physiotherapist was accredited, higher fees were paid for services provided by these EIPF physiotherapists to encourage participation. WSV also provided incentives for physiotherapists who had their initial consultation for injured workers within 7 months post-injury [
11].
An initial evaluation was undertaken immediately post-EIPF program delivery [
12]. However, the duration of this evaluation was too short (3 months) to identify data trends and determine the impact of the program on RTW outcomes. In [
12], the authors suggested that another evaluation should be undertaken with a sufficient follow-up period. In the current study, we initiated the second evaluation to examine the performance of the EIPF program three years after implementation in 2017. We also studied the differences in physiotherapy services and RTW outcomes for injured workers to examine the impact of the EIPF program on WSV clients.
1.1. Aims
This study aims to determine if the implementation of the EIPF program is associated with differences in the physiotherapy services provided or RTW outcomes for injured workers.
The study examines the following research questions:
RQ1. Are there differences in physiotherapy services provided to WSV clients between EIPF-trained physiotherapists (EP) and regular physiotherapists (RP) over the three-year intervention period (2014–2017)?
RQ2. Are there differences in the RTW outcomes of WSV clients treated by either EP or RP over the three-year intervention period (2014–2017)?
Specifically, any difference between the time taken from the injury date to the RTW date, adjusting for explanatory variables (age, gender, type of injury, and occupation) as required.
The time to RTW is a common measure to evaluate the performance and success of injury intervention and healthcare improvement programs [
13,
14].
1.2. Definitions
The following definitions are used in the data analysis:
EIPF—Early Intervention Physiotherapy Framework program (the intervention)
EP—Physiotherapists who completed the EIPF program
RP—Regular physiotherapists who did not complete the EIPF program
WSV—WorkSafe Victoria.
2. Materials and Methods
To evaluate differences between types of physiotherapists and the effectiveness of the EIPF on client outcomes (addressing the research questions), a comparison of EP and RP was made. To assess the impact of the EIPF program, only claims which were served exclusively by physiotherapists of either the EP or RP group were analyzed. The manuscript complies with Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement [
15] using the TRIPOD checklist that is presented in
Table 1.
2.1. Data
The source of data is the Compensation Research Database (CRD) which was held by the Institute for Safety, Compensation and Recovery Research (ISCRR). The CRD includes the details of all claims, payments, services, hospital admissions, and medical certificates for WSV since 1985. It is an administrative database that is fully de-identified, and consent to use data for research purposes is obtained from clients [
16,
17]. The selection criteria for claims included in this study are as follows:
Claims that had at least one day of wage compensation payment (standard time loss claims) with the injury date on or after the first of January 2010,
Claims that had physiotherapy services provided either by EP or RP,
Claims that had their initial physiotherapy consultation on or after the first of August 2014,
If claims resulted in RTW, only claims with RTW on or after the date of initial consultation were included.
According to the selection criteria, 17,991 claims were identified, from which 7363 claims were served only by the EP group, 3998 claims were served only by the RP group, and 6630 claims were served by a mix of EP and RP groups. To provide a better investigation of the performance of the EIPF program, the claims in the mixed group were excluded from further analysis.
2.2. Outcomes
Time to RTW is calculated as the number of days between the injury date and the resumed work date. Comparing this outcome between two groups allows for an analysis of the effectiveness of the EIPF on client RTW outcomes.
2.3. Analysis
Different data analysis approaches have been used to answer the research questions. We used descriptive statistics to comprehensively compare the differences between the EP and RP groups in terms of physiotherapy services provided to clients and time to RTW.
We performed survival analysis using Kaplan–Meier curves to estimate the probability of RTW in each time interval. Kaplan–Meier curves are commonly used tools to analyze ‘time-to-event’ data [
18]. These have been used widely in healthcare areas such as job survival of impaired employees [
19] and vision loss after Diabetic Vitrectomy surgery [
20]. In this study, we used the time to RTW in survival analysis.
We also used the log-rank test, which is a non-parametric test, to compare survival curves between two groups. The log-rank test, like the Kaplan–Meier curves, is used to compare two groups, e.g., treated versus the control group in a randomized trial. Also, the follow-ups can be divided into smaller time periods, and the number of occurrences within all time periods is compared. Similar to the Kaplan–Meier curves, the log-rank test should be used only when follow-ups are reasonably current. The log-rank test is limited to assessing the effect of just one variable at a time. A more complex method, such as the Cox model, should be considered for assessing multiple variables [
21].
We assessed the association between time to RTW and claimants’ characteristics as predictors using univariate regression analysis. These predictors are gender, age, type of injury, and occupation. We also used multivariate regression to determine whether there is a difference in RTW outcomes achieved after adjusting for variables that are significantly associated with the RTW outcome.
4. Discussion
The objective of this study was to describe the outcomes of an evaluation of the effects of the Early Intervention Physiotherapist Framework (EIPF) program on the return to work (RTW) outcomes for injured Victorian workers. The RTW outcomes were assessed three years after the initial implementation of the EIPF, and the effects on clients were examined in comparison with clients treated by physiotherapists not trained in the EIPF (RP group).
Within the examination period, comparing physiotherapists with EIPF training (EP group) to the RP group revealed the following results:
Physiotherapists in the EP group visited more WSV clients per physiotherapist (average of 10.2 claims) than those in the RP group (average of 4.6 claims) over the three-year period.
Injured workers returned to work on average 25 days sooner when treated by EP compared with RP. This could be a direct result of EIPF by motivating physiotherapists (EP group) for earlier post-injury intervention.
Survival analysis showed that the clients of the EP group returned to work significantly faster than the RP group. After two years, this difference became statistically significant, as shown by the log-rank test, confirming the necessity of a three-year follow-up analysis such as that performed in this study.
The time to return to work was significantly associated with age and injury type in both physiotherapy groups. Younger injured workers (between 15 and 24 years old) with fractures had returned to work faster, and the injured workers between 45 and 54 years old with musculoskeletal injuries had taken more time to get back to work.
After adjusting age and injury type variables, injured workers in the EP group still returned to work significantly faster than those treated in the RP group (by 21 days). These results show that the difference between these two groups was substantially associated with the early intervention by EP physiotherapists post-injury.
The results support the positive findings of the initial study [
12] on the EIPF program (3 months after initiating the program) in terms of adhering to EIPF goals and RTW outcomes.
Strengths and Limitations
The main strength of this study is the use of a well-structured and population-based dataset to evaluate the performance of the early intervention program. The findings result in an insightful conclusion on the important factors that affect RTW outcomes.
The main limitation of this study is that the data are for injured workers in Victoria, Australia. Therefore, the results cannot be generalized to every group of patients. The data we used in this study are administrative and payment data, which meant we relied on wage compensation to define RTW. Also, because the payment date for the physiotherapy services could be different from the actual date of receiving the service, the time to the first consultation session cannot be reliably calculated. Hence, we did not include this indicator in the analyses.
5. Conclusions
This evaluation has shown that three years after implementation, the EIPF resulted in positive outcomes for injured workers. More claims were managed by physiotherapists trained in EIPF than non-EIPF physiotherapists. The earlier intervention by physiotherapists (possibly within seven months after the injury) due to the incentives and the increased reimbursement provided by WSV for services led to a faster return to work and better outcomes for the injured worker.
The EIPF is achieving its aim of focusing on early intervention and sustainable return to work. Further monitoring of outcomes and performance will be important to ensure gains continue to be made on the time taken to the initial consultation post-injury, as it seems that any small improvement in this aspect can have a significant impact on the RTW outcomes of injured workers.
Further monitoring of outcomes and performance will be important to ensure gains continue to be made on the time taken to the initial consultation post-injury, as it seems that any small improvement in this aspect can have a significant impact on the RTW outcomes of injured workers. Early intervention programs and follow-up studies can be used in other allied health professions like chiropractic and osteopathy that play similar roles to physiotherapists in treating injured workers. In addition, the quality of the prediction by the conducted regression analysis can be investigated for future cases.