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Return to work may be easily monitored as a surrogate of long-term functional outcome for benchmarking and performance improvement of trauma systems. We hypothesized that employment rates among survivors of traumatic brain injury (TBI) decrease following injury and remain depressed for an extended period of time. Data were obtained from a statewide surveillance system of 3522 TBI patients (aged >15 years) who were discharged alive from acute care hospitals and followed yearly using telephone interviews (1996–1999). The study population consisted of patients with severe TBI (head abbreviated injury score 3, 4, or 5) and complete follow-up for 3 years postinjury (n = 572). Patients were mostly young males (43 ± 19 years, 65% male) with blunt TBI (92%). The preinjury employment rate was 67%, which declined to 52% (P < 0.001) in the first year and slowly rose in subsequent years but never reached the preinjury level (54% in year 2, P < 0.001; 57% in year 3, P = 0.001). Increasing severity of TBI was associated with a lower employment rate. Patients who remained employed worked the same number of hours as they did before the injury (47.8 ± 10.5 hours). Female employment rates rose similar to rates for males. However, women who were employed full-time before TBI were more likely to work part-time after TBI than men (50% vs 24%, P < 0.001). In conclusion, survivors of severe injury do not attain preinjury employment levels for several years. Once validated in other studies, postinjury employment may be used as an indicator to monitor functional outcomes in trauma registries.
Traumatic brain injury (TBI) is a leading cause of death and disability in trauma patients, with approximately 2% of the US population (5.3 million) living with TBI-related functional deficits (1). So far, trauma centers have focused on risk-adjusted survival rates as a measure of their performance (2). Recently, there has been an increasing interest in the trauma community to develop a set of quality indicators to determine outcomes of trauma patients other than survival alone (3). This coincides with a 1998 consensus statement of the Institute of Medicine identifying the need to broaden the domain of performance measures by developing outcome measures that go beyond immediate morbidity and mortality to include various measures of functional status (4). Functional status is an important determinant of quality of life of patients, but it is inadequately measured by existing trauma registries. Some centers capture functional status using measures such as Functional Independence Measure scores at discharge from acute hospitalization (5, 6). However, little is known about the functional status of trauma patients in the weeks, months, and years following discharge from acute hospitalization.
There are several measures of functional status, such as the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), Sickness Impact Profile, Quality of Well-Being scale, Health Utilities Index, and EuroQol (7, 8). However, most of these measures require instruments that are long and cumbersome, require several minutes to more than an hour to complete, and require additional training before they can be used (9). Hence, there is a need to identify a simple, easy-to-use measure that can be used repeatedly to monitor patients' functional status. From patients' perspective, return to employment after injuries has been shown to be a valued long-term indicator of quality of life (10). Employment is important not only for earning a livelihood, but in our society, for determining access to health care, social support systems, and self-esteem. Lack of employment also has ripple effects on patients' family members through loss of income, interpersonal relationships, and interactions with society at large. From society's perspective, return to employment after injury has significant economic benefit. The lifetime cost of injuries to society is estimated at $406 billion per year, almost 80% of which is related to lost productivity (11).
Long-term TBI surveillance projects, such as the Traumatic Brain Injury Model Systems and the Centers for Disease Control and Prevention's (CDC) Traumatic Brain Injury Surveillance Program, routinely collect information on employment status before and after injury. It is an indicator of quality of life and long-term functional outcomes, which can be measured repeatedly by asking a few questions of the family or the caregivers. However, the topic of the long-term impact of TBI on postinjury employment has received scant attention in the trauma community. We hypothesized that employment rates among survivors of TBI decrease following injury and remain depressed for an extended period of time.
The Colorado Department of Public Health and Environment started a population-based statewide surveillance of all TBI-related deaths and hospitalizations to determine their long-term postinjury outcomes (12). This project was funded by the CDC in 1995 as the Colorado Traumatic Brain Injury Registry and Follow-up System. This registry contains 3522 adult (aged >15 years) residents of the state of Colorado who were discharged alive with TBI from an acute care hospital between the years of 1996 and 1999, of whom 2771 were eligible for at least 3 years of follow-up. Data were collected from hospital records as well as through telephone interviews with the patients yearly on the anniversaries of their injury until 2001. The inclusion criteria for the current study consisted of patients with severe TBI (defined as head abbreviated injury scale 3, 4, 5) who had complete follow-up for 3 years after TBI. These criteria identified 572 patients who constituted the study population.
Employment status was determined through self-report. Full-time employment was defined as at least 40 hours of work per week. Less than 40 hours worked per week was defined as part-time employment. Employment rates were calculated for each postinjury year and compared with the preinjury rate. Results are presented as mean ± standard deviation and percentages, with P value < 0.05 considered significant for all statistical analyses. Statistical software SPSS (SPSS Inc., Chicago, IL) was used for all statistical analyses.
The study population consisted of 572 patients; their mean age was 43 years, with 65% males. The most common cause of injury was motor vehicle accidents. Among the population, 381 (66%) were employed before they were injured. As shown in Table Table11, the employment rate in the first year after injury declined to 52% and rose slowly in the subsequent years, but did not reach preinjury levels. When considering only those patients employed at the time of injury, 31% lost their jobs the first year following injury. Of the people who lost their jobs, only 40% found employment in subsequent years. Loss of employment after injury correlated with severity of head injury: patients with more severe head injuries were more likely to lose employment. Women were less likely to be employed before injury and lost employment in the years after injury at a rate similar to their male counterparts. Patients in the older age groups were more likely to lose employment. Those in the most productive age groups of 25 to 64 years sustained the most dramatic loss of employment the first year following injury. Unemployment levels in these age groups, 25 to 44 and 45 to 64 years, remained statistically significant (P < 0.05) throughout the study period.
Of those employed before injury, 23% were employed part-time and the remainder full-time. Women who were employed full-time prior to their injury were more likely to be employed part-time by year 3 than the men (38% vs 10%, P < 0.001). Patients who remained employed after injury worked the same average number of hours after their injury as they did before they were injured (Table (Table22).
Patients who were employed 3 years following their injury were significantly more likely to have health insurance than the unemployed patients (96% vs 86%; P < 0.001).
Our study demonstrates that severe TBI has a significant long-term impact on patients' ability to gain and retain employment. Several years after sustaining TBI, the employment rates remained well below the preinjury level in TBI patients and likely had a significant adverse impact on the quality of life of patients and their families. Similar findings have been demonstrated earlier and underline the importance of following long-term outcomes of injuries (13). According to the CDC, approximately 1 in 4 adults with TBI is unable to return to work 1 year after injury (1). Several factors may hinder a patient's ability to return to work after TBI. These include severity of injuries, age, education, occupation, preinjury income, presence of a social support network, and marital status (13–16). The study findings are consistent with previous work demonstrating that younger patients who were employed before injury are more likely to return to work than those over 45 years of age (13, 17). Return to work is also influenced by type and severity of TBI and the resultant motor and cognitive deficits. MacKenzie found return-to-work rates of 57%, 57%, and 29% at 12 months for head abbreviated injury scores of 3, 4, and 5, respectively (14). When the Glasgow coma scale was used to classify mild, moderate, and severe injury, return-to-work rates have been shown as 86%, 79%, and 59%, respectively (15). Again, these reports are consistent with our findings.
The relative importance of factors that may influence a patient's ability to return to work likely vary from individual to individual, and some are clearly beyond the realm of clinical care. However, it is an important functional outcome, especially from patients' perspective, and has been reported as one of the most important determinants of quality of life and life satisfaction (10, 18–21). Inability to obtain employment may have significant consequences on all aspects of patients' lives. For example, employed patients were more likely to have health insurance, and loss of health insurance due to loss of employment has serious implications (22–24). Furthermore, unemployed persons are more likely to divorce, become homeless, lack access to health care, suffer from social isolation, become victims of crime, develop mental health problems, fall into drug and alcohol abuse, and get injured again (23, 25–27). So far, these consequences of TBI have largely gone unnoticed and unmeasured by society. The trauma community has long focused on a singular outcome, survival during acute hospitalization. However, a clear objective of organized systems of trauma care is to return the injured persons to their preinjury status in society. Our study identifies employment as an important measure of long-term functional outcome that can be identified and tracked to assess patient recovery from injury. Hence it may be used as a yardstick to measure quality of care within a trauma system. The multifactorial nature of this outcome will require trauma centers to work closely with other stakeholders in society, such as employers, insurers and other third-party payers, and families, to enable patients to return to work after sustaining TBI. These efforts may include an early and aggressive focus on rehabilitation, job retraining, workplace reconfiguration to accommodate workers with disabilities, and expanded insurance coverage for long-term rehabilitation services.
The nuances of employment—such as the type of job, part-time versus full-time, occupation, and pre- and postinjury income—will need to be addressed before adopting postinjury employment as a routine outcome measure. For example, a surgeon who is unable to operate after sustaining TBI but is able to see patients in an outpatient clinic represents a significant decrease in productivity for the individual and society. In such a situation, “return to work” by itself is not a sensitive enough measure of this loss. However, even with additional details related to postinjury employment that will need to be collected to adequately determine return to work status, this measure may still be simpler and quicker when compared with other instruments such as the SF-36, Sickness Impact Profile, Quality of Well-Being scale, Health Utilities Index, and EuroQol.
Our study has a few limitations. A large number of patients were excluded due to missing data and incomplete follow-up. It is unclear how patients who were lost to follow-up were different from the ones with complete follow-up in terms of employment status. It appears likely that patients who were unemployed were less likely to be followed. Hence, the estimate of employment rate in our study is likely to be inflated, which will strengthen our conclusions. Furthermore, in our study, only 51% of the sample was employed full-time prior to injury. This figure appears low when compared with other studies, such as MacKenzie's 1998 study in which 75% of the study cohort was employed full-time prior to injury (4). In any event, this is a large series of patients with long-term post-TBI employment outcomes. Another limitation is that the type of employment was not known, which makes it difficult to estimate if patients were able to return to their preinjury jobs or if they needed to change the type of work, move to a different position, or move to a different employer. Also, it is not known if their wages were affected by TBI. Our study shows that patients who were employed after TBI were able to put in the same number of hours as before TBI, but we do not have any data on their wages. MacKenzie demonstrated that the receipt of replacement income, especially workers' compensation, was associated with lower rates of return to work. Our study is limited by incomplete data on the receipt of replacement income such as workers' compensation (28). Also, employment status may not be a useful measure of functional recovery and quality of life in patients who are not employed before the injury. The study also relies on self-reporting with no external validation of data. We did not exclude patients who turned 65 years during their follow-up as these people might have retired anyway. Finally, in the absence of any other measure of functional status, it is hard to explain if the loss of employment was due to physical deficits, cognitive deficits, or other reasons. Further studies are warranted to delineate factors associated with failure to return to work in this patient population.
In conclusion, this study demonstrates that survivors of severe injury do not attain preinjury employment levels for several years afterwards, which is likely to worsen their quality of life. Postinjury employment status is an important functional outcome that can be measured and monitored over time and should be incorporated in trauma registries.