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Original Investigation |

Relationship Between Stressfulness of Claiming for Injury Compensation and Long-term Recovery:  A Prospective Cohort Study

Genevieve M. Grant, LLB, PhD1,2; Meaghan L. O’Donnell, PhD3,4; Matthew J. Spittal, PhD2; Mark Creamer, PhD3,4; David M. Studdert, LLB, ScD, MPH5,6
[+] Author Affiliations
1Faculty of Law, Monash University, Victoria, Australia
2Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia
3Australian Centre for Posttraumatic Mental Health, University of Melbourne, Victoria, Australia
4Department of Psychiatry, University of Melbourne, Victoria, Australia
5Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
6Stanford Law School, Stanford, California
JAMA Psychiatry. 2014;71(4):446-453. doi:10.1001/jamapsychiatry.2013.4023.
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Importance  Each year, millions of persons worldwide seek compensation for transport accident and workplace injuries. Previous research suggests that these claimants have worse long-term health outcomes than persons whose injuries fall outside compensation schemes. However, existing studies have substantial methodological weaknesses and have not identified which aspects of the claiming experience may drive these effects.

Objective  To determine aspects of claims processes that claimants to transport accident and workers’ compensation schemes find stressful and whether such stressful experiences are associated with poorer long-term recovery.

Design, Setting, and Participants  Prospective cohort study of a random sample of 1010 patients hospitalized in 3 Australian states for injuries from 2004 through 2006. At 6-year follow-up, we interviewed 332 participants who had claimed compensation from transport accident and workers’ compensation schemes (“claimants”) to determine which aspects of the claiming experience they found stressful. We used multivariable regression analysis to test for associations between compensation-related stress and health status at 6 years, adjusting for baseline determinants of long-term health status and predisposition to stressful experiences (via propensity scores).

Main Outcomes and Measures  Disability, quality of life, anxiety, and depression.

Results  Among claimants, 33.9% reported high levels of stress associated with understanding what they needed to do for their claim; 30.4%, with claim delays; 26.9%, with the number of medical assessments; and 26.1%, with the amount of compensation they received. Six years after their injury, claimants who reported high levels of stress had significantly higher levels of disability (+6.94 points, World Health Organization Disability Assessment Schedule sum score), anxiety and depression (+1.89 points and +2.61 points, respectively, Hospital Anxiety and Depression Scale), and lower quality of life (−0.73 points, World Health Organization Quality of Life instrument, overall item), compared with other claimants. Adjusting for claimants’ vulnerability to stress attenuated the strength of these associations, but most remained strong and statistically significant.

Conclusions and Relevance  Many claimants experience high levels of stress from engaging with injury compensation schemes, and this experience is positively correlated with poor long-term recovery. Intervening early to boost resilience among those at risk of stressful claims experiences and redesigning compensation processes to reduce their stressfulness may improve recovery and save money.

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Figure 1.
Determinants of Long-term Health Outcomes Following Injury

The boldface arrow indicates the relationship of interest. Nonbold solid arrows indicate baseline predictors of long-term health outcomes. Dashed arrows indicate predictors of stressful claims experiences.

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Figure 2.
Health Status Differences Between Stressed and Nonstressed Claimants at 6 Years After Injury

Y-axes describe stressors in the compensation process. X-axes are based on the relevant scale for each outcome measure. The point estimates (symbols) and 95% confidence intervals (error bars) represent differences between highly stressed claimants and all other claimants. Where confidence intervals cross zero on the x-axis (dotted vertical line), there is no statistically significant difference between high-stress claimants and other claimants. All estimates come directly from coefficients in multivariable regression models (1 per point estimate).

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Figure 3.
Predicted Health Status for Individuals With Low, Median, and High Levels of Claim-Related Stress

The combined stress measure is the sum of the 6 stressors, each scored from 0 to 5. Low, median, and high are defined as the 10th, 50th, and 90th percentiles of the combined stress measure. A, Disability, measured on a scale of 0 to 48; B, overall quality of life, measured on a scale of 1 to 5; C, anxiety, measured on a scale of 0 to 21; D, depression, measured on a scale of 0 to 21.

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