Abstract
Objective: In patients with mild traumatic brain injury (MTBI), to assess: (1) changes in financial compensation-seeking status over time and (2) the relationship between compensation-seeking and return to work.
Design: Longitudinal evaluation of financial compensation-seeking status (i.e., at intake, 3 months postinjury, and 12 months postinjury) and relationship of such status to return to work.
Setting: Outpatient rehabilitation clinic.
Subjects: Ninety-seven patients with MTBI.
Main outcome measures: Compensation-seeking status at 3 and 12 months and days taken to return to preinjury vocational activity.
Results: Those in litigation at intake generally continued to be in litigation at 3 and 12 months postinjury. Those seeking or receiving compensation via administrative means (e.g., sick pay or workers' compensation) at intake were generally not seeking or receiving compensation by 3 months or later, as was the case for most of those not seeking any financial compensation at intake. Patients seeking or receiving financial compensation via litigation and/or administrative means at intake took longer to return to work than did people who were not seeking or receiving compensation at intake.
Conclusions: The present study design does not allow for determination of the reasons for the strong relationship between financial compensation-seeking soon post-MTBI and a slow return to work. However, the strength of the present findings indicates that the presence or absence of financial compensation-seeking soon post-MTBI should be routinely evaluated when return to work is an issue.
SUBSTANTIAL RESEARCH has shown a relationship between financial compensation-seeking and greater likelihood of a poor outcome after mild traumatic brain injury (MTBI). In a meta-analysis of the relationship between financial incentives and outcomes after traumatic brain injury, Binder and Rohling 1 reported a moderate effect size (ES = 0.47) for financial incentives across multiple studies and dependent variables, using patients with varying TBI severity. Patients with financial incentives scored more poorly than those without such incentives, by an average of almost one-half of a standard deviation, on outcome variables such as symptom reports, neuropsychologic test scores, clinician ratings, or return to work. The effect size was even stronger when only patients with MTBI were compared with other groups, suggesting that the former were particularly likely to have poor outcomes when financial incentives were present. Binder and Rohling concluded, in part, that secondary gain must be considered in every case of mild closed head injury and that, absent financial compensation, some patients would have fewer problems and some patients' problems would be eliminated. They added that severe cognitive deficits many months after a mild head injury, in the setting of financial incentives for illness behavior, raised the possibility of malingering or other nonorganic explanations.
That being said, the reasons for the strong relationship between financial incentives and worse outcomes, across a variety of disabilities, has been the subject of substantial debate in recent years. 2-5 Potential explanations have ranged from patient malingering 1 to insurance companies' failure to provide adequate treatment. 3 Regardless of their conclusions, researchers evaluating compensation effects after MTBI have generally taken a cross-sectional approach to studying compensation seeking and outcome, by comparing groups of individuals at a single point in time. We are aware of no longitudinal studies assessing change in compensation-seeking status over time after MTBI, or assessing the relationship between such changes and work status. Longitudinal research can provide information about the progression of compensation-seeking behavior after a MTBI, as well as associated changes in functioning (e.g., return to work).
The Binder and Rohling meta-analysis 1 assessed the relationship of various outcome measures to all types of compensation-seeking (e.g., disability pay, workers' compensation payments, litigation). However, the experiences people have with each of these compensation-seeking or receiving processes can differ substantially. For example, taking a few days of sick leave after a MTBI is likely a substantially different experience than going through a lengthy and adversarial personal injury litigation process. We are aware of no research assessing varying outcomes across different types of compensation-seeking. Given the strong overall association of compensation seeking with poorer outcomes after MTBI, it is a logical next step to determine if various types of compensation-seeking differ in strength of association with poor outcomes.
Because of the particularly strong association noted by Binder and Rohling between MTBI (as opposed to moderate or severe brain injury) and poor outcomes when financial incentives are present, the current study focused on MTBI. We longitudinally assessed compensation-seeking/receiving and return to work status of patients with MTBI at intake, 3 months postinjury, and 12 months postinjury. The first goal of this article is to assess duration of, and changes in, compensation-seeking/receiving behavior, specifically comparing (1) MTBI survivors seeking/receiving compensation through litigation with (2) those seeking compensation through administrative means (e.g., sick leave or disability), or (3) not seeking or receiving compensation at all. Our second goal was to determine the relationship between different types of seeking/receiving compensation, and return-to-work status. Because no previous research has compared compensation-seeking duration between litigants and administrative seekers, we hypothesized that there would be no significant differences on this variable. We also hypothesized that compensation-seeking/receiving would generally correspond to longer times to return to work than would not seeking or receiving compensation.