Beyond symptom resolution: insurance case manager’s perspective on predicting recovery after motor vehicle crash

Abstract

Purpose

Insurance company case managers can play a critical role in the rehabilitation process of people with musculoskeletal disorders sustained following minor motor vehicle crash injury due to their interaction with multiple stakeholders and their role in approving various services. This study aimed to identify factors that case managers perceive as predictive of recovery in people with musculoskeletal disorders after minor motor vehicle crash injury.

Materials and methods

To explore the perspectives of cases managers in Australia and the United States, semi-structured interviews explored factors that case managers thought provided an early indication of likely recovery outcomes in people with musculoskeletal disorders after minor motor vehicle crash injury. A framework analysis was applied and factors were displayed within the ICF-framework.

Results

Case managers (n = 40) demonstrated a broad, detailed understanding of biopsychosocial and contextual issues influencing recovery. They emphasized the importance of the injured worker’s expressed affect and motivation, style of communication, the role of lawyers, the worker’s family and friends, as well as cultural and geographic influences. The overarching themes perceived as having a major influence on recovery outcomes were general health, pain processing and response, work situation, and compensation entitlement.

Conclusions

Case managers’ broad and detailed perceptions about recovery may provide additional, valuable perspectives for professionals involved in the rehabilitation process of people with musculoskeletal disorders after minor motor vehicle crash injury. Further research needs to be conducted to explore the effects of case manager involvement in the process of recovery.

Implications for rehabilitation

• Insurance Case Managers identified multiple factors including affect and motivation, style of communication, the role of lawyers, family and friends, cultural and geographic variation provide opportunities for more effective treatment of people with musculoskeletal disorders related to minor motor vehicle collisions. These managers’ perceptions about recovery may be informative to and provide opportunities for health professionals involved in the rehabilitation of people with musculoskeletal disorders related to minor motor vehicle collisions.

• While the Insurance Case Managers involved in this research did not use formalized assessment techniques, tools and assessment protocols could be developed jointly between for the needs of Insurance Case Managers and other stakeholders to tackle recovery of people with musculoskeletal disorders related to minor motor vehicle collision.

Keywords:

• Motor vehicle crash
• injury
• case management
• claimant
• compensation system
• whiplash

Introduction

Injuries associated with motor vehicle crashes are a major cause of burden for individuals and society [1]. Globally, road crash-related injuries are ranked twelfth in terms of contribution to Disability Adjusted Life Years [2]. The most frequent injuries following road crashes are musculoskeletal disorders related to minor motor vehicle collisions (MSD-MV) [3]. These injuries include contusions, skin abrasions, lacerations, sprains and strains including whiplash-associated disorders (WAD) as defined by the Ontario Minor Injury Guideline [4]. While MSD-MVs are defined as nonpermanent and less incapacitating, they can be traumatizing and debilitating [3,5]. MSD-MV can have a long-term impact on physical and mental well-being, health-related quality of life and employment [3,6].

People who recover poorly generate the majority of costs associated with MSD-MV [7,8]. There is growing evidence that health and social outcomes following MSD-MV are primarily related to the cognitive and psychosocial responses of the injured person, the interaction between the injured individual and the social, medical and legal systems they experience following an injury [9,10]. Understanding and improving these interactions early in the recovery process may be crucial to reduce the burden of MSD-MV for the individual and society.

The USA, among other Western countries such as Australia, has a complex and fragmented network of legal arrangements for the provision of financial support and health care services for those affected by MSD-MV, that varies by jurisdiction within the country [11]. Despite this diversity, claims management (also known as injury management or case management) is a critical component in all injury insurance systems. Case managers (CMs), also known as claims managers or adjusters, are the primary interface between the person with an MSD-MV and the insurance system’s coordination of benefits, ultimately charged with achieving optimal outcomes and controlling costs. While their role and competencies may vary in the different countries, CMs relationship with the injured person may often be much longer than the duration of interaction with any health care provider – it starts very soon after the event and may continue for years until claim resolution. Though, delayed treatment and payment approvals may hamper that relationship [12], based on their longitudinal familiarity with the hundreds of cases they manage each year, CMs represent a unique source of information on early predictors of recovery outcome. Additionally, their perspective is broader than most health care providers, because they interact with more of the key persons involved in the injury – including injured person, various health care providers, attorneys and family.

Little is known about the perceptions of claims managers about predictors for recovery after MSD-MV, despite their close interactions with injured persons and observation of outcomes over time. A few qualitative studies have collected information from CMs, but have focused on insurance processes, their role commitments, or satisfaction and stressors in their jobs [13]. The importance of the CMs role is supported by one study showing that interventions to improve satisfaction with CMs-injured person interactions led to improved outcomes – less prolonged pain, lost work time, costs and litigation [14]. These findings are remarkable because attempts to improve outcomes in MSD-MV through early education, medical care, counseling and rehabilitation have not been very successful [15,16].

Thus, insights and experiences of CMs offer a unique perspective on the relationship between predictors, interventions, and outcomes in MSD-MVs. Integrating their experience with evidence-based informed knowledge about prognostic factors may potentially enhance the treatment and recovery process, and ultimately improve both satisfaction and outcomes. Hence, the aim of the study was to explore factors that insurance case managers perceive as predictive of recovery in people with musculoskeletal disorders related to minor motor vehicle collisions.

Materials and methods

This study was embedded in a larger study performed in Australia and the US which aimed to study CMs perceptions about recovery and treatment of persons with MSD-MV.

Participants

CMs were recruited from two insurers in the US operating in the same site and one in Australia. All worked exclusively within a motor vehicle collision compensation scheme, covering a total of five different jurisdictions. Each of these insurers employs in-house claims-management staff. All participants were directly responsible for managing motor injury claims, including interactions with injured persons. The first interactions with injured were usually through telephone calls and email and/or letter correspondence with the injured person. However, direct communication between CM and injured persons may have been restricted in those cases where a lawyer was involved during the course of recovery. CMs were included if they had been employed in their current position within their respective compensation schemes (not necessarily at the same company) for a minimum of 2 years (ideally managing a wide range of claims) and also held a senior claims manager position. CMs in a more junior position at these locations were only included if they had extensive experience in a similar role (e.g., >10 years).

Context

Participants in Australia were managing claims in a motor vehicle injury compensation scheme that is largely “fault” based. This means that compensation can be sought for injuries sustained when the injured person is deemed not to be at fault in causing the crash. Participants from the US managed claims from four different state no-fault schemes, where medical care and compensation were not linked to determinations of fault, for the most part. In both Australia and the United States, the insurance schemes provide coverage for health care following injury and the CMs have responsibility for approving payments for healthcare. Details about the insurance schemes can be found in Supporting Information Table S1.

Table 1. Participant demographic characteristics.

Characteristic	USA n = 20	Australia n = 20	Total N = 40
Age (Median, IQR)	46.5 (42–55)	35 (28–44)	42 (32–51)
Gender, female (n, %)	17 (85)	16 (85)	33 (82.5)
Hours worked per week (Median, IQR)	38 (38–38)	37.5 (33–38)	37.8 (32–50)
Experience as CM, years (Mean, SD)	14.5 (6.2)	7.6 (5.7)	11.1 (6.8)
Handling claims from various states (Yes, %)	9 (45)	0 (0)	9 (25)
Health care profession background (Yes, %)	1 (5)	9 (45)	10 (25)
Highest educational qualification (n, %)
Professional Diploma, Certificate	8 (40)	0 (0)	8 (20)
Bachelor	8 (40)	14 (70)	22 (55)
Post graduate	4 (20)	6 (30)	10 (25)

Procedure

Given that we wanted to interview experienced CMs of varied ages and genders, a purposive sampling technique was used. A key person within each company assisted with recruiting participants. Participation was voluntary, and management permission to participate in confidential interviews during work hours was obtained in advance. The companies employing the CMs did not influence the nature or scope of interviews and did not have access to any individual results. One-on-one semi-structured interviews lasting between 45 and 60 min were completed by one interviewer in each country (MT, KL). The issue of saturation was regularly discussed during project-progress meetings. The research team made a joint decision to discontinue sampling when the interviewers reported feeling that they were no longer accessing new information.

Questions were centered on factors believed to be good or bad for recovery, especially what was most important early on in the claims process. The typical question was:

What are the things that give you an indication, early on, that a person will recover well or that recovery will be delayed?

As a formal and universally accepted definition of ‘recovery’ has yet to emerge, we used the following concept based on a rehabilitation and clinical perspective: “recovery as remission of symptoms and restoration of functioning” [17]. The CMs were presented with this operationalization, and during the pilot phase, their views on recovery were discussed to assure that it was consistent with this formulation across interviews. The interview guide including the socio-demographic items are described in the Supporting Information Table S2.

Six pilot interviews were video and audio recorded for the purpose of training, adherence, and peer-review. The interviews were reviewed by a third researcher (AY) experienced in qualitative interview research who was not involved in the interviews. Based on this review, adjustments were made to the interview procedure and interview pro forma. The terms “recovery” used in the research question, appeared to not be a source of ambiguity and participants were consistently able to answer with their personal perceptions on topic.

Approval of this study was obtained by the appropriate ethical/human subjects committee for each participating study location (New England Institutional Review Board, USA and Northern Sydney Local Health District, Ethics Committees, AUS).

Data interpretation and presentation

Transcripts were coded using the conceptual framework afforded by the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) [18]. The ICF describes functioning as the interplay of body functions, body structures, activities and participation, environmental and personal factors and provides a taxonomy that includes component and second-order codes [18,19]. Previous researchers conducting qualitative investigations of injured persons’ functional problems have used the ICF, and it has been found to accommodate most patient articulations [20–22]. Although the ICF has proven useful, it has been found that some meaning is not captured through the application of the ICF to develop a coding structure [20]. Therefore, while data is presented within the overarching ICF framework and interpreted referencing existing codes, if the application of an existing code resulted in a loss of meaning, a code was not applied. Instead, a descriptive emergent code was developed and applied. This approach is consistent with ICF-supporting material, which states that the ICF should be considered as a building block and applied according to the needs of the user depending on their creativity and scientific orientation [18]. So as to ground our interpretations [23], representative quotes were chosen to reflect observed themes. (Note: ID codes (e.g., US1) are provided following quotes. These can be referenced in Supporting Information Table S3 to obtain the relevant participant’s demographic information. In some cases, quotes were edited to improve readability).

Six researchers were involved in the analysis of the interviews (the personal characteristics of the researchers are displayed in Supporting Information Table S4a). The interviewers (XX, XY) independently and then collectively reviewed a subset of transcripts. Through a process of constant comparison, codes were scrutinized for similarities, differences, and linkages. After this process, the codes were clustered according to various topics and then thematically grouped. Disagreement on coding was resolved by a third researcher (AY) who has experience with this methodology, and in the case of remaining uncertainty, were resolved by consulting with the other researchers (GP, NE, IC). The data was summarized – “charted” – from each transcript. Sample coding was reviewed by all researchers using a multistage procedure based on the framework analysis method [24]. The framework analysis included the following seven steps: transcription, familiarization with the interview, coding, developing a working analytical framework, applying the analytical framework, charting data into the framework, interpreting the data. Regular telephone conferences were held to discuss the results with all the involved researchers. We followed the recommendations of CORE-Q Checklist (COnsolidated criteria for REporting Qualitative research) displayed in Supporting Information Table S4b.

Results

Forty-one CMs were invited to the interviews. One CM was excluded because the person did currently not have direct (verbal or written) interaction with injured persons. Thus, data from 40 interviews were analyzed. Demographic and professional characteristics of participants are summarized in Table 1 and more in detail in Supporting Information Table S3. The CMs generated a large number of issues that they felt were related to prognosis for recovery, both good and bad, that were categorized by the major ICF headings: health condition, body functions and structures, activities and participation, environmental factors and personal factors.

Health condition

CMs thoughts on the predictive value of injury severity information were mixed. Some CMs felt that more severe injuries such as fractures were associated with worse outcomes. However, others reported the opposite: that moderate injuries seem to have better outcomes compared to minor soft tissue injuries (e.g., sprains of the back or neck). Others thought that injury severity was not highly indicative and that other characteristics played a more important role in predicting an outcome. As expected, pre-existing health conditions were seen as negative prognostic factors.

Yeah, and they can be diabetic. That sometimes depending on the injuries, that’s a health thing, that’s a slow recovery regardless (US13).

Body functions and structures

Body structures, that is, anatomical parts of the body such as organs, limbs and their components [18] were not specifically mentioned by CMs. However, at a general level, better physical and mental health and fitness were predictive of better outcomes.

If somebody is mentally and physically in good health they’re going to recover a lot quicker than someone who is either depressed or not in good physical health (US1).

Mental functioning, including emotional functioning, as well as attitudes and beliefs were spoken about in more detail. CMs felt that if the injured person was emotionally positive or neutral in regards to their injury, saying they feel better today than they did yesterday, not angry that the accident has occurred, then this was a positive predictor for recovery. If injured persons thought that their injury would greatly impact their lives, this was viewed as a negative sign.

I'm not going to be able to take out my garbage, and I don't know who's going to take my kids to school”. You could tell. You could follow that conversation – you know it’s going down a different path (US4).

Positive coping strategies were consistently viewed as positive predictors, in contrast to catastrophizing and feelings of distress and pain.

If they talk about that they are constantly in pain and can’t do anything, then that’s a very, to me, things won’t sort of go so smoothly. They [claimants] believe that pain is harm for a soft tissue injury, and so they then stop moving (AUS19).

Negativity around RTW, including statements such as “I’m not going to go back to work for ages”, was seen as a negative sign. Conversely, expressed motivation to RTW soon after injury was viewed as a positive predictor.

You can tell by their, "I've gone back to work. I've still got a bit of niggling pain." "Okay. Well, we can do something about that. You’ve gone back to your normal duties?" AUS4).

Activities and participation

The ability to execute particular tasks or actions (or activities as defined by the ICF) was not commonly spoken about by the CMs. However, the level of engagement in activities performed within the context of everyday life (i.e., participation as defined by the ICF), particularly work, family and leisure activities, was seen as an important predictor.

So they generally get on with life, and they see the doctor when the pain or symptoms haven't gone away after two, three weeks; it could be a month. […] They're back at work, more or less, shortly after the accident has happened (AUS1).

Employment was generally seen in a positive light, although high levels of work stress and limited job satisfaction were negative predictors. If people remained off work and dependent on others, this was seen as a bad sign.

People who might call and will say, "Well, you know, this injury is going to have me out several months from work," that would be a red flag because they're already telling you they don't plan on going back to work for quite some time (US20).

If the injured person’s work was perceived as highly demanding physically or psychologically, this was seen as a predictor of delayed recovery.

Disability support workers, age care workers, nurses, teachers, police officers, anything with a high stressful job, they tend to claim, and there tends to be usually preexisting. […] I see a disability support worker coming, you just know it's going to be there for a very long time (AUS17).

There were cases where the CMs thought that having more domestic responsibilities might be either enhancing or detrimental to recovery.

If it’s a claimant who has children or a spouse, they tend to recover a little bit faster because there are things going on in their daily home life that they have to do. […] They have to manage it. And I think sometimes that’s a detriment to them because they don’t get the treatment that they need (US19).

If injured people were communicative, open and honest, this was viewed as a positive sign (e.g., US13). Communication that was vague, guarded and involved the extensive use of jargon was viewed as a bad sign.

In the early conversations, if they're directing you back to their solicitor or, "Speak to my solicitor," or, "I don't want to comment on that." I guess that gives the indication that maybe they're not here for, you know, they're not in the claim for recovery or for rehabilitation (AUS15).

Environmental factors

Environmental predictors of recovery included accident and treatment characteristics, as well as features of the workers’ physical, social, compensation and legislative environments. Minor vehicle damage was predictive of recovery difficulties, especially in the context of claims for multiple injuries.

It's a very light impact to the car, and the person is claiming all sorts of injuries. That's a red flag (US20).

Treatment issues also featured prominently. Case managers talked about “dimensions of treatment”, including timeliness, having an effective treatment plan and amount of treatment (primarily overtreatment). Inappropriate diagnostic tests, especially imaging, were identified as negative factors.

The reason I don't put their doctors in that first conversation is their doctors may actually be facilitating there being a major barrier to their health and recovery by sending them off for an MRI or physio[therapist] just as a blanket treatment plan (AUS14).

Treatment that focused on activity, reassurance, and independence was viewed positively (e.g., AUS15). Conversely, treatment plans reinforcing rest and dependency on treatment were viewed as a bad sign.

I think encouraging active exercises […] Too often we're seeing GPs restrict them from activity or prevent them from going back to work, even [for those] who just have some neck symptoms. And a lot of the time when I do get on the phone to the injured person, they're surprised to hear, "Oh, really? I can be still doing sport? I can be? Oh, my GP never said that." I'm thinking the GP is holding the person back unnecessarily (AUS15).

Case management was identified as potentially both a positive and negative prognostic factor. CMs saw an early response and communication by CMs as a factor predicting faster recovery (e.g., AUS4). Delayed communication and claims processing were seen as bad signs.

Yeah, if they've waited six months, […] to lodge the claim, and they haven't sort of bothered sort of going and seeking out any treatment, then it's a real concern (US6).

The injured person’s geographic location was also referenced. CMs from the USA cited specific geographic regions where inappropriate or excessive treatment was more likely. According to the CMs, it appeared that in these regions there was a high density of lawyers which together with HCP encourage the use of bad and excessive treatments.

[…] so Brooklyn, Bronx, you'll have more of the little fender bender accidents that people require much more treatment than, say, somebody upstate that lost control and went into a ditch, and their vehicle rolled. It's definitely different (US16).

Cultural factors in the workplace were more often cited as predictive of recovery than physical environment features. In particular, good employer support was viewed as predictive of a positive outcome.

If their employer is supportive and they get along with their employer, then they are more willing to give it a go and go back to work (AUS14).

The injured person’s level of workplace engagement was also spoken about.

Also if the claimant is happy with their job, they’re more willing to, I guess, go back to work (AUS14).

A social network i.e., family and friends that was encouraging was viewed as a good sign, as long as it did not support adopting a sick role.

I guess having a support network in place. Often if people don't have good social network or family support that can be an indication that recovery might be slow. (…) [However] When there's support at home from, let's say the spouse or from other members of the family, it's not necessarily a good thing because especially with different cultures, there could be a lot of people encouraging rest and that sort of stuff (AUS15).

Financial support and reimbursement, particularly with reference to returning to work were mentioned as a prognostic factor.

You need to look at what they are the gaining from not working. […] If people have income protection, things like that, quite unconsciously, there’s not the same mindset and need to get that remuneration (AUS21).

In cases where the injured person was at fault, this indicated a better prognosis.

It was her fault. She totaled the vehicle. But, of course, she wasn't injured because it was her fault (US8).

Lawyer involvement was consistently mentioned as a negative predictor.

A solicitor [lawyer] involvement is the biggest [barrier] because they act counter to recovery. It’s not financially helpful to recover (AUS19).

Personal factors

Personal factors encompassed demographic characteristics including age, education, socioeconomic status (SES), occupation, prior compensation claims history and cultural background, as well as knowledge of their injury and recovery processes. A number of the CMs talked about how the injured person’s age could give an indication as to likely outcome. Some spoke about how advanced age may be a positive predictor, but others indicated that advanced age may predict delayed recovery.

A lot of older people, like I'm going to say mid-60s and up, are reluctant to get medical care […]. I've had older men say that to me, "I've had a lot of pain in my life. This is nothing” (US17).

Age wise, I think with elderly people you would expect their recovery to take a bit longer as well. So even like for minor whiplash, they probably still have ongoing symptoms for like quite a few months (AUS14).

CMs from both the USA and Australia felt that those with a higher SES would be more likely to go back to work.

I think, but I'm not sure, that sometimes college-educated are more determined to get back to work, with their lives (US20).

I found like high-income earners, they’re probably willing to go back to work earlier (AUS14).

Prior claims, especially for similar types of injuries, or multiple claims were viewed negatively.

[…] if they have a lengthy sheet of previous accidents, because then it kind of is an indicator that they might know or are familiar with no-fault processes, what they can do to possibly build their bodily injury settlement (US13).

The injured worker’s cultural background was also spoken about as indicative.

I do find that there are some cultures where the female in the family is the household worker. They do everything around the house except for mow the lawns. But they’ve also got a full-time job. And once they get injured and they’re off work and they’re unable to do their household duties, it’s an experience they’ve never had before. And they can get to like it because they’re getting a break finally (AUS12).

More knowledge and personal understanding of the injured person about his/her injury and recovery process was viewed as predicting faster recovery (AUS21). Conversely, if the worker was not informed, CMs saw the potential for them to take treatment paths that may not result in the best outcomes.

For me, the people that have gone to have a lot of massage sessions are the ones that often [experience difficulties] – just because I feel like some people might not understand injuries well, and they're not getting the education that they might need. So the people that are going to have a massage, it helps them for that day. And then it gets worse in another few days (AUS13).

Discussion

Study participants demonstrated a broad and detailed understanding of key biopsychosocial and contextual issues influencing recovery after minor motor vehicle crash injuries. Their observations were consistent with prior scientific studies on prognosis, encompassing a wide range of factors, and insights about the nuances associated with several predictors.

As it relates to claimants’ health condition, CM’s perceptions about the predictive value of information on injury severity reflect the challenges in defining and operationalizing severity for injuries that often lack objective clinical findings [25,26]. Some viewed severe injuries, and others regarded very minor injuries as predictors of delayed recovery. CMs perceived that persons with greater clinical severity and more objective findings have better recovery when the treatment plan is clear and their attitude is positive. The CMs perceived greater variation in more subjective, less clinically defined conditions, especially where there appears to be a disconnection between the extent of injury and level of symptoms. In persons with minor injuries following a motor vehicle crash, the literature suggests that socio-economic factors in terms of seeking financial compensation were much more important than injury severity [6,27]. Co-morbidities and preinjury health status were consistently cited as very relevant predictors. CMs considered co-morbidities as potentially more relevant to recovery than the physical injury itself. This is in line with a large population-based study which showed that poor subjective health before the injury was associated with subsequent chronic whiplash-associated disorder [28,29].

CMs perceived psychological factors such as negative affect, low motivation, poor recovery expectations, catastrophizing and high levels of distress as predictors of delayed recovery. All these factors are deemed to be relevant predictors for recovery across different settings, regulatory and injury contexts. Poor expectations for recovery are associated with poor outcomes after minor MSD-MV injury [30]. Persons with minor to moderate MSD-MV and high level of distress were found to have 4.3 times higher compensation costs than persons with low or no distress [31]. Also, pain catastrophizing has been found to be an important predictor for the transition from acute to chronic MSD-MV [32]. While the CMs we interviewed did not assess all these psychological factors systematically (i.e., by means of standardized questionnaires) they appeared able to identify many of the relevant signs of distress early in the claims handling process.

As it relates to activities and participation, CMs spoke mostly about participation rather than about activities. Injured persons who continued engagement in work and leisure activities were perceived as having better outcomes than those who were sedentary, off work or dependent on others. Longitudinal research has found that participation in society is prospectively related to better health five years following multi-trauma injury [33]. A population cohort study has shown that pre-injury physical activity was protective from developing chronic WAD (OR = 0.67, 95%CI: 0.49–0.91; [28]. A study in the UK measured the level of self-reported fitness in persons with WAD [34]. Pre-injury physical fitness had a marked effect on recovery at three and six months, with the medium and high fitness groups having a significantly better recovery than the low fitness group. Thus, research from quantitative studies is consistent with the findings of our study that engaging in physical activities and participation in daily life predicts longer-term recovery success.

Environmental indicators of recovery included aspects of the person’s physical, social, compensation and legislative environments and how these influence accident and treatment characteristics. Inappropriate diagnostic testing and treatment that was not consistent with guidelines were seen as predicting a poor outcome. CMs perceive diagnostic testing, including imaging, to be important early on to rule out potentially severe, though very rare instances of structural damage, and to have some value for legal purposes. However, they understand that excessive imaging is bad for recovery. Their views are somewhat inconsistent with current guidelines, which, given the potential for false-positive results and inappropriate labeling, discourage diagnostic testing in all instances unless clear signs of a potentially serious condition are present [35–38]. Similar to the CMs in our study, persons with whiplash injuries reported that family and health care provider were influential and could be a source of reassurance or of heightened concern [39] In that study some injured persons were worried by being instructed to rest or being told that one would never recover completely.

Lawyer involvement was also seen as a major barrier for recovery, by the majority of participants. CMs perceived that lawyer involvement would cause deterioration of their relationship with the injured person and would lead to more health service consumption. A recent meta-review has reinforced the detrimental effect of compensation and legal involvement on recovery after whiplash injury [40]. Another systematic review about chronic pain following MVC injuries found five studies which compared Tort “common law” and No-Fault schemes directly [41]. The authors concluded that tort claimants with lawyer involvement had poorer recovery compared to claimants without.

Personal factors mentioned by CMs encompassed demographic characteristics including age, education, SES, occupation, prior compensation claims history and cultural background, as well as knowledge of their injury and recovery processes. The personal factors of age, level of education and income and socioeconomic status were identified as relevant, but CMs varied in their impressions of the impact of these factors. These controversies are also reflected in the scientific literature [39,40,42–45]. CM’s impressions about the importance of distress, injury and recovery beliefs, motivation, anger and blame are reflected in several studies of persons with these injuries. A related topic was the style of communication that the injured person used. “Honest and open” was seen as positive, while “vagueness” or suspiciousness was seen as negative.

Important overarching indicators

Consistent with the ICF conceptualization that a person’s functioning is an interaction between his or her health condition, environmental and personal factors, we identified a number of important indicators that involved aspects from more than one of the major ICF groupings. These centered on concepts we labeled general health, pain processing and response, work situation and compensation entitlement and focus.

For the purpose of this discussion, general health is perceived of as being the health of the injured individual within their environmental contexts. People that were both physically and mentally healthy, fit and actively participating in life were viewed as being less likely to have a complicated recovery. In addition to the physical and mental health of the injured person, CMs also perceived health-related messaging from family and friends, often referred as “significant others” (SOs), as a major factor influencing recovery. For example, reports about an encouraging family environment, being a mother with responsibilities for others, or being a valued worker with a long period of employment were perceived as relevant by CMs. A study with 1649 persons with MVC injuries found that family and friends’ support was associated with better physical health among persons with >1-day hospital stay. Support from family, friends and neighbors was associated with less persistent pain. Among women, support from family was negatively associated with recovery and RTW, whereas support from friends was positively associated with recovery [46]. A range of policy and empirical evidence has stressed the need to acknowledge the role of family members in order to improve health and work outcomes in persons with common musculoskeletal disorders such as low back pain [47]. Some evidence suggests that appropriate support includes empathic and positive responses [48–50] and unhelpful support could be excess solicitousness, or punishment [51,52]. However, providing help with daily tasks, SOs may reduce the amount of (beneficial) activity for the person with pain and therefore, reduce the capacity to develop coping strategies. The role of SOs in recovery in injured persons with MSK-MV is a promising area for future research, and feedback from CMs to rehabilitation professionals caring for the injured person about the perceived influence of SO’s may provide opportunities for these professionals to enhance recovery.

As it relates to pain processing and response, pain is a body function that is a key issue for injury recovery. High levels of pain are predictive of limited recovery after traffic injuries [6,53]. While pain level, which is commonly measured in quantitative studies of recovery, was not commonly spoken about by the CMs, and responses to pain were frequently mentioned. If people were not overly dramatic or focused on pain, did not let pain stop them from doing what they normally do, and were coping well with the pain they were experiencing, these were seen as indicators that the recovery should progress smoothly. This is consistent with research that has found that pain catastrophizing, poor coping, pain avoidance and activity restriction is related to worse return-to-work outcomes [54]. From the perspective of assisting recovery, focusing on functioning as the main issue is likely to be more adaptive and effective than focusing on pain. This is the recommendation of treatment guidelines [35,37,38,55,56] and thus the case managers implicitly were taking a recommended approach.

Various aspects of the injured person’s work situation were also commonly referenced. These covered multiple ICF categories including participation, environmental contact and personal background. More specifically, the work situation (i.e., whether not the worker had returned to work), attitude towards work, relationship with employer, physical and mental workload were all cited as predictive of outcome. For injured persons who had returned to work, a positive attitude about work, good relationship with their employer and acceptable levels of physical and mental stress, were associated with a good prognosis. Conversely, if the injured person was challenged in any of these areas, CMs were less confident that their recovery would progress smoothly. Support for the perceptions of CMs comes from the return to work literature. Return to work is often interpreted as an indicator of recovery following disabling injury [57–59]. As reviewed by Booth-Kewley et al (2014), research on this topic has shown that all of the factors mentioned by the CMs are related to return to work outcomes [60].

CMs mentioned compensation-related factors, such as prior claims, delayed claim lodgment, entitlement related questions, pre-existing complaints, prompt communication by the CMs and attorney involvement. CMs thought that those who were not focused on compensation eligibility, not involved in litigation, and were compensated for care that was within treatment guidelines was predictive of a better outcome. Being involved in a compensation process has been cited as a negative factor for recovery by most systematic reviews [27,61,62]. Even though the compensation contexts in the USA and Australia are quite different, case managers from both countries spoke about how they perceived that people who were focused on compensation entitlement would not recover well. Participants also referred to their own role within the compensation context as potentially supporting better recovery outcomes, through a faster early response, with supportive communication; this is also highlighted in prior studies [63–65].

Strengths, limitations and future research

Strengths of this study include participation by experienced claims managers across a range of different jurisdictions and contexts, with an approach that sought to capture in-depth and nuanced responses. This represents one of the few studies that evaluate this unique and well-informed perspective on prognosis in a common condition that has a large societal burden. There are also some limitations to this study. The sampled CMs represent a number of jurisdictions but from only two countries. Interviews were performed by a different interviewer at each study site. Moreover, the interviewers were different in gender. It is possible that both factors may have influenced the participant’s reports. Reflexivity is an important part of the analysis process and the interpretation will be influenced by the background of the researchers [66]. The study team included psychologists, physicians, case managers and physiotherapists; as such, the researchers with the different professional background may have interpreted the data differently [67]. However, coding was independently checked by another researcher and regular peer debriefing was performed to ensure the findings reflected the data.

As it relates to future research, studies on early risk stratification and intervention in musculoskeletal disorders, where resources are focused on those injured persons at high risk for nonrecovery, have shown promising results [68–70] As CMs have a broad, longitudinal perspective on the major factors important for risk prediction, they may have a valuable role in early triage to selective interventions, monitoring progress, and informing rehabilitation professionals about potential barriers to recovery. Future research may identify whether a more formalized approach to assessing the factors predicting recovery after MSD-MV would lead to better outcomes. There is a need for prospective controlled studies to understand the effect of nonmedical interventions such as CMs involvement or modifications in the legal- and compensation system [71].

Conclusions

CMs in two countries (the USA and Australia) demonstrated a clear and detailed understanding of key biopsychosocial and contextual issues influencing recovery after MSD-MV. In particular, their perceptions regarding environmental and personal factors are consistent with previous findings from the scientific literature and opinions from injured persons. The findings of this study have the potential to be informative to the parties involved in the recovery process to improve recovery outcomes. Further research should be built on these findings and quantitative studies need to be conducted to make conclusions about the value of involvement of CMs in the recovery process.

Ethics and consent to participation section

Consent for publication

All participants provided written consent to publish their de-identified data prior enrollment to the study.

Ethics approval and consent to participate

This study has been performed in accordance with the Declaration of Helsinki. The New England Institutional Review Board (reference number: 20160718) and the Northern Sydney Local Health District ethics committee approved the study (reference number: RESC/16–170).

Acknowledgments

We thank all participating case manager and their supervisors for their time and willingness to participate in this study. We owe gratitude to Dr. Monika Finger for advising us as subject matter expert of the International Classification of Functioning (ICF).

Data availability statement

Availability of data and materials

Additional data will be available upon request from the corresponding author.

Disclosure statement

The authors declare that they have no competing interests.

Additional information

Funding

Funding was provided in part by the Australian National Health and Medical Research Council Practitioner Fellowship and the Liberty Mutual Research Institute for Safety. The funding bodies had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.