From Injury to Recovery: Mechanisms Promoting Return to Work After a Health Shock

Injury is a major cause of death, poor health, and disability. But in addition to its health consequences, an injury often causes important financial hardships, limiting a person’s ability to work, if not causing permanent loss of employment, and leading to significant health care costs. While other studies have documented rates of return to work after injury, labor dynamics and predictors of successful return to work remain poorly understood. This study aims to fill these gaps and investigates the mechanisms that facilitate a successful recovery after an injury, using mild traumatic brain injury (mTBI) as a case study. Despite the term “mild”, mTBI often leads to post-concussive syndrome, the symptoms of which can take years to resolve and contribute to persistent physical, emotional, and cognitive stress, all of which can impair return to work of injured patients.

We use data from a large, prospective study cohort of TBI patients, the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study. These unique data include detailed information on socioeconomic status of patients, clinical data, treatment, follow-up, employer support, and multiple outcome measures in periodic follow-ups after discharge. Since head injury is a low-probability random shock in working-age Americans, we are able to compare outcomes across baseline differences without worrying about patient selection with relatively minor identifying assumptions (e.g., we assume that individuals do not select to work for more supportive employers because they anticipate having an elevated injury risk). Moreover, the detailed clinical information collected by TRACK-TBI (such as findings on a head CT and patient biomarkers) allow us to precisely control for the differences in underlying injury severity that predict both treatment selection and outcomes.

We first use TRACK-TBI data to document the consequences of mTBI for employment status at 2 weeks, 3 months, 6 months, and 12 months after discharge. While most patients who were employed at the time of injury return to work by 3 months after discharge (73.0%), disability incurred because of the injury prevents 14.1% from working, and another 3.9% of injured patients are unemployed. These unsuccessful return-to-work figures largely persist at one year and display a prominent gradient by educational achievement. For instance, only 3.5% of those with a bachelor’s degree or higher report that disability prevents them from working 12 months after discharge, versus 14.0% of those with less than high school. Our study then estimates probabilistic regression models of return to work by milestone to investigate the plausible causal factors behind an unsuccessful return to work, including injury severity, follow-up care, access to rehabilitation treatments, employer accommodation (e.g. sick leave, modified schedule, reduced hours, access to assistive technology), and illegal drug utilization. We find that injury severity and post-concussive symptoms are the strongest predictors of a quick return to work in the weeks following a health shock, while SES, work environment, and insurance status are significant predictors of a successful recovery in the longer term. Overall, the study provides important new information about the dynamics of recovery after a health shock.