Exploring “Return to Productivity” Among People Living With Burn Injury: A Burn Model System National Database Report

Abstract

Burn survivors experience barriers to returning to work. For those who do return to work, little is known regarding whether they achieve preinjury productivity (i.e., equivalent or gain in income compared to preinjury income). Identifying patients at risk of not achieving preinjury productivity is important for targeting services that support this population. They extracted occupational and income data through 24 months postinjury from the multicenter, longitudinal Burn Model System National Database. Annual income was reported in six groups: <$25k, $25k–50k, $50k–99k, $100k–149k, $150k–199k, and $>199k. Participants were classified by change in income at each follow-up (i.e., gain, loss, and equivalent). Explanatory variables included demographics, injury characteristics, insurance payer, employment status, and job type. Multilevel, multivariable logistic regression was used to model return to productivity. Four hundred fifty-three participants provided complete income data at discharge and follow-up. Of the 302 participants employed preinjury, 180 (60%) returned to work within 24 months postinjury. Less than half (138) returned to productivity (46% of participants employed preinjury; 77% of those who returned to work). Characteristics associated with return to productivity included older age (median 46.9 vs 45.9 years, OR 1.03, P = .006), Hispanic ethnicity (24% vs 11%, OR 1.80, P = 0.041), burn size >20% TBSA (33.7% vs 33.0%, OR 2.09, P = 0.045), and postinjury employment (54% vs 26%, OR 3.41, P < 0.001). More than half of employed people living with burn injury experienced loss in productivity within 24 months postinjury. Even if they return to work, people living with burn injuries face challenges returning to productivity and may benefit from vocational rehabilitation and/or financial assistance.

People living with burn injury undergo physical and psychosocial changes during their recovery that can pose major challenges for employment. Although three-quarters of burn survivors return to work within 3 years of injury, about a quarter of burn survivors are unable to work or find employment.^1,2 Barriers to return to employment have been thoroughly evaluated and include multiple factors (e.g., age, burn size and location, pain, psychosocial factors, preinjury occupation type, and postacute care setting).^1,2,3

For those who return to work, less is known about whether burn survivors work in similar disciplines and job types or earn similar income after injury. There are no investigations to date that evaluate whether burn survivors achieve preinjury productivity (i.e., equivalent work output and/or income). Understanding patients who are at risk of not achieving pre-injury productivity is important for targeting services that support this vulnerable population and their families.

To address this gap, we aimed to investigate patterns of productivity change among burn survivors after their injury compared to their preinjury income. We hypothesized that survivors who obtained employment postinjury would have greater return to productivity than those who were unemployed, regardless of workers compensation status. In addition, we hypothesized that a significant proportion of burn survivors would have difficulty achieving their preinjury productivity, particularly in the more immediate period following reentry into the workplace.

METHODS

Database and Inclusion

The National Institute of Disability, Independent Living, and Rehabilitation Research (NIDILRR) supports the multicenter, longitudinal Burn Model Systems (BMS) National Database.⁴ BMS prospectively enrolls working-age people living with burn injury who meet one of the following criteria:

• 18–64 years of age with a burn injury ≥20% total body surface area with surgical intervention;

• ≥65 years of age with a burn injury ≥10% total body surface area with surgical intervention;

• ≥18 years of age with a burn injury to their face/neck, hands, or feet with surgical intervention; or

• ≥18 years of age with a high-voltage electrical burn injury with surgical intervention.

The database follows participants longitudinally after hospital discharge and surveys participants at 6 ± 2, 12 ± 3, and 24 ± 6 months after injury from their index hospitalization.⁵ All adult participants (i.e., age ≥18 years) who reported data for annual income at any subsequent follow-up interval were included to allow complete case-analysis. Participants who did not report data regarding to pre- or post-injury employment status or annual income were excluded. The annual income variable has been collected since 2015, and the dataset was accessed in late 2020 to allow for 24-month follow-up for participants enrolled in 2018. This investigation was approved by the Burn Model System for investigation and the University of Washington Institutional Review Board.

Variables

Participant annual income is reported as one of the six income groups: <$25,000, $25,000–50,000, $51,000–99,000, $100,000–149,000, $150,000–199,000, and >$199,000. Change in income at each follow-up interval was evaluated and labeled categorically as gain, loss, or equivalent income. Return to productivity was defined as maintaining or increasing annual income at follow-up interval compared to preinjury annual income. This variable was described at each postinjury interval (i.e., 6, 12, and 24 months) and also analyzed in a binary fashion such that a participant was labeled as achieving return to productivity regardless of which time point it occurred. In the event that participants achieved return to productivity at 6 or 12 months postinjury, but subsequently had decline in income, they were labeled as having achieved return to productivity for the primary analysis. Participant explanatory/independent variables included demographics (age, gender, and race/ethnicity), pre- and post-injury employment status, job type (executive/administrative/managerial, professional, technician, sales, administrative support, homemaker, security, service/hospitality, farming, crafts and carpentry, machinist, transportation, laborer, military, and others), and burn severity (mechanism, % total body surface area [TBSA] parsed into three categories [<5% TBSA, 5%–20% TBSA, and >20% TBSA], hand involvement, and number of operations during index admission). Job type was condensed into three categories into order to facilitate analysis (e.g., manual labor, office, and other). Payer was also included as a covariate (commercial/private, Medicare, Medicaid, workers compensation, and self-pay), appreciating that workers compensation would act as a surrogate for burn injury occurring while working.

Analysis

The primary outcome (return to productivity) was modeled with multi-level logistic regression using the aforementioned covariables as explanatory/independent variables. Given possible variations in access to vocational counseling across BMS sites, the regression model includes BMS site as a cluster variable. Model fitness was assessed with a c-statistic. Appreciating that responders to the income question may not represent the greater BMS population, we conducted a nonresponder analysis. The response variable was whether income was reported (binary), and the explanatory variables included those listed above along with BMS site as a cluster variable. Multilevel logistic regression was again used. Statistical significance was determined at an alpha level of 0.05. All analyses were conducted with Stata/IC version 15.1 (StataCorp LLC, USA).

RESULTS

Four hundred fifty-three participants reported complete income preinjury and at least at one of the three follow-up surveys (44.7% of all participants in the BMS National Database since 2015). Income reports were 266 at 6 months, 217 at 12 months, and 136 at 24 months. Of the 302 participants who were employed prior to injury, 180 (60%) were employed within 24 months postinjury, and 194 (64%) had return to productivity regardless of employment status (i.e., receiving supplemental income; Figure 1). Of participants who were employed both before and after injury, 138 (77%) achieved return to productivity; 46 (23%) participants were employed after their injury and had decreased productivity. Seventy participants maintained or gained income without employment (e.g. disability, supplemental income, and trust) before and after injury (preinjury income <$25,000/year in 43, $25,000–$50,000 in 15 participants, $51,000–$99,000 in 11, and >$199,000 in 1).

At 6 months postinjury, 186 participants (70%) reported being in the same income bracket, while 45 (17%) had risen at least one bracket (Figure 2). Conversely, 35 participants (13%) had fallen at least one income bracket 6 months postinjury. At 12 months postinjury, 138 participants (64%) were in the same income bracket, while 31 participants (15%) rose at least one income bracket (Figure 3). Forty-eight participants (22%) fell an income bracket 12 months postinjury. Finally, at 24 months postinjury, 68 participants (50%) reported similar income to preinjury, whereas 30 participants (20%) had gain in income (Figure 4). Thirty-eight participants (28%) had loss of income at 24 months.

In terms of occupation type, people living with burn injury represented a diverse workforce (Figure 5). Those occupations reported by over 10% of participants included other (73, 13.3%), crafts and carpentry (64, 11.7%), laborer (64, 11.7%), and executive/administrative/managerial (57, 10.4%). The next most frequent occupations were professional (53, 9.7%), service (49, 8.9%), technician (41, 7.5%), machinist (35, 6.4%), and transportation (29, 5.3%). The remaining occupations were reported in less than 5% of participants: sales, administrative support, homemaker, security, farming, and military. Grouping occupations yielded 29% working in office jobs (executive/administrative/managerial, professional, sales, and admin support) compared 57% in physical jobs (technician, security, service, farming, craftsman, machinist, transportation, and laborer). Fifteen percent of participants worked in other occupations (other, military, and homemaker).

Four covariates were associated with increased return to productivity: age, race/ethnicity, %TBSA burn size, and postinjury employment status (Table 1). Medicaid payer was associated with lower likelihood of return to productivity. Participants who achieved return to productivity were slightly older (46.9 vs 45.9 years, OR 1.03, 95% CI 1.01–1.05, P = 0.006). The age distributions between those with return to productivity and those without were similar. The return to productivity cohort had a minimum age of 20 years, maximum age of 87 years, median of 48 years, and standard deviation of 14.9 years. The cohort with decline in income had a minimum age of 19 years, maximum age of 80 years, median of 47 years, and standard deviation of 16.1 years. Hispanic compared to white non-Hispanic was more likely to return to achieve return to productivity (23.6% vs 11.3%, OR 1.99, 95% CI 1.01–3.97, P = .041). Compared to commercial insurance as reference, participants with Medicaid as payer were less likely to have return to productivity (14.9% vs 19.8%, OR 0.37, 95% CI 0.20–0.67, P = .001). Workers compensation, which would presumably assist with disability income, was not associated with return to productivity. In addition, there was weak evidence that participants who sustained a burn injury ≥20 %TBSA were more likely to return to productivity compared to participants with burn injuries <5%TBSA (OR 1.67, 95% CI 1.11–3.71, P = .045). Employment after burn injury was strongly associated with having achieved return to productivity (OR 3.47, 95% CI 2.04–5.89, P < .001). Gender, occupation, hand burn, and head/neck burn were not associated with return to productivity.

The nonresponder analysis for the income item revealed multiple differences between the two cohorts (Table 2). Participants who had hand burn injuries were more likely to respond to the income question compared to those who did not have hand burn injuries (OR 1.93, 95% CI 1.12–3.33, P = 0.019). Conversely, participants who had Medicaid as a payer were much less likely to respond to the income question compared to those who were covered by commercial insurance (OR 0.27, 95% CI 0.15–0.49, P < 0.001). Participants of Hispanic ethnicity were more likely to respond to the income question (OR 2.26, 95% CI 1.08–4.71, P = .030) than white non-Hispanic participants. The remainder of covariates was not significantly associated with a response to the income question.

DISCUSSION

Whereas prior investigations of people living with burn injury have focused on employment status,^1,2,6,7,8,9 this study is the first to report on whether burn survivors have changes in income after injury. Notably, of the participants who regained employment after their burn injury, nearly one quarter of them experienced decreased productivity, which expands our understanding of employment and economic productivity after burn injuries. The concept of underemployment¹⁰ could explain this phenomenon whereby burn survivors return to work, yet not to a position or occupation that pays equivalent salary or provides sufficient hours compared to their employment preinjury. Occupational change has been described in prior publications; 39–45% of burn survivors return to work with a different employer or switch occupations from their position pre-injury.^6,11 The psychosocial and physical changes associated with recovery after burn injury may limit ability to work the same number of hours or with the same efficiency, which could explain the decreased productivity. Burn survivors may also have decreased stamina earlier in their recovery that could take many years to increase.¹² Not surprisingly, the covariable mostly associated with return to productivity was postinjury employment, suggesting that regaining or starting a job after burn injury is the single most important factor in return to productivity. While this study was unable to evaluate disability income as a unique variable in its contribution to income, workers compensation was included as a covariate, which should act as a proxy for injury while working and subsequent disability support. Future investigations could evaluate the relationship between disability income and return to productivity.

Our data suggest that older age was associated with return to productivity; however, although statistically significant, the difference in mean age between those with income loss and those with return to productivity was only a year. While the difference in age is not large enough to suggest that older patients fare much better, this finding does suggest that younger patients have challengers in returning to productivity. This finding is contrary to published literature showing that younger burn survivors have less difficulty in regaining employment.^13,14 A possible explanation for the difference in these findings stems from the financial security that comes with age. Possibly, older patients are able to maintain income from a variety of sources that do not directly involve employment. For example, older patients may have social security, investments, retirement funds, or annuities that contribute to their reported income even if they are not employed. The current data are unable to clarify this hypothesis.

Hispanic participants were significantly more likely to regain income compared to White non-Hispanic participants. Whereas our data are not sufficiently granular to provide an explanation for this notable observation, the Pew Research Center determined that Hispanic households were more likely to be multigenerational, and incomes are often combined and reported accordingly.¹⁵

Surprisingly, larger burn size was associated with return to productivity. Prior literature^6,13 has reported that larger burns are less likely to return to work, primarily because there is increased time between loss of employment and re-entry into the workplace, particularly during short periods of follow-up. However, the discrepancy in these findings has a plausible explanation. The primary outcome of interest in the present study is return to productivity and not return to employment. Possibly, participants with larger burns received more frequent and intensive vocational and rehabilitative counseling, which facilitated earlier return to work and maintenance of pre-injury wages due to workplace adaptations.¹⁶ Thus, while people recovering from larger burn injuries may be less likely to return to work, the ones who are able to secure employment do so in jobs that remunerate at equivalent or higher levels. Given the risk of being unable to return to productivity, patients of all burn sizes might benefit from targeted vocational rehabilitation or qualify for financial assistance programs, such as disability/supplemental social security income, supplemental nutritional assistance program, housing vouchers, and energy assistance.

When considering a prescribed intervention informed by this investigation, we recommend reevaluation of prior studies¹⁷ on the success of a vocational rehabilitation counselor. Important follow-up questions should include salary, which can be compared to pre-burn income. This can prompt the counselor to various recommendations and resources if the burn survivor has loss in productivity. For one, the vocational counselor can help the burn survivor consider other job options that pay better or explore reasons for the drop in salary (e.g., ways to improve stamina or alter approach to work). In addition, the vocational specialist can refer the patient to formal financial counseling including financial resources from foundations or governmental assistance.

Our analysis is limited by missing responses to the income survey item. Notably, participants who responded to the income item were significantly less likely to have Medicaid insurance. Medicaid is the payer for patients with little financial means, which suggests that patients with the lowest income were less likely to respond to the question. Further, participants with Medicaid payer were also associated with lower likelihood of return to productivity. Thus, this population was both underrepresented in our analysis and struggled to regain economic productivity

We evaluated return to productivity in a binary sense, which may not adequately capture burn survivors who gain income equivalence postinjury and then subsequently lose income. Achieving return to productivity may be vicissitudinous, particularly on broader time horizons (i.e., >24 months after injury). This investigation is also limited by data regarding disability income. Participants may be receiving income through disability or other state/federal financial assistance programs. Burn survivors may qualify for disability income, which could affect their total income as reported in this study. This analysis was unable to assess the contributions of these types of income. Despite these limitations, these findings allow reasonable conclusions to be drawn about the challenges faced by people living with burn injuries with regard to returning to productivity. We recommend that current strategies targeting return to work such as vocational rehabilitation¹ also consider return to economic productivity and opportunities for financial assistance.

CONCLUSION

One quarter of employed burn survivors experienced loss in productivity during their recovery. Notably, younger patients with smaller burn injuries may have a lower likelihood of achieving return to productivity despite regaining employment. Clinicians should assess people living with burn injuries for challenges with return to productivity to identify those who may benefit from vocational rehabilitation and financial assistance programs (e.g., disability and supplemental social security income, supplemental nutritional assistance program, housing vouchers, and energy assistance).

Funding: The contents of this manuscript were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DPBU001, 90DPBU003, 90DPBU0004). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this manuscript do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government.

Conflict of interest statement. The authors report no conflicts of interest or financial disclosures related to this manuscript.

REFERENCES