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Age, sex, and the changing disability burden of compensated work-related musculoskeletal disorders in… Macpherson, Robert A; Lane, Tyler J; Collie, Alex; McLeod, Christopher B Jun 19, 2018

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RESEARCH ARTICLE Open AccessAge, sex, and the changing disabilityburden of compensated work-relatedmusculoskeletal disorders in Canada andAustraliaRobert A. Macpherson1* , Tyler J. Lane2, Alex Collie2 and Christopher B. McLeod1,3AbstractBackground: The objectives of this study were (1) to identify age and sex trends in the disability burden ofcompensated work-related musculoskeletal disorders (MSDs) in Canada and Australia; and (2) to demonstrate ameans of comparing workers’ compensation data internationally.Methods: All non-fatal, work-related MSD claims with at least one day of compensated time-loss were extracted forworkers aged 15–80 during a 10-year period (2004–2013) using workers’ compensation data from five Canadianand eight Australian jurisdictions. Disability burden was calculated for both countries by sex, age group, and injuryclassification, using cumulative compensated time-loss payments of up to two years post-injury.Results: A total of 1.2 million MSD claims were compensated for time-loss in the Canadian and Australian jurisdictionsduring 2004–2013. This resulted in time-loss equivalent to 239,345 years in the Canadian jurisdictions and 321,488 yearsin the Australian jurisdictions. The number of time-loss years declined overall among male and female workers, butgreater declines were observed for males and younger workers. The proportion of the disability burden grew amongolder workers (aged 55+), particularly males in the Canadian jurisdictions (Annual Percent Change [APC]: 7.2, 95% CI 6.7to 7.7%) and females in the Australian jurisdictions (APC: 7.5, 95% CI 6.2 to 8.9%).Conclusions: The compensated disability burden of work-related MSDs is shifting towards older workers andparticularly older females in Australia and older males in Canada. Employers and workers’ compensation boards shouldconsider the specific needs of older workers to reduce injuries and time off work. Comparative research made possiblethrough research-stakeholder partnerships offers a unique opportunity to use existing administrative data to identifylong-term trends in disability burden. Future research can apply similar approaches for estimating long-term trends inoccupational health.Keywords: Work disability, Age, Sex, Canada, Australia, Compensation data, Administrative data, Comparative research,Occupational healthBackgroundIn developed countries, longer life expectancy and lowerfertility, increased functional ability of older adults, andfinancial insecurity at older ages have resulted in an age-ing workforce [1, 2]. In 2015, Canadians aged 55–64accounted for 20.0% of the working-age population(aged 15–64) and 16.8% of total employed population,compared to 12.7 and 8.2% two decades earlier [3]. Simi-larly, the proportion of Australians aged 55–64 in theworking-age population grew from 12.7% in 1996 to17.5% in 2015 while their proportion of the total employedpopulation grew from 7.9 to 15.0% [4]. Ageing workforcespose a challenge for employers and workers’ compensationboards as older workers experience poorer return-to-work(RTW) outcomes following work-related injury, such as* Correspondence: robert.macpherson@ubc.ca1Partnership for Work, Health and Safety, School of Population and PublicHealth, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3,CanadaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Macpherson et al. BMC Public Health  (2018) 18:758 https://doi.org/10.1186/s12889-018-5590-7lower likelihoods of RTW [5], greater likelihoods of dis-ability recurrences [5], and greater time-loss duration [6].Work-related musculoskeletal disorders (MSDs) are themain cause of disability among occupationally activeadults [7], and older workers typically experience a higherprevalence of musculoskeletal complaints than youngerworkers [8].Another factor contributing to the changing demograph-ics of workforces has been the increasing proportion of fe-male workers [9, 10]. There are important sex differencesin disability resulting from work-related injury, evident indifferent likelihoods of RTW [11, 12], transitioning offwork disability benefits [6, 13], and transitioning ontopermanent disability pension [14]. There is also evidenceto suggest that the sex differences in work-related healthmay be changing over time [10]. Despite several studieshaving examined the role of ageing on work-related dis-ability [15–17], these studies have not focused on how sexcan interact with ageing and disability over time. Further-more, they have been restricted to the analysis of single re-gional or national jurisdictions.International comparative studies have advantages, suchas enabling the examination of similarities and differencesin effective OHS prevention and work disability manage-ment strategies, and may help improve the developmentand analysis of occupational health data by identifying bestpractices [18]. There has been growing evidence on theimportance of providing greater access to data for re-search purposes [19]. The Global Burden of Disease(GBD) Study is an example of how using comparabledata across multiple countries can help identify key pri-ority areas. Findings from the most recent GBD Study2016, focusing on injuries and risk factors, demonstratedhow low back pain was one of the leading causes of yearslived with disability (YLD). While the study estimatedage-standardized incidence, prevalence and YLD forMSDs, it was unable to determine whether the workwas the main cause of the MSDs [20]. In another GBDstudy which focused on environmental risks, diseases areexamined by environmental cause, including occupation,but study results were not stratified by age, sex, and typic-ally relied on data from one time point [21]. Comparativeresearch using physician reporting and compensation datafrom 10 countries has examined occupational disease inci-dence, while accounting for the variation in data collectionmethods employed in each country, and demonstratingthe potential of data sharing in this area [22]. This re-search has focussed on incidence of work-related injuryand illness, but not on time-loss resulting from it.A comparative study of six countries identified thatdifferences in RTW after chronic low back pain are largelyexplained by cross-country differences in applied workinterventions [23]. However, this study did not examineage and sex differences in disability resulting fromwork-related MSDs. The study conducted pooled analysisthat adjusted for country rather than stratifying the analysisto examine differences across countries. Identifyingwhether the growth in the number of older and femaleworkers is contributing to a greater burden of disability al-lows us to understand the effects of demographicchange on the compensation system and whether this isconsistent cross-nationally. This is timely as trends ininjuries and compensation claims are sensitive to busi-ness cycle fluctuations, with the uneven impact of theglobal economic recession likely to have affected thenumber of claims among younger workers due to theirhigher injury rates and lower job stability [24].Canada and Australia have similar economies, labourmarket institutions, and occupational health and safetyand workers’ compensation systems [25]. The global eco-nomic recession had an effect on economic growth inboth countries although only Canada experienced a reces-sion. The extent and costs of work-related injuries are alsosubstantial in both countries. For example, in Canadathere were 239,643 lost time claims in 2014, contributingto benefit costs of $7.2 billion CAD [26] and 107,355claims with at least one week of time loss in Australia,costing $8.4 billion AUD [27]. An advantage of usingCanada and Australia as international comparators is thatresearchers in both countries have access to rich ad-ministrative register data through multiple provincial,state and territorial workers’ compensation boards. How-ever, a challenge is making the data comparable within andacross countries due to differences such as compensationcoverage, data coding, legislation, and claims management.This study represents the first cross-national comparisonof workers’ compensation data between Canada andAustralia.AimThis study has two aims: (1) to identify age and sex trendsin the disability burden of compensated work-relatedMSDs in Canada and Australia; and (2) to demonstratea means of comparing workers’ compensation datainternationally.MethodsWorkers’ compensation dataThe study included claim-level data from five Canadianworkers’ compensation jurisdictions (Alberta, BritishColumbia, Manitoba, Ontario, and New Brunswick) andeight Australian workers’ compensation jurisdictions (NewSouth Wales, Victoria, Queensland, South Australia, WesternAustralia, Tasmania, Northern Territory, and AustralianCapital Territory private scheme). Based on 2014 statis-tics, the percentage of the total national workforcescovered under the compensation schemes of the studyMacpherson et al. BMC Public Health  (2018) 18:758 Page 2 of 11jurisdictions was 67.9% in Canada [26] and 90.8% inAustralia [28].Canadian data were accessed via a secured researchenvironment provided by Population Data BC [29]. Useof data for research purposes was governed by an agree-ment between the data stewards and the researcher team[30]. Personal identifiers were removed from the dataprovided to the researchers and replaced with an anonym-ous claim identifier. Australian data access was providedthrough the National Data Set for Compensation-basedStatistics (NDS), compiled by Safe Work Australia [31], aspart of the Compensation Policy and Return to Work Ef-fectiveness (ComPARE) Project. Ethical approval for theresearch project was obtained from the Behavioural Re-search Ethics Board at the University of British Columbia(certificate number H13–00896) and the Monash Univer-sity Human Research Ethics Committee (project numberCF14/2995–2014001663).Study populationThe study population was workers aged 15–80 who re-ceived compensation for at least one day of time-loss forMSDs sustained between 2004 and 2013. Workers witha claim with missing age or sex data, or aged below 15 orabove 80 years were excluded. MSDs were identified usingthe Canadian Standards Association (CSA) Z795–03 [32],and the Australian Type of Occurrence ClassificationSystem (TOOCS 3rd Edition Revision 1) codes [33].Two additional injury/disease subgroups were identified:(1) fractures and (2) MSDs of the back excluding fractures.The former group was defined using nature of injurycodes and the latter group with nature of injury andpart of body codes (see Additional file 1 for full listof codes).The additional groups of fractures and MSDs of theback represented injury/disease groups in which we ex-pected the age and sex-based differences in the prevalenceand duration of claims. A higher proportion of femaletime-loss claims are associated with musculoskeletal injur-ies, and the proportion associated with fractures increaseswith age to a greater extent than among males [17]. Inaddition to greater difficulty in diagnosing and claiminglong-term chronic conditions like MSDs of the back, frac-tures represent sudden, traumatic, and easily diagnosedinjuries that are expected to show less variation associatedwith the business cycle [34]. It is expected that temporalvariations in disability burden will be shaped differentlybetween the injury/disease groups due to short-termbusiness cycle fluctuations and long-term changes overthe 10-year period.Outcome measures and analysesThe study focused on the compensated disability burdenof work-related MSDs, measured as time-loss years.Time-loss years were calculated using cumulative compen-sated weekly time-loss, censored at 104 weeks (two yearsbased on a five-day workweek). Censoring at 104 weekshas been used in previous studies using similar data [35],and for the purpose of our study, avoided biasing time-lossburden due to claims with longer follow-up times. TheAustralian data were available at the claim-level withhourly compensation estimates standardized to a 5-dayworkweek. Canadian data were available at the claim-payment-level with full and partial time-loss paymentswith varying daily, weekly, or monthly payments ofdifferent work schedules. To harmonize the data, theCanadian data were adjusted to full time-loss paymentsfor a 5-day workweek.Since the outcome measure was derived solely fromworkers’ compensation data, it enabled us to interpretour main findings in respect to the workforce eligible forworkers compensation, in contrast to the GBD studywhich typically relies on multiple data sources to estimateYLD for MSDs [20]. A common approach for estimatingtime trends in MSDs is to calculate incidence rates usingworkforce denominators, which enables analysis over timeto account for changing compositional changes in theworkforces. However, changes in workers’ compensationcoverage by industry, occupation, and injury/disease makeestimation of reliable workforce denominators challengingand calculating comparable rates of injuries in the absenceof reliable workforce denominators may not be possible.In particular, one is not able to determine whether a claimrate is changing due to an actual change in the number ofclaims or changes in the denominator, such as the numberof workers eligible for compensation. Smith et al. [36]adjust for self-employment, unemployment, part-timeemployment, employment in specific industrial sectorsexcluded from insurance coverage to estimate denomi-nators for the province of Ontario. Using a similar pro-cedure for 10 years of data and 13 jurisdictions in thisstudy would be challenging. Therefore, this study usesworkers’ compensation data and estimates the burdenof compensated work-related disability of MSDs.Descriptive analysis was conducted for each countryby sex and age group representing varying stages of careerand injury risk (15–34, 35–54 and 55+) for the overallstudy period (2004–13). To examine whether expecteddifferences in disability burden by injury/disease groups,additional analyses were conducted for periods represent-ing different stages in the business cycle, including theeconomic growth period (2004–07), global economic re-cession (2008–09), and subsequent recovery (2010–13).For each analytical group and time period, the percentagechange in the number of time-loss claims and time-lossyears was calculated, as was the percentage change in eachgroups’ annual proportion of the total time-loss claimsand time-loss years. In addition to this, the annual percentMacpherson et al. BMC Public Health  (2018) 18:758 Page 3 of 11change (APC) of the proportion of total time-loss claimsand time-loss years for each age/sex group was estimated.This differs from other studies that have estimated theAPC of MSD incidence rates [37]. To estimate the APC,the estimates were rescaled by dividing each percentage inthe time series by the percentage at year 1 and then multi-plying by 100. The slope estimates of the resulting linearregression were then used to estimate the APC [37].ResultsMSD time-loss claimsFollowing the application of inclusion and exclusion cri-teria, there were 1,194,393 MSD claims in Canada and1,232,818 in Australia. The majority of these claims wereamong males (62.2% in both countries). Over the 10-yearstudy period, the number of claims declined by 24.6% inCanada and 20.5% in Australia. The decline was greateramong males in Canada (males: −28.9%; females: −16.7%)and Australia (males: −20.5%; females: −15.9%). While thenumber of claims declined for workers aged 15–54, itgrew for workers aged 55+ (Canada: 29.7%; Australia:32.3%), particularly among females (males: 24.7%; females:36.8% in Canada; males: 19.1%; 55.0%: females inAustralia) (Fig. 1 and Table 1).In both countries, the proportion of the total claimcount decreased for males (APC: −0.8, 95% CI −1.0% to−0.5% in Canada; APC: −0.8, 95% CI −1.1% to −0.6% inAustralia) and increased for females (APC: 1.4, 95% CI 0.9to 1.8% in Canada; APC: 1.5, 95% CI 1.1 to 2.2% inAustralia). The total proportion of claims increased for allworkers aged 55+, with greater increases among femalesin both countries (APC: 9.7, 95% CI 8.7 to 10.7% inCanada, APC: 11.2, 95% CI 10.3 to 12.1% in Australia) incontrast to males (APC: 7.2, 95% CI 6.8 to 7.6% in Canada;APC: 5.2, 95% CI 5.3 to 6.0% in Australia).Compared to the period of economic growth (2004–07), the global economic recession period (2008–09)resulted in a greater claim reduction in both countriesbut the decline was substantially larger in Canada(2004–07: −2.6%, 2008–09: −15.5% in Canada; 2004–07:−2.6%, 2008–09: −6.9% in Australia).MSD disability burdenTime-loss claims due to MSDs resulted in 239,345time-loss years in Canada and 321,488 in Australia (Fig. 2).Higher proportions of time-loss years were attributable tofemales (Canada: 64.4%; Australia: 61.5%). The number oftime-loss years decreased more in Canada (−38.1%) thanin Australia (−13.4%), and the decline was greatest amongmales (males: −42.0%, females: −35.9% in Canada;males: −14.8%, females: −12.6% in Australia). The APCof the proportion of time-loss years in Canada was 0.5%(95% CI 0.4 to 0.7%) for males and −1.0% (95% CI −1.3%to −0.6%) for females, with corresponding measures of−0.1% (95% CI −0.4 to 0.2%) for males and 0.2% (95% CI−0.3 to 0.7%) for females in Australia (Table 2).The number of time-loss years for workers aged 55+declined by 1.5% in Canada, with an increase for males(4.0%) and decrease for females (−10.9%). In contrast,time-loss years increased by 25.8% in Australia forworkers aged 55+, with an increase of 19.5% among malesand 38.0% among females. In Canada, the APC in the pro-portion in time-loss years was 7.2% (95% CI 6.7 to 7.7%)among males and 5.2% (95% CI 4.8 to 6.2%) among fe-males aged 55+. In Australia, males aged 55+ had a slowergrowth in the proportion of time-loss years (APC: 4.5,95% CI 3.9 to 5.0%) compared with females aged 55+Fig. 1 Number of time-loss claims for musculoskeletal disorders by country, sex, and age groupMacpherson et al. BMC Public Health  (2018) 18:758 Page 4 of 11(APC: 7.5, 95% CI 6.2 to 8.9%) (Fig. 3). Another notabledifference between the countries was the extent of changein time-loss years before and during the global economicrecession period: in Canada, this changed from 1.4%(2004–07) to −19.9% (2008–09), compared to 3.4% (2004–07) to −6.6% (2008–09) in Australia (see Additional file 2).Injury stratification: Fractures vs. MSDs of the backThe number of time-loss claims declined by a smallermargin for fractures (Canada: −14.8%; Australia: −13.2%)than MSDs of the back (Canada: −34.4%; Australia−30.8%) (Table 1). The growth in absolute number ofclaims for workers aged 55+ in Canada was greater forfemales than males, and greater for fractures (male: 32.3%;female: 49.9%) than MSDs of the back (male: 5.5%; female:13.2%). Similar trends were evident in Australia (male:8.8%, female: 59.5% for fractures; male: 0.8%, female:36.7% for MSDs of the back).Time-loss years presented a sharper decline in MSDsof the back (Canada: −56.0%; Australia: −25.7%) thanfractures (Canada: −19.6%; Australia: −11.5%). The APCin Canada showed that there was a growing proportion oftime-loss years attributable to females with fractures(APC: 1.0, 95% CI 0.1 to 2.0%), but no increase for MSDsof the back (APC: −0.1, 95% CI −0.6 to 0.3%). In Australia,there was a decreasing APC for males in both injury group-ings (APC: −0.7, 95% CI −1.0% to −0.4% for fractures;APC: −0.1, 95% CI -0.5 to 0.2% for MSDs of the back).Table 1 Summary of changes in time-loss claims between 2004 and 2013, by sex, age group, injury type, and countryCanadaMSDs Fractures MSDs of the back% Change APC % Change APC % Change APCTotal Total −24.6 – −14.8 – −34.4 –Male −28.9 −0.8 (−1.0 to −0.5) −20.3 −0.8 (−1.1 to −0.6) −37.7 −0.7 (−0.9 to −0.4)Female −16.7 1.4 (0.9 to 1.8) 2.8 2.7 (1.8 to 3.5) −28.2 1.2 (0.8 to 1.7)15–34 Total −34.0 −1.6 (−2.0 to −1.2) −26.3 −1.8 (−2.5 to −1.0) −40.4 −1.1 (−1.4 to −0.8)Male −38.1 −2.2 (2.9 to −1.7) −28.8 −2.1 (−2.9 to −1.2) −44.2 −1.7 (−2.1 to −1.4)Female −24.5 −0.1 (−0.5 to 0.3) −14.0 −0.1 (−1.1 to 0.9) −32.0 0.2 (−0.4 to 0.8)35–54 Total −29.6 −0.7 (−0.9 to −0.4) −24.3 −1.2 (−1.4 to −0.9) −37.8 −0.5 (−0.7 to −0.3)Male −33.0 −1.3 (−1.4 to −1.2) −28.2 −1.7 (−2.1 to −1.3) −40.3 −1.1 (−1.3 to −0.9)Female −24.1 0.4 (−0.3 to 1.0) −12.2 0.5 (−0.5 to 1.5) −33.4 0.5 (−0.2 to 1.1)55+ Total 29.5 8.2 (7.7 to 8.7) 38.7 7.3 (6.4 to 8.2) 8.4 7.4 (6.9 to 8.0)Male 24.7 7.2 (6.8 to 7.6) 32.3 5.8 (4.8 to 6.8) 5.5 6.6 (6.1 to 7.1)Female 36.8 9.7 (8.7 to 10.7) 49.9 9.8 (7.8 to 11.8) 13.2 8.8 (7.9 to 9.7)AustraliaMSDs Fractures MSDs of the back% Change APC % Change APC % Change APCTotal Total −20.5 – −13.2 – −30.8 –Male −25.2 −0.8 (−1.1 to −0.6) −21.2 −1.0 (−1.2 to −0.8) −36.0 −1.0 (−1.2 to −0.7)Female −11.9 1.5 (1.1 to 2.0) 9.1 2.8 (2.3 to 3.3) −20.3 2.0 (1.4 to 2.5)15–34 Total −33.9 −1.9 (−2.4 to −1.5) −24.8 −1.7 (−2.0 to −1.3) −39.8 −1.4 (−1.8 to −1.0)Male −37.5 −2.5 (−3.1 to −2.0) −29.6 −2.2 (−2.7 to −1.7) −44.4 −2.2 (−2.7 to −1.6)Female −25.5 −0.5 (−0.8 to −0.3) −3.6 0.6 (−0.2 to 1.4) −27.6 0.5 (0.1 to 1.0)35–54 Total −22.1 −0.2 (−0.5 to 0.0) −16.3 −0.5 (−0.7 to −0.3) −31.8 −0.2 (−0.5 to 0.1)Male −24.7 −0.8 (−1.1 to −0.6) −20.6 −1.0 (−1.3 to −0.8) −35.4 −1.1 (−1.4 to −0.7)Female −18.0 0.7 (0.0 to 1.4) −5.7 0.8 (0.4 to 1.3) −25.6 1.2 (0.5 to 2.0)55+ Total 32.3 7.7 (7.3 to 8.1) 28.7 6.1 (5.2 to 7.0) 12.9 7.2 (6.8 to 7.6)Male 19.1 5.6 (5.3 to 6.0) 8.8 3.5 (2.8 to 4.2) 0.8 5.1 (4.6 to 5.7)Female 55.0 11.2 (10.3 to 12.1) 59.5 10.1 (8.4 to 11.8) 36.7 11.3 (10.4 to 12.2)MSDs refers to musculoskeletal disorders. % change refers to the absolute change in time-loss claims for each subgroup between 2004 and 2013. Annual percentchange (APC) refers to the slope estimate from the linear regression of the subgroup proportions of total time-loss claims rescaled to 2004. 95% confidenceintervals are in parenthesesMacpherson et al. BMC Public Health  (2018) 18:758 Page 5 of 11In Canada, the number of time-loss years for workersaged 55+ increased overall and among both men andwomen with fractures (male: 19.3%, female: 21.1%) anddecreased overall for MSDs of the back (male: −33.5%,female: −38.9%). In contrast, the number of time-lossyears for the same age group in Australia grew overalland for both men and women across all injury groups(male: 2.2%, female: 47.7% for fractures; male: 0.3%;female: 11.7% for MSDs of the back). APC statistics forCanada show that the proportion of time-loss yearsattributable aged 55+ were similar for males and femalesfor fracture injuries and MSDs of the back (male APC:5.0, 95% CI 3.6 to 6.3%, female APC: 5.2, 95% CI 3.8 to6.7%) (male APC: 5.6, 95 4.7 to 6.5%; female APC: 5.3,95% CI 3.4 to 7.2%). Corresponding figures for Australiashow that proportion of time-loss years attributable tofemales aged 55+ grew faster across all injury groups butwith greater differences in fractures (male APC: 2.7,95% CI 1.7 to 3.7%; female APC: 8.7, 95% CI 6.6 to10.8%), than MSDs of the back (male APC: 4.4, 95% CI3.5 to 5.3%; female APC: 6.5, 95% CI 4.4 to 8.6%). Accord-ingly, greater sex differences were observed in time-lossyears in Australia in both absolute and relative terms.DiscussionThe objectives of this study were (1) to identify age andsex trends in the compensated disability burden of work-related MSDs in Canada and Australia; and (2) to demon-strate a means of comparing workers’ compensation datainternationally. The findings illustrate how disabilityburden is subject to age and sex group differences, anddependent on the nature of the injury. Fractures representan injury that is easier to diagnose, claim, and recoverfrom, compared to MSDs of the back (for example, backstrains) which are subject to age and sex differences inpain threshold, and may have stronger psychosocialcharacteristics related to them [34, 38]. In addition tothe trends over the 10-year period, a noticeable short-term trend was evident in the decline in claims andtime-loss years coinciding with the global economicrecession (2008–09). Potential reasons for the drop inclaims and time-loss years are that during recessions,layoffs, closures and reduced hiring result in fewer inex-perienced workers on the job, and therefore fewer work-place injuries; and, workers may have greater motivationto defer or suppress the reporting of work-related injuryor illness due to concerns about their job security [24].Another factor may be changes in medical practices withlower propensity of physicians to suggest patients to claimfor compensation [39]. By using comparable data fromtwo different countries, this study has shown that the dropin claims and time-loss years was greater in Canada thanAustralia. This finding is likely a reflection of how the glo-bal economic recession had a larger and more immediateeffect in Canada than Australia [40]. Furthermore, thisstudy also revealed greater variation with business cycleamong more complex injury groups (e.g., MSDs of theback) than a more easily diagnosable traumatic injurygrouping (e.g., fractures) [34].This study has a number of strengths and uniquecontributions. We analysed large, administrative data-sets to provide a population-based overview of the timetrends in age and sex on disability due to work-relatedMSDs. In contrast to other studies on ageing [15–17],this study examined both age and sex differences ondisability and did so using data from 13 jurisdictionsacross two countries over 10 years. Building on existingwork disability studies using multiple jurisdictions at theFig. 2 Number of time-loss years for musculoskeletal disorders by country, sex, and age groupMacpherson et al. BMC Public Health  (2018) 18:758 Page 6 of 11national level [6, 41], this study demonstrates a method inwhich workers’ compensation data can be comparedinternationally. The study also adds further knowledgeon trends in work-related MSDs from single [37], andmulti-jurisdictional studies on MSDs [22] by not onlylooking at the number of time-loss claims but also sub-sequent years of time-loss to show relative similaritiesand differences between the two measures. Lastly, itdemonstrates how novel partnerships between workers’compensation boards and academic research institu-tions can maximize the potential of rich administrativedata to conduct research with policy relevance [19].The study has the following limitations. First, the dataused only work-related MSDs with at least one day ofcompensated time loss. As such, this study underestimatesthe true burden of disability, as it did not capturework-related MSDs that go unreported, do not have timeoff, or are rejected. It is possible that supplementing thisstudy with additional data sources, such as hospital re-cords would show different trends, as found in other stud-ies [42]. Second, the outcome measure, time-loss years,only captured compensated time-loss for injured workersin which RTW was expected within a given time point.This differs from other, more extensive measures, such asdisability-adjusted life years (DALY) which combines yearsof life lost (YLL) due to premature mortality and yearslived with disability (YLD) [43], or years of productivitylost (YPL) which uses actual compensated and futureTable 2 Summary of changes in time-loss years between 2004 and 2013, by sex, age group, injury type, and countryCanadaMSDs Fractures MSDs of the back% Change APC % Change APC % Change APCTotal Total −38.1 – −19.6 – −56.0 –Male −35.9 0.5 (0.4 to 0.7) −21.7 −0.3 (−0.6 to 0.0) −56.6 0.1 (−0.2 to 0.3)Female −42.0 −1.0 (−1.3 to −0.6) −12.2 1.0 (0.1 to 2.0) −55.1 −0.1 (−0.6 to 0.4)15–34 Total −44.2 −0.7 (−1.5 to 0.1) −28.8 −1.0 (−2.1 to 0.1) −57.1 0.3 (−0.7 to 1.3)Male −43.4 −0.4 (−1.2 to 0.5) −27.8 −1.1 (−2.1 to 0.0) −57.7 0.4 (−0.5 to 1.3)Female −46.1 −1.5 (−2.4 to −0.5) −34.5 −0.8 (−3.3 to 1.6) −55.7 0.2 (−1.3 to 1.7)35–54 Total −44.9 −1.4 (−1.7 to −1.0) −28.3 −1.3 (−1.9 to −0.9) −59.6 −1.2 (−1.6 to −0.8)Male −42.8 −0.8 (−1.1 to −0.4) −30.7 −1.5 (−2.0 to −0.9) −60.6 −1.2 (−1.6 to −0.7)Female −48.3 −2.3 (−2.9 to −1.7) −18.8 −0.9 (−2.5 to 0.7) −57.9 −1.2 (−2.0 to −0.5)55+ Total −1.5 6.5 (6.1 to 6.8) 16.8 5.1 (4.0 to 6.1) −35.4 5.5 (4.4 to 6.5)Male 4.0 7.2 (6.7 to 7.7) 19.3 5.0 (3.6 to 6.3) −33.5 5.6 (4.7 to 6.5)Female −10.9 5.2 (4.5 to 5.9) 12.1 5.2 (3.8 to 6.7) −38.9 5.3 (3.4 to 7.2)AustraliaMSDs Fractures MSDs of the back% Change APC % Change APC % Change APCTotal Total −13.4 – −11.5 – −25.7 –Male −12.6 −0.1 (−0.4 to 0.2) −15.6 −0.7 (−1.0 to −0.4) −25.8 −0.1 (−0.5 to 0.2)Female −14.8 0.2 (−0.3 to 0.7) 0.2 2.1 (1.2 to 2.9) −25.6 0.3 (−0.4 to 0.9)15–34 Total −24.8 −1.5 (−2.4 to −0.5) −25.9 −1.8 (−2.5 to −1.2) −32.3 −0.9 (−1.9 to 0.2)Male −26.4 −1.8 (−2.8 to −0.8) −27.7 −2.1 (−2.9 to −1.4) −34.7 −1.2 (−2.4 to 0.0)Female −21.1 −0.7 (−1.7 to 0.2) −17.3 −0.4 (−2.2 to 1.4) −25.9 0.1 (−0.5 to 0.6)35–54 Total −18.2 −0.7 (−1.1 to −0.3) −12.9 −0.6 (−1.1 to 0.0) −28.0 −0.5 (−1.1 to 0.0)Male −14.0 −0.5 (−0.9 to 0.0) −12.5 −0.8 (−1.6 to −0.1) −25.7 −0.4 (−1.3 to 0.4)Female −23.7 −1.1 (−1.8 to −0.5) −13.8 0.1 (−0.6 to 0.9) −31.4 −0.7 (−1.5 to 0.1)55+ Total 25.8 5.5 (4.9 to 6.2) 17.2 4.7 (3.6 to 5.7) 3.9 5.1 (4.1 to 6.1)Male 19.5 4.5 (3.9 to 5.0) 2.2 2.7 (1.7 to 3.7) 0.3 4.4 (3.5 to 5.3)Female 38.0 7.5 (6.2 to 8.9) 47.7 8.7 (6.6 to 10.8) 11.7 6.5 (4.4 to 8.6)MSDs refers to musculoskeletal disorders. % change refers to the absolute change in time-loss years for each subgroup between 2004 and 2013. Annual percentchange (APC) refers to the slope estimate from the linear regression of the subgroup proportions of total time-loss years rescaled to 2004. 95% confidenceintervals are in parenthesesMacpherson et al. BMC Public Health  (2018) 18:758 Page 7 of 11predicted time-loss from work due to work-related injuryor illness [44]. Nonetheless, cumulative compensatedtime-loss has been identified as the most accuratemeasure of time-loss when using administrative data[45]. Third, by restricting this study to only numerators(compensated MSDs by sex and age group), the estimatesare not adjusted for compositional changes in the Canad-ian and Australian workforces and are therefore notgeneralizable to the overall workforce. Fourth, there arelikely to be remaining jurisdictional differences in the datadespite the efforts taken to make them comparable. Forexample, it was not possible in the Australian data toensure that time-loss compensation was only for tempo-rary total disability or temporary partial disability, as itwas with the Canadian data. As a result, it is possible thatthe greater time-loss years observed in Australia may beinflated by the inclusion of time-loss payments for injuredworkers undergoing vocational rehabilitation or medicalvisits. The final challenge and limitation with the analysisof this study is that it is difficult to distinguish between achange in claims or time-loss due to economic conditionsor policy. For example, the drop in claims and time-loss inCanada during 2008–09 coincides with the global eco-nomic recession as well as major policy changes intwo of the jurisdictions. For instance, Ontario’s Work-place, Safety and Insurance Board, which oversees 38.3%of the Canadian claims, introduced a change in the wayclaims were paid compensation in 2009, resulting inclaims no longer being paid for extended durations.Similarly, it is likely that the decline in the time-lossclaims in the Australia data during the 2012–13 wasinfluenced by a 2012 legislative change in the state ofNew South Wales [46].The findings from this study are relevant to occupa-tional health researchers, workers’ compensation boards,and employers in informing future research and practice.The ageing of the workforce is likely to continue in-creasing for the foreseeable future and will contribute toa greater proportion of the disability burden due to workinjury. Despite the growing proportion of female andolder female workers in developed countries, the evi-dence in Canada suggests that attention should be givento both older male and female workers, especially as re-sults showed that the proportion of compensated dis-ability burden was growing faster among males aged 55+than females aged 55+. This finding suggests that claimsmanagement should focus on identifying areas in whichreductions can be made to the disability duration ofolder workers, such as more opportunities for education,modified duties, and vocational rehabilitation [1].Through conducting an international comparisonstudy of Canada and Australia, this study identified simi-larities and differences in the burden of work-related dis-ability. Similarities included: the long-term decrease inthe total number of claims and time-loss years overall;the relative increase in total number of claims andtime-loss years among older workers (aged 55+); and,the short-term decrease in claims and time-loss yearscoinciding with the global economic recession. Differ-ences included: the long-term decrease in time-loss yearsbeing greater in Canada; the increase in time-loss yearsgrowing faster among older males in Canada but olderfemales in Australia; and the steeper decline in claimsand time-loss during recession period in Canada. Theimplications are that while the overall disability burdenhas decreased, age-stratification showed an increasedFig. 3 Percentage of total time-loss years for musculoskeletal disorders by country, sex, and age groupMacpherson et al. BMC Public Health  (2018) 18:758 Page 8 of 11disability burden of older workers. The consistency ofthis finding suggests that Canada and Australia facesimilar challenges in terms of changing demographics ofdisability burden, as may other developed and ageingeconomies.ConclusionsWorkforces in developed countries are becoming olderand have growing proportions of females. These demo-graphic changes to workforces are resulting in a grow-ing proportion of the disability burden towards olderworkers but not necessarily older female workers. Em-ployers and workers’ compensation boards should focustheir efforts on helping reduce the number and durationof time-loss claims among older workers. Comparativeresearch made possible through research-stakeholderpartnerships offer a unique opportunity to use existingadministrative data to identify long-term trends in dis-ability burden. Future research can apply similar methodsand approaches for estimating long-term trends in occu-pational health to similar data sources in other countrycontexts.Additional filesAdditional file 1: Injury codes and descriptions used to identify similarinjury claims in the Canadian and Australian workers’ compensation data,including Canadian Standards Association (CSA) Z785 nature of injuryand part of body codes and Australian Type of Occurrence ClassificationSystem (TOOCS) nature of injury and disease, and bodily location codes.(XLSX 19 kb)Additional file 2: Supplementary results tables, including the annualnumber of time-loss claims by MSDs/Fractures/MSDs of the back by sexand age group, 2004–13, Canada and Australia; annual number of time-lossyears by MSDs by sex and age group, 2004–13, Canada and Australia.(XLSX 111 kb)AbbreviationsAPC: Annual percent change; CI: Confidence interval; ComPARE: CompensationPolicy and Return to Work Effectiveness; CSA: Canadian Standards Association;DALY: Disability-adjusted life years; GBD: Global Burden of Disease;MSD: Musculoskeletal disorder; NDS: National Data Set for Compensation-basedStatistics; RTW: Return-to-work; TOOCS: Type of Occurrence ClassificationSystem; YLD: Years lived with disability; YLL: Years of life lost; YPL: Years ofproductivity lostAcknowledgementsThe authors would like to acknowledge the contribution of provincial, state,and territory workers’ compensation organizations for data provision.Acknowledgements are also extended to the comparative research team,including Benjamin Amick, Sheilah Hogg-Johnson, Mieke Koehoorn, andPeter Smith, Hui Shen and Jon Fan for assistance with preparation of theCanadian data, and Dawn Mooney for the creation of the figures.FundingSupported by a grant from Canadian Institutes for Health Research OperatingGrant ‘Return to work after work injury and illness: An international comparativeeffectiveness study of Canada, Australia and New Zealand (Application Number326950), the Research and Workplace Innovation Program of the WorkersCompensation Board of Manitoba, and SafeWork Australia and WorkSafeVictoria for the Insurance, Work and Health Group’s ComPARE Project. Allinferences, opinions, and conclusions drawn in this study are those of theauthors and do not reflect the opinions of WCB Alberta, WCB Manitoba,WorkSafeBC, WorkSafeNB, WSIB Ontario, WorkSafe Victoria, State InsuranceRegulatory Authority of New South Wales, Office of Industrial RelationsQueensland Government, ReturnToWork South Australia, WorkCover WesternAustralia, WorkCover Tasmania, NT WorkCover, the Department of Treasury ACTGovernment, or SafeWork Australia.Availability of data and materialsThe datasets analysed in this study are not publicly available. The datasetswere under various information sharing agreements adhering to Canadianand Australian privacy legislation that impose legal restrictions in accessing,using, and further disclosing of workers’ compensation data. Furthermore,British Columbia privacy legislation restricts research data to be accessible inCanada only. As this is a comparable study, all the Canadian data fall underthis legislation.Authors’ contributionsRAM, TJL, AC, and CBM contributed to the design of the study. RM and TLconducted the analyses, results interpretation, and drafted the manuscript.AC and CBM contributed to results interpretation and manuscript preparation.All authors approved the final manuscript.Ethics approval and consent to participateEthical approval for the research project was obtained from the BehaviouralResearch Ethics Board at the University of British Columbia (certificate numberH13–00896) and the Monash University Human Research Ethics Committee(project number CF14/2995–2014001663).Canadian data access was provided by Population Data BC. Use of data forresearch purposes were governed by an agreement between the datastewards and the researchers. Australian data access was provided bySafeWork Australia as part of the Compensation Policy and Return to WorkEffectiveness (ComPARE) Project at the Institute for Safety, Compensationand Recovery Research.Competing interestsThe authors declare they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Partnership for Work, Health and Safety, School of Population and PublicHealth, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3,Canada. 2Insurance, Work and Health Group, Faculty of Medicine Nursingand Health Sciences, Monash University, Melbourne, VIC, Australia. 3Institutefor Work & Health, Toronto, ON, Canada.Received: 19 December 2017 Accepted: 23 May 2018References1. Algarni FS, Gross DP, Senthilselvan A, Battié MC. Ageing workers with work-related musculoskeletal injuries. Occup Med. 2015;65:229–37. https://doi.org/10.1093/occmed/kqu213.2. 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