J Occup Rehabil (2010) 20:220–234DOI 10.1007/s10926-009-9210-3 A Systematic Review of Workplace Ergonomic Interventions with Economic Analyses Emile Tompa • Roman Dolinschi • Claire de Oliveira • Benjamin C. Amick III • Emma Irvin Published online: 5 November 2009 Ó Springer Science+Business Media, LLC 2009 Abstract Introduction This article reports on a systematic sector limited evidence, and in remaining sectors insuffi- review of workplace ergonomic interventions with eco- cient evidence. Conclusions Most intervention studies nomic evaluations. The review sought to answer the ques- focus on effectiveness. Few consider their financial merits. tion: ‘‘what is the credible evidence that incremental Amongst the few that do, several had exemplary economic investment in ergonomic interventions is worth undertak- analyses, although more than half of the studies had low ing?’’ Past efforts to synthesize evidence from this literature quality economic analyses. This may be due to the low have focused on effectiveness, whereas this study synthe- priority given to economic analysis in this literature. Often sizes evidence on the cost-effectiveness/financial merits of only a small part of the overall evaluation of many studies such interventions. Methods Through a structured journal focused on evaluating their cost-effectiveness. database search, 35 intervention studies were identified in nine industrial sectors. A qualitative synthesis approach, Keywords Economic evaluation Ergonomics known as best evidence synthesis, was used rather than a Systematic review quantitative approach because of the diversity of study designs and statistical analyses found across studies. Evi- dence on the financial merits of interventions was synthe- Introduction sized by industrial sector. Results In the manufacturing and warehousing sector strong evidence was found in support of Workplace ergonomic programs are implemented to help the financial merits of ergonomic interventions from a firm ensure that work systems (equipment, tools, work stations, perspective. In the administrative support and health care work and workplace organization and policies/procedures) sectors moderate evidence was found, in the transportation enhance employee health and safety and optimize business performance (i.e. efficiency, productivity, quality and E. Tompa (&) R. Dolinschi C. de Oliveira profitability). In the last few years, there has been increasing B. C. Amick III E. Irvin recognition of the importance of ergonomics in workplace Institute for Work & Health, 481 University Avenue, Suite 800, settings. The scientific evidence on the effectiveness of Toronto, ON M5G 2E9, Canada ergonomic programs, policies and practices for reducing e-mail:
[email protected] injuries is less robust than one might expect despite the E. Tompa increased use of ergonomic standards and guidelines [1]. Department of Economics, McMaster University, Several systematic reviews have investigated the effec- Hamilton, ON, Canada tiveness of ergonomic interventions. Among them, Rivilis E. Tompa et al. undertook a systematic review of the effectiveness Dalla Lana School of Public Health, University of Toronto, of participatory ergonomic interventions [2]. The review Toronto, ON, Canada found partial to moderate evidence that participatory ergo- nomic interventions can reduce musculoskeletal (MSK) B. C. Amick III School of Public Health, University of Texas symptoms, workers’ compensation claims and sickness Health Science Center, Houston, TX, USA absence. Brewer et al. conducted a systematic review of 123 Ergonomic Abstracts and Business ventions is as critical for decision making as is knowledge Source Premier. We also searched the given to economic analyses by evaluators. Specifically. or due to the low priority studies identified by content experts. framework was subsequently customized for the remaining databases. cost-benefit analysis). (3) financial merits. First. mation on the financial implications of ergonomic inter. and (4) the type of economic analysis or outcome measure dence that incremental investment in ergonomic interven. Relevant English-language studies were identified published ergonomic intervention studies focus on an through four sources: (1) structured database searches. established methodology that has been used extensively to tions among computer users have an effect on MSK or visual synthesize evidence of quantitative phenomena in cases health.g. dence about a phenomenon. Several additional inclusion/exclusion criteria were Methods developed and considered while reviewing titles.The systematic review process However. They found mixed evidence that office interven. [1]. complete infor. personal communication). (3) study draws these conclusions from a synthesis of several identifying relevant studies. financial merits of ergonomic interventions. and (6) synthesizing to provide actionable messages for safety professionals. intervention). effectiveness evaluations is also likely related to practical For articles with multiple case studies. (e. There is no strong across studies—to make statements about the level of evi- evidence for any one specific intervention being effective. good quality financial data. (4) assessing the quality of systematic reviews on the topic of ergonomics. there is effectiveness evidence for multi-compo. The ducting a structured and comprehensive literature search. Undoubtedly. (2) con- nent programs and combinations of interventions [1]. (2) the setting (e. and (4) a request for and safety (OHS) researchers. bibliographies of included studies for incremental studies. EMBASE. not its cost-effectiveness/ other systematic reviews completed or underway [2. systematic reviews of ergonomic interventions to investi. it workplace). or review the findings from several systematic reviews where each review synthesizes the evidence on one Literature Search and Study Identification aspect of ergonomics to identify best-practice guidelines. each study was workplace limitations that can make it difficult to obtain considered separately. 5]. This is a well users [3]. Given the growing awareness of workplace ergonomics This review is a sub-set of a systematic review that importance amongst safety professionals and researchers. 2006. 7]. This decision was based on the findings of an environmental scan [8]. and (3) the consistency of findings integrated approaches to control exposure. only studies published 123 . Five journal databases were considered: MEDLINE. (5) extracting data from studies. BIOSIS. Amick et al. abstracts and full articles in an effort to narrow the focus. Most study. Thus. where In this study we synthesize the evidence on the financial few workplace studies with economic evaluations published merits of ergonomic interventions that include an economic prior to 1990 were identified. At least one keyword from each tions is worth undertaking?’’ This is one of the first of the four categories needed to be included in the title. the lit- is surprising that the literature regarding the financial erature search described draws on the methods from that merits of ergonomic programs is underdeveloped. The intent is studies. The lack of cost. The question guiding this review was identified since they are unlikely to sift through the mass of scientific above.g. the evidence. (3) the outcome measure (e. reviewed.g. work injury) seeks to answer the question: ‘‘What is the credible evi. This gate the financial merits of such interventions. (2) specific ergonomic tools/procedures. in an article on evidence-based best ergo. A keyword search was to provide new information to decision makers by syn. The essence of the approach involves considering three nomic practices. Several other databases were tested. developed for use with MEDLINE based on four criteria: thesizing the evidence across a number of studies on the (1) the type of study (e.g. but are more about the number of studies. consists of six steps: (1) developing a question. it included all types of OHS interventions [6].J Occup Rehabil (2010) 20:220–234 221 workplace interventions directed at preventing/reducing evaluation using a qualitative evidence synthesis approach MSK and visual symptoms and disorders among computer known as ‘‘best-evidence synthesis’’ [4. but about their effectiveness. suggest that best practices are not about aspects of the evidence base—(1) the quality of studies. Below we describe steps two through six in detail. no effect of rest breaks and study designs and statistical analyses in the literature being exercise and positive effect of alternative pointing devices. This may be due to limited expertise in a summary table of studies on office ergonomics (Goggins economic evaluation methodologies by occupational health RW. publications. Second. abstract or classification terminology of a citation. The study also found moderate evidence for no effect where Meta analysis is not possible due to the diversity of of workstation adjustment. studies Overview had to be published from 1990 onward. This systematic review attempts did not produce relevant studies. (2) intervention’s effectiveness. In some cases where a question Quality Assessment was not applicable to a particular study the question was labeled ‘NA’ and was not counted in the quality assessment All studies that met the subject matter and other inclusion scoring for that study. These guidelines have been expanded average of the overall scores between the two reviewers upon and discussed at length in an economic evaluation constituted the final study score. For example. We refer readers to these were excluded based on several criteria concerning context sources for details. The average score across the 14 items in the tool con- surement and analytic factors. The quality assessment tool we developed was tion of OHS interventions assessed the quality of each based on a recently published environmental scan of OHS study. study design and issues related to evaluating the interven- related or on a military base. A study with a final score Table 1 Quality assessment Overarching questions that frame the purpose of the study and the nature of the intervention tool (1) Was the conceptual basis of. and (3) computational and stituted the overall study score given by a reviewer. The intent of these meetings was methodological issues and identified guidelines for good not to reach consensus. primary focus was to assess the quality of evidence related ondary prevention outcome). In contrast. The tool’s (these were included only if there was a primary or sec. (2) developed countries). a (Table 1). categories: (1) study design and related factors. a study on a particular dimension is a common technique in best-evidence synthesis. (2) mea. The reporting factors. and subject matter: (1) if the intervention was undertaken in The questions in the quality assessment tool were divi- a developing country (based on the notion that the OHS ded into four sections: (1) overarching issues that frame the context in developing countries is very different than that in purpose of the study and the nature of the intervention. Third.222 J Occup Rehabil (2010) 20:220–234 in a peer-reviewed journal were considered. (3) measurement and analytic issues focused exclusively on non-health consequences such as related to the economic analysis. criteria were retained for quality assessment and data Two reviewers with expertise in the economic evalua- extraction. given the perspective? (11) Are the measures of costs and consequences appropriate? (12) Was there appropriate adjustment for inflation and time preference? (13) Was there appropriate use of assumptions and treatment of uncertainty? Discussion and interpretation of results (14) Did the presentation and discussion of study results include all issues of concern? 123 . and intensity of involvement in the intervention appropriate? (7) Are the outcomes included in the analysis appropriate? Measurement and analytic issues related to the economic evaluation (8) Were all relevant comparators explicitly considered? (9) Was the study perspective explicitly stated and appropriate? (10) Were all important costs and consequences considered in the analysis. clustered under three broad ation of all relevant aspects of the study. The guidelines consist of 10 issues to consider assessment of each study was based on a sound consider- in an economic evaluation. to increase productivity. though consideration was given study that focused on redesigning equipment and work flows to the effectiveness analysis. and (4) issues related to cost reduction and/or productivity/quality improvement the discussion and interpretation of results. where one corresponded to the lowest score and five included if it gave consideration to the health outcomes to the highest. The reviewers met on a regular basis to discuss their intervention studies with economic analyses that reviewed assessment of each study. and/or the need for the intervention explained and sound? (2) Was the intervention clearly described? (3) Were the study population and context clearly described? Study design and issues related to evaluation of the intervention’s effectiveness (4) Rank the means by which selection and confounding are controlled for through study design? (5) Were appropriate statistical analyses conducted? (6) Are exposure. Each item was ranked on a five-point Likert study that focused on reducing insurance costs. but rather to ensure that the quality practice [8]. without considering or measuring The quality assessment tool included 14 questions health consequences would not be included. would be scale. (2) if the industry/context was army. Use of a Likert scale to assess the quality of underlying insurance claims and costs. studies methods text for researchers [9]. an engineering to the economic analysis. and (3) if the intervention was tion’s effectiveness. involvement. and (4) characteristics of the economic and from the Ministry of Labour in Ontario. and matter inclusion criteria underwent data extraction. then at least 67 per cent of the medium and high quality studies agree. If score between 3. Canada). rep- evaluation. Although all studies meeting subject tions in Ontario. a private sector business representative. EMBASE in evidence.381 hits. and also for the subset of review such as subject matter framing. industry and occu- pational group targeted. The industrial sector. (2) details of the intervention. strategy. As noted. 6.696 hits.568 hits.4 was considered to provide low quality Evidence for a particular stratum of studies was first tested evidence related to the economic analysis. BIOSIS in 2. Only these criteria were not met. and if it was not between 2. Literature Searches The level of evidence was ranked on a five-category scale consisting of strong evidence. The Data Extraction evidence ranking algorithm can be found in Table 2. criteria for the three levels. synthesis criteria and presentation of findings. and a met. limited The MEDLINE search resulted in 6. The committee was consulted at the initial Evidence Synthesis stages of developing the project. then it fit into one of the two categories. The group met at three points during the systematic review process.) Mixed None of the above criteria are met and findings from medium and high quality studies are contradictory Insufficient There are no high quality studies.J Occup Rehabil (2010) 20:220–234 223 between 1 and 2.5 and 5 indicated high quality. 5]. the criteria for moderate evidence were considered. Results tionship based on the quality. then at least 50 per cent of the medium and high quality studies agree. the criteria for limited evidence studies receiving a score in the medium and high quality were considered. moderate evidence. If the evidence did not meet any of the range were retained for evidence synthesis.5 and 3. Business Source Premier Table 2 Criteria for levels of evidence Level of evidence Minimum criteria Strong Three high quality studies agree on the same findings (If there are more than three studies. review scope. A final score against the criteria for the strong evidence. mixed evidence and insufficient evidence. review. Evidence was also synthesized across all committee was consulted to get feedback on aspects of the studies regardless of sector. mixed evidence or insufficient/no evidence. it is a qualitative approach that assesses the level of evidence on a particular rela.4 represented medium quality. In total there were more than 40 items extracted resentatives from the provincial health and safety associa- from each study [6]. then at least 75 per cent of medium and high quality studies agree.) Moderate Two high quality studies agree or Two medium quality studies and one high quality study agree (If there are more than three studies. Data extraction focused on four areas of the study: (1) Stakeholder Involvement contextual factors such as jurisdiction.) Limited There is one high quality study or Two medium quality studies that agree or One high quality study and one medium quality study that agree (If there are more than two studies. (3) An advisory committee consisting of representatives from characteristics of the epidemiologic design and related the policy arena (from the workers’ compensation authority statistical analyses. search studies that were about participatory ergonomic interven. only one medium quality study and/or any number of low quality studies 123 . only a senior academic researcher in the ergonomics field was medium and high quality studies were included in evidence formed to guide the design and execution of this systematic synthesis. quantity and consistency of findings in the relevant studies. tions. Slavin’s best evidence synthesis approach was used for this purpose [4. mid-way when study identification stage had been completed and near the end of The primary stratification for evidence synthesis was by the project when the final report was being developed. some of which were example. a study by Rempel et al. Once these citations were merged and provide a detailed description of the key methodological duplicates were removed. retail and trade and transportation. 7 low quality Information and culture As noted. manufacturing and Public administration warehousing. studies receiving a low quality score were ment and health care components of these expenses and the monetary value of absenteeism. 67 studies were in six industry sectors: administrative and articles with 72 case studies with economic analyses were support services. four Retail and trade had a sufficient number of studies to make a definitive 1 intervention: 1 medium quality statement about the evidence. Two studies were in Canada. 4 low quality health care. mechanical patient lifts customer service workers at a computer based call center. two in Australia and few good quality studies assessing the effectiveness of one each in Sweden and the Netherlands. 5 low quality effectiveness and economic analyses. but the occupational group was others were capital intensive (e. public administration and Multi-sector multi-sector) had only one low quality study each. information and culture. not because there are States. The 16 remaining 12. while two undertook a partial evaluation (i. Ergonomic Abstracts in 25 hits and other excluded from the synthesis). information and culture. It includes an overall Administrative and support description of the intervention and details on both the 8 interventions: 2 high quality. 2 medium quality substantive conclusions about the level of evidence. which was insufficient to make any 3 interventions: 1 high quality. Table 3 Summary of the number of ergonomic studies identified Table 4 provides details on each of the sixteen studies by industry retained in the systematic review.g. 1 intervention: 1 low quality Health care Evidence Synthesis 10 interventions: 3 medium quality. A summary of the number of participatory ergonomic interventions and three were ergonomic studies identified by industry can be found in ergonomic education programs on back health and safety. in hospitals. health care.e. 123 . Three 1 intervention: 1 low quality sectors (educational services. 35 of which focused on ergonomic interventions. fact that few effectiveness studies in the OHS literature Most studies (10 of 16) were undertaken in the United undertake an economic evaluation. Most studies were focused on primary prevention with one study considering both primary and secondary prevention. all adopted a firm perspective.224 J Occup Rehabil (2010) 20:220–234 in 687 hits. 1 medium quality. 9 interventions: 3 high quality. the total number of citations was shortcomings identified in the studies. left. and retail and trade—had only one medium quality study each. evaluations (i. They sector based on the occupation rather than industry. After inclusion/exclusion criteria were applied. In the discussion section we sources in 199 hits. For covered a wide range of features. The spe- a few cases. an intervention was assigned to an industrial cific interventions ranged in scale and intensity. [10] was undertaken in labor-intensive (e.e. including both the wage replace- phase (i. retail and trade and that the modest number of studies identified was due to the transportation. the first cut of the evidence synthesis was by 1 intervention: 1 medium quality industrial sector. Four studies were ergonomic interventions. Descriptive Statistics of Included Studies Disability management interventions with an ergonomic education component are reported elsewhere [11] and were The studies covered a broad range of industries (n = 9). There were six sectors that had high and/ Manufacturing and warehousing or medium quality studies: administrative and support. participatory ergonomics teams) while the health care sector. Of the 1 intervention: 1 low quality six sectors with high and/or medium quality studies. In therefore excluded from this evidence synthesis. 2 medium quality.e.903. Two sectors—administrative Transportation and support. considered both costs and consequences). In terms of perspective. as well as details on Educational services the quality assessment of each study. Table 3. sector because other studies in this group also focused on Fourteen of the sixteen studies undertook full economic workers at computer terminals. considering nomic evaluations were identified. retained in the synthesis based on the criteria of receiving a The predominant economic outcomes were workers’ medium or high quality score in the quality assessment compensation expenses. only sixteen were only consequences in monetary terms).g. highly adjustable office chairs and workstation The study was included in the administrative and support modifications). Although 35 ergonomic intervention studies with eco. Note manufacturing and warehousing. (5) 4. (14) 2. (11) 3. (10) 4. Back school workshops were also mechanical lifts and Intervention B: trackball and ergonomic conducted concurrently with the chair conducted repositioning aids. productivity loss due to payments) related to resident low-back pain at work. (12) 1.6 months. (2) 5.5. (6) 4. (11) 1. (8) 3.61 Net savings per year were $70.5. individual (13) 3. (12) 1. (7) 4. (14) (8) 2. Table 4 Details of high and medium quality studies Study DeRango et al.5 (11) 3. (10) 3. a zero lift training distribution policy. (9) 2. (14) 4 item scores) 225 123 . (8) 3. (12) 5. (7) 4. (11) 3. (6) 3.55 (High) Overall: 3. (3) 4.5. (3) 4. (9) 4. (5) 4.5. (9) 3. (3) 3. The benefit-to-cost ratio based on the assumption that the less than 3 years results was 84. (4) 3. (13) 1. trackball. (13) 4. (2) 3.5. (2) 4.5 months (2002 dollars) shoulder injuries among customer service operators at the company is 0. [10] Collins et al.5 1. [12] Lahiri et al. [15] Sector Administrative and Support Administrative and Support Administrative and Support Health Care Country United States United States United States United States Intervention Highly adjustable chair and a one-time Lumbar pads and backrests were made Four workplace interventions compared: A musculoskeletal injury details office ergonomics training workshop available to employees to reduce back Intervention A: ergonomics training prevention program consisting of with a series of educational follow-ups discomfort.5. score and 4. and ergonomics training Type of study Before-after with control Before-after uncontrolled Randomized controlled trial Longitudinal (interrupted time series) uncontrolled Measurement 12 months 144 months 12 months NA time period Type of Cost-benefit analysis Cost-benefit analysis Cost-benefit analysis Cost-benefit analysis economic evaluation Perspective Employer Employer Employer Employer Key outcome Value of productivity per year Medical care costs associated with low-back Workers’ compensation expenses Workers’ compensation expenses measures pain cases. (4) 2.0144 and the neck/shoulder injury reduction from the intervention is 49% (taken from the estimated hazard rate) Details of Study Overall: 3.5.5. (4) 4. (5) 4. [13] Rempel et al. (2) 5. (10) 5. (6) 2. (12) NA. (8) 5. (7) (1) 3. (3) 3. (1) 5. (9) 2. (4) 4.441 with savings The payback period was 10.5 4. (13) (6) 3. (10) 1. (1) 3. value of lost work time due to sick (medical and indemnity leave (productivity). (14) 2.35 (Medium) Score (overall (1) 4. The payback period was slightly evaluation per worker of $111. (5) 3. and worker training on Intervention C: forearm and support board lift usage J Occup Rehabil (2010) 20:220–234 (armboard) and ergonomics training Intervention D: forearm support board (armboard).9 and the payback period was incidence of accepted claims for neck/ 0. (7) 4.55 (High) Overall: 2.8 (Medium) Overall: 3. and productivity handling injuries enhancements due to intervention Economic The benefit-cost ratio was 24. (3) 1. (9) 2. apparently ineffective in reducing injury. and then committee progressively assessed and improved the equipment and associated work practices for a range of projects. (5) 3. (12) 5. [14] Evanoff et al. Type of study Before-after uncontrolled Before-after with control for effectiveness Before-after with control (set of injuries Longitudinal (interrupted time series) analysis not associated with manual handling) uncontrolled before-after without control for economic analysis Measurement 108 months 110–110 months 48 months 57 months time period Type of Cost-benefit analysis Cost-consequence analysis Cost-benefit analysis Cost-benefit analysis economic evaluation Perspective Employer Employer Employer Employer Key outcome Workers’ compensation expenses Workers’ compensation expenses Manual and non-manual handling Direct and indirect expenses associated measures accidents expenses with back-related injuries Economic Upper.995. Six principal problems were training. over the time period that included future lower and upper bounds respectively intervention ($139 per FTE). (12) 1. (8) 2. (3) 4. (9) 3. (7) (1) 3.64) and results 2.5.50 years and 0. (11) 2.4 (Medium) Overall: 3.and lower. (11) 3. (9) 1. (2) 5. (2) 5.5. (14) 4 (13) 2. (6) 2.000. presentations. (10) 4.bounds estimates Total workers’ compensation expenses for The net present value was $3. (4) 2. time period (1989 Canadian dollars) $5.982. (8) 3.5. (8) 3.5. (5) 2. [16] Hocking [26] Lanoie and Tavenas [17] 123 Sector Health Care Health Care Information and Culture Manufacturing and Warehousing Country Canada United States Australia Canada Intervention Introduction of mechanical ceiling lifts Introduction of a participatory ergonomics An intervention consisting of workplace A participatory ergonomic intervention to details and training team ergonomic assessments and the reduce back disorders at an alcohol introduction of new equipment and distributor. (6) (1) 5. (7) (overall score 3. paradoxically it was economical (note projections was $187. which were subsequently released in the field with instructions.758. (12) 1. (7) 3.5.9 (Medium) Overall: 2. (11) 3.5.5.000 costs incurred over 2 years Details of Overall: 2. 3.79.5.5. (8) 2. (13) 2. Table 4 continued 226 Study Chhokar et al. (10) 2. Three teams of engineers were addressed by the joint worksite safety trained in ergonomics. (10) 4. (12) 3. (5) 2. consequences provided in the study do year following the measured intervention These savings can be compared to the not add up correctly). 4. (3) 4.443 pre-intervention Although the Telecom project was the intervention was (-$7. (4) 3.55 (Medium) Overall: 3. (11) 4. The net (1998 Canadian dollars) representing a 41% decrease in expenses that the individual costs and present value becomes positive in the per worker. (9) 4. (3) 2.5. (4) 3. for the ($237 per FTE) and $34. (7) (1) 5.5. (2) 4. (5) 4. and publicity. (6) 4.700. (14) 5 (13) 3.207 post. (6) 2. (4) 3. (2) 4. The net present value for the duration of evaluation translate into a payback period of orderlies was $24. (14) 5 3.83 years. (10) 2. and (13) 3. or total savings of $22. (14) 3 individual item scores) J Occup Rehabil (2010) 20:220–234 .85 (High) Study Score (1) 4. 556.3 months (2002 dollars) payback period was 3. Workers’ compensation expenses measures low-back pain cases. conveyors. and catwalks to minimize the use mechanical lift assists. while the per MSK claim expenses fell from $31. $2. $54.000. productivity loss (productivity).846 to $5. lift tables.000.000 respectively each year following the (2002 dollars) annuity method) was SEK 2.409. [13] Lahiri et al. The benefit-to. while workers’ compensation expenses per claim fell from $6. The tools/equipment.000 before the intervention to $420. due to low-back pain at work.000 in the third year of the intervention (overall decrease in total expenses of 42%). For sewing operations: results The benefit-to-cost ratio was worker of $1. The internal interest rate period rose from 514 to 700.40 and the payback period cost ratio was 5. The intervention included a number evaluations.281 (a 52% decrease).334. production quality. the workers’ compensation expenses related to MSK 15.g. value of and production efficiency lost work time due to sick leave lost work time due to sick leave (productivity).053. and was 5. value of low-back pain cases. and medical and claims management of ladders various platforms and risers were transport routes and production flows. based on a suggestion from a risk management instituted following ergonomic dollies were redesigned (to which used different participatory and consulting firm.3 months 2. pedagogical methods in the process of of engineering changes and related training to use new introduced included adjustable lift and tilt tables were installed designing the new department.872. [13] Abrahamsson [18] Halpern and Dawson [19] Sector Manufacturing and Warehousing Manufacturing and Warehousing Manufacturing and Warehousing Manufacturing and Warehousing Country United States United States Sweden United States Intervention Engineering controls and A number of engineering controls Development of new ladle service A participatory ergonomic program was introduced details workstation modifications were were implemented. Table 4 continued Study Lahiri et al.500 during the same period. and environment. Net savings per year were The Net Present Value was SEK The number of employees at the plant over the study evaluation with savings per worker of $625. workstation heights). New equipment reduce the amount of bending). 227 123 .000. grabbers.821 to $3. design committee. J Occup Rehabil (2010) 20:220–234 anti-fatigue matting. while the profit (using the $11. increased use of modified duty program).5 and the pay-off time (payback period) was disorders fell from $414. and the ladle service in the steelworks. Ergonomic department by a consultant company. the role of and an awareness education effort. and productivity enhancements and productivity enhancements due to intervention due to intervention Economic Net savings per year were $76. return-to-work chairs. Steering committee.732.000 introduction of the intervention (overall decrease of 97%).000 to $100. committee worked together with top management introduced (to reduce loads and The new ladle service department had participation at the implementation stage awkward back postures) an advanced climate and ventilation system that kept the heat and smoke from the ladles out of the working area Type of study Before-after uncontrolled Before-after uncontrolled Before-after uncontrolled Before-after uncontrolled Measurement 36 months 48 months 36 months 36 months time period Type of Cost-benefit analysis Cost-benefit analysis Cost-benefit analysis Partial economic analysis (before-after comparison of economic workers’ compensation expenses) evaluation Perspective Employer Employer Employer Employer Key outcome Medical care costs associated with Medical care costs associated with Value of absenteeism.2 years. with savings per 12.(internal rate of return) was 36%. climate factors. a stretching program. productivity loss due to low-back pain at work. For all operations: total workers’ compensation expenses decreased from $723. (to allow adjustment of intervention addressed issues related to activities (e. (4) 2. and injury. (7) 3. (10) 5. (8) 3. i.5. (10) 3. (1) 5. (4) 2. handling. and body mechanics exercises. posture exercises and mind–body interactions in relation to biomechanics. (2) 3. (3) 2. The training sessions. The first session minutes covered topics such as spinal anatomy. The therapists sessions reviewed participants’ static posture. workers’ compensation (indemnity and medical care) expenses J Occup Rehabil (2010) 20:220–234 . pain-sensitive structures. (1) 4. (12) 5.5.55 (Medium) Study Score (1) 3.5. stores: program included principles of covered topics such as motivation. (12) 5. (9) 4.2 (6) 3. relationship of back pain to Group C stores: status quo. effective Group B stores: old cutters with (instructors) also examined each relaxation training.5. (4) 3. a tour of provided additional experiences since the first session and the workplace was undertaken so that potential reinforcement training six included a summary of the first session problem areas could be identified and brought months after the first sessions to the workers’ attention during the lecture. (8) 3. (14) 4. The therapists illness. [20] Versloot et al. (13) 4. and yearly thereafter Type of study Randomized controlled trial Randomized controlled (not Randomized controlled (not blinded) Randomized controlled (not blinded) blinded) Measurement 12 months 65 months 48 months 6 months time period Type of Cost-benefit analysis Partial economic analysis (total Cost-benefit analysis Costs and consequences considered separately economic expenses per back injury claim evaluation compared using the Wilcoxon rank-sum statistic) Perspective Employer Employer Employer Employer Key outcome Wage value of time-loss from Back injury expenses Absenteeism expenses Absenteeism expenses measures work due to injury. (14) 4. and ergonomics. [21] Tuchin and Pollard [22] Sector Retail and Trade Transportation Transportation Transportation Country United States United States The Netherlands Australia Intervention Three ergonomic interventions Back school program consisting of Back school program consisting of three A comprehensive lecture of approximately 120 details were implemented in 3 groups of two training sessions. pain management.55 (High) Overall: 3. (8) 2. workstation and suggested including sports. [13] Abrahamsson [18] Halpern and Dawson [19] 123 Details of Overall: 3.e. and effects of cutters (control group) modifications. (10) 5. (14) 4 individual item scores) Study Banco et al. (4) 2. The second and third occupation and tasks involved. (2) 5. (5) 3. (9) 3.5. (5) 2. [27] Daltroy et al. (13) 4. (9) 4. spinal cutters with education. (5). (10) 2. (11) 2. (8) 2. analysis and explanation of education.3 (Medium) Overall: 2. (12) 1.5. (7) 4. correct lifting techniques. old physical and procedural seat adjustment. causes of back pain Group A stores: new safety case back safety. (overall (6) 2. (5) 3.5. (3) 3. stress. (2) 5. (2) 3. (1) 3. (6) 2. (11) 3. (3) 3. correct lifting and responsibility for one’s own health. (12) 3.5. (6) 5.55 (High) Overall: 3.5 (13) 2. (7) 4. coping strategies and methods of care for back problems.5.5 (11) 3. [13] Lahiri et al. (3) 3. types of back injuries. Prior to giving lecture. (14) 3 score and (11) 3. (7) 2. (13) 1. Table 4 continued 228 Study Lahiri et al. working posture. (9) 2. (8) 4.5. then the net present value is the saving could be in excess of $50.000 for a status quo (Group C stores). The authors mentioned that the chain when compared to the expenses were presented. (14) (13) 3. (7) 3. (10) 3. (2) 5. (6) (1) 4. the control group. (6) 4. (12) 1. (13) 1. Workers with a history of low-back injury had higher median total expenses.5. (7) (1) 3. (9) 2. (8) 3.5. (12) NA. individual item 2.6 (High) Overall: 3. (10) 3.5 229 123 .400. (7) 4. (5) 4. (3) 2.75 (Medium) Score (overall (1) 4. the implied net present results store and $29. medical expenses and personnel- replacement expenses than did workers without such a history Details of Study Overall: 2. Group $70. (8) 4. (6) (1) 4. (3) 5. (3) 2. (11) 4. (9) 3.080.5. The group. (6) 1. (12) 1. [27] Daltroy et al. (2) 4. (7) 3. (10) 3. score and 2. (13) NA/1. (13) 1. 3.5. [20] Versloot et al. (4) 5. If the change in absenteeism 3-month period Benefits for Group B stores were injury were $309 for the is assessed only within the intervention less dramatic and totaled $106 intervention group. (2) 5. (4) 4. [21] Tuchin and Pollard [22] Economic Estimated savings for Group A The effectiveness of the If the change in absenteeism for the Though costs and consequences were only evaluation stores were $245 per year per intervention was not established.413 per year for though descriptive statistics of relation to the change in the control value was $52. (12) 1.5 (Medium) Overall: 3. intervention group is assessed in considered separately.000 man-hours per store. (10) 2. (8) 4. (5) 1. (9) 3. (14) 4 (14) 3 scores) 4.773 assignment (intervention or J Occup Rehabil (2010) 20:220–234 for the chain control) and training status were not significantly associated with cost. and $103 for group. then the net present value is per 100. (5) 4.200 with total net savings of $12.5. (4) 2.35 (Medium) Overall: 2. (2) 4.5. median total expenses per back $103. (11) 3. (4) 3. (5) 3. (14) 3 (11) 2. (9) 3. (3) 2. (11) 2. Table 4 continued Study Banco et al. dence that such interventions result in economic returns. From these studies we equipment and back school workshops. while a third study was a before-after study merits. Only insurance consequences were considered in transportation sector. two of provided strong evidence that ergonomic interventions are which used regression modeling techniques to control for worth undertaking for their financial merits. was: ‘‘what is the credible evidence that incremental 123 . the economic analyses. ergonomic interventions were cost-effective in this sector. Of the sixteen studies. This results in sidered. 18. taking for economic reasons. Two studies had concluded that there is moderate evidence that ergonomic more than one intervention arm including a control (both interventions in the administrative and support services also used regression modeling techniques to control for sector are worth undertaking on the basis of their financial confounders). All were before-after uncon- each was undertaken in a different country. The three studies included in For the health care sector. ergonomic interventions. when con. Studies in the manufacturing and warehousing sector Study designs were before-after without controls. Equipment included highly adjustable chairs.e. with one using regression modeling tech- Unites States. costs and consequences are analyzed separately rather than The last stratum with substantive evidence was the jointly). the Netherlands and Australia. only four studies were participatory ergo. This stratum provided limited evi. Regarding the economic evaluation method high quality studies (two in Lahiri et al. each study undertook a different type of economic returns for the firm. tions are worth undertaking based on their financial returns for the company. other. the inter- this group there were three interventions. Consequently. namely the trolled studies. 19]. Discussion Summary of Studies in Sectors with Substantive Evidence Evidence of Financial Merits of Ergonomic Interventions The interventions in the administrative and support sector targeted work station equipment and training for office The research question addressed in this systematic review workers. and all concluded that the while the other conducted a cost-consequence analysis (i. [13]. hospital setting. there was a total of six high quality were ergonomic education programs focused on back studies and 10 medium quality ones. injury prevention. One was of high ventions focused on a broad range of MSK injury prevention quality [20] and found that the intervention was not measures for individuals working with machinery. Two medium quality studies [21. variance was undertaken to assess the difference between sidering evidence across all sectors. the second a As noted. 22] found the cases the interventions were participatory. nurses’ aides and orderlies. two studies undertook a cost-benefit analysis two medium quality ones [18. In In the manufacturing and warehousing sector. two lumbar pads and backrest and track ball and armboards intervention evaluations of high quality [12. there was also moderate this sector all undertook a cost-benefit analysis. One study was a partial analysis. Interestingly. One of these was of high quality [17] ysis. All were randomized controlled trials all but one found the interventions to be worth undertaking though not blinded. and con- evidence that ergonomic interventions are worth under. sidered insurance and productivity consequences. 19]. such as nurses. whereas it was in the other two. while in the other interventions to be cost-effective. and one of with computer use. and one was a partial analysis that only was insufficient evidence on the cost-effectiveness of OHS considered insurance consequences. The intervention was not found to be effective in moderate evidence that participatory ergonomic interven. In three effective. interventions included the quality studies in this sector [14–16]. one study. Four studies undertook a In all other sectors in which studies were identified there cost-benefit analysis. niques to control for confounders. analysis. while the third evaluated the introduction of a par. The three studies identified in the transportation sector Across all sectors. without a separate control.230 J Occup Rehabil (2010) 20:220–234 In the administrative and support services sector. There were three confounders. and [17]) and employed. cost-consequence analysis and a third a cost-benefit anal- nomic interventions. Training included appropriate use of medium quality [10] were identified. With regards to the economic evalua- is strong evidence that ergonomic interventions result in tion component. Two of the studies in introduction of mechanical patient lifts in two cases and the this group evaluated the introduction of mechanical patient implementation of a participatory ergonomics team in the lifts. Insurance and productivity consequences were con- and three of medium quality [16. There were three medium In the health care sector. these two instances they consisted of engineering controls and interventions were all ergonomic education programs and workstation modifications. 13]. The target populations were individuals working in a ticipatory ergonomics program. Regression modeling and analysis of based on their financial merits. we conclude that there and within groups. Also. 27]. Following is a list of key differ- ergonomic interventions result in financial returns for the ences: (1) the policy arena of OHS and labor legislation is firm. (2) there are substantial evidence in support of the financial merits of these types of differences in the perceptions of health risks associated interventions across all sectors. (5) there are multiple employer’s perspective. but did not consider 123 .’’ The phrase ‘‘partial economic analy- outlines key issues to consider in OHS economic evalua. Also included are other method- the effectiveness of office ergonomic interventions [3] and ological details and the key outcomes considered in each of participatory ergonomic interventions [2]. Most meth- was insufficient evidence due to the small number of ods texts are designed for use in a clinical setting. 26. 18. Indeed. hiring temporary workers and self-employed Methodological Recommendations contractors. so there was only moderate flicting incentives and priorities. ought to count as a benefit or cost of compensation insurance and absenteeism costs. interventions. Although there were several high quality economic systematic review is unique in that no other review has analyses identified in the systematic review [12. readers to the following sources [6. several recommen- ventions is that ‘well-designed and conducted evaluations dations are offered to help improve future applications of of programme costs and benefits were nearly impossible to these methods. For a more complete discussion of stantive statements about the evidence in some industrial methodological issues and recommendations we refer sectors. (3) there is a con- tation was motivated by a high number of workplace sequential lack of consensus amongst stakeholders about injuries. poli- In the majority of the studies. sis’’ is used to describe studies that considered only con- tions. As noted. the review did identify a sufficient across all the studies considered in this review. there guidance available on how it should be done.g. evaluation methods in this literature. complex. 9]. Details on sequences in monetary terms. health effectiveness. manufacturing and warehousing sector and OHS interventions can be difficult. and (2) the intervention studies that do of data available from organizations making it both chal- undertake economic analyses present a diversity of meth. and why the have come to similar conclusions [23–25].J Occup Rehabil (2010) 20:220–234 231 investment in ergonomic interventions is worth undertak. and a number of medium quality ones [10. 14–16. outsourcing non-core activities) can make it difficult to identify all work-related injuries and illnesses. lenging and expensive to obtain good measures. 8. 13. such consequences borne by the employer. The above odological approaches and quality with a large number of list of reasons might explain why few studies of OHS low quality studies. a synthesis of number of factors in the workplace setting are different studies across all sectors suggests strong evidence that than the clinical setting. Other reviews of the OHS literature interventions contain an economic evaluation. of their prevention. with work experiences amongst workplace parties. 9]. examined the financial merits associated with ergonomic 20]. regarding costs and consequences combined with a dearth nomic evaluation. in principle. intervention implemen. Nonetheless. but a studies and/or their low quality. Based on observation of the application of economic erature on the economic evaluation of workplace inter. All studies included in the synthesis took the ferent stakeholders in the system. with multiple stakeholders and sometimes con- tory ergonomic interventions. the benefits the major shortcomings in this literature. There were only four high and/or medium participa. study scores for each of the 14 quality assessment items ing?’’ Previous reviews have synthesized the evidence on can be found in Table 4. focusing on monetary costs and providers of indemnity and medical care coverage. 19. and a methods text on good practice [8. As well. 22. (4) the were the two main economic outcomes examined in most burden of costs and consequences may be borne by dif- studies. a quality of economic evaluations is usually poor. including number of high and medium quality studies to make sub. Two key methodological findings from the review are that: and (7) in general there is an absence of good guidelines (1) few ergonomic intervention studies undertake an eco. The focus on only that no one measure accurately captures the full cost of one perspective and a limited set of outcomes was one of work-related injury and illness. as these intervening or not intervening (this is an issue related to the may bear on business performance. The recommendations are drawn from find’ [25]. In the other five of the nine sectors. this study. undertaking economic evaluations of care sector. (6) industry-specific human resources practices (e. Related to this was a concern about workers’ what. more than half of the intervention From the nine sectors identified. and there is little transportation. the quality assessment of studies was based on A number of studies identified undertook a ‘‘partial a tool developed from previously completed research that economic analysis. nor conversely. cymakers and other OHS stakeholders. common complaint in the assessments of the research lit. This is likely due to about the level of evidence could be made in four industrial the focus in this literature on effectiveness rather than cost- sectors: administrative and support services sector. 21. However. These costs outcomes appropriate perspective to be taken in a study). the low quality ones. a definitive statement studies identified were of low quality. 17. One concern with using workers’ compensation from most national statistical agencies. others well as for a disaggregation of the costs and consequences the payback period. There is a consequences. The literature search was quite thorough. first aid reports. after without a concurrent control group and no statistical The perspective taken matters for the workplace mea- adjustment for confounders). In some other stakeholders. before. In fact. other social roles. studies. as quences in monetary terms used net present value. and a through primary data collection or exploitation of other detailed and lengthy search strategy was used to ensure all administrative data sources (e. one should adjust for inflation and time compensation wage replacement costs) and medical care preference. some studies with cost and conse. measurement and analytic time frame. consequences. yet others a cost-benefit ratio. and possibly undertaking a sensitivity analysis using a the losses borne by the insurer are not fully offset by range of rates. and private indemnity claims). tions. [28] and A number of standard computational practices were also Tompa et al. when the costs Most studies that undertook economic analyses focused and/or consequences of an intervention are realized over on work absence costs (primarily wage costs or workers’ more than a year. then the full cost of a claim is borne by the employer. of reference case as suggested by Gold et al. For example. making it difficult to compare results across strong case to be made for considering other perspectives. A fraction of the undertaken with all key assumptions to test the robustness costs may be pooled across all firms in a particular rate or of results to these assumptions. Several studies went further in their limited subset. even if consequences are not measured in even from a firm’s perspective. inclusion of a stakeholder advisory group from the early 123 . For many studies the eco. particularly injured workers and their cases. A number measures of health and their associated costs. overlooked in some analyses.g. Data on inflation rates are readily available costs. Strengths and Weaknesses of the Review tified made an adjustment for this fact [17]. particularly those of the worker and system or society. considering only those approaches to the computation and analysis of costs and costs and consequences experienced by the firm. human capital approach (a measure of productivity) to ered both costs and consequences. The real discount rates (net of insurer’s claim expenses in the cost-benefit analysis. Many jurisdictions stipulate the discount rate at may be incurred by a firm that results in costs substantially which public sector investments are to be discounted. a type sition and distribution. workers’ compensation claims do not reflect the full extent One of the key strengths of this study is its broad scope. either of journal databases were considered and included. All studies included in the Another concern is that studies employed different synthesis took the firm perspective. Amongst the studies that consid. For example. and a separate set of analyses be of primary interest to most firms. A range of indirect costs dollars. modified relevant studies were captured. assessment of productivity implications and considered connect between the effectiveness and economic evalua. Only one study we iden. spective bears on all the costs and consequences considered gation. firms may have their own specific rate many studies taking the firm perspective was to use the used for project investments. we sometimes found a dis. To adjust for time claims costs as the sole or primary outcome measure is that preference. sures of health used in an evaluation. and ysis. and for some it was a very small component. In fact. such studies were not of sufficient quality to remain in took cost-benefit analysis. many considered only a value absence time.and medium-quality studies under- 20]. at-work productivity changes due to the intervention. Many workplace Evidence on the financial merits of ergonomic interven- injuries and illnesses go unreported. We by stakeholder in order to better understand their compo- would suggest a standard approach to computations. sensitivity analysis should be premium increases to the injury employer. and others are not tions of different types and across all sectors was consid- compensable [29]. and used some variant of a the evidence synthesis. Furthermore. one set of analyses fed into the Although financial outcomes and productivity issues may effectiveness evaluation. the intrinsic value of good health to workers and the value but also used different study designs. discounting is required for both costs and it does not capture the full set of costs and consequences.g. For larger than the direct absence costs.232 J Occup Rehabil (2010) 20:220–234 intervention costs. Many of the high. Another strength is the duty. in some jurisdictions workers’ compensation [30]. the value of health to were undertaken for the economic component. we suggest considering both rates in an anal- insurance provided by an insurer are experience rated. Specifically. A common approach in the private sector. with economic of health associated with the ability to better perform in evaluation often employing a weaker design (e. in an economic evaluation. inflation) commonly used in the literature are 3 and 5% However. the per- nomic analysis was not the principal focus of the investi. risk group. Researchers need to consider other ered. the two types of analyses not only relied on different families includes much more. [9]. of work-related injuries and illnesses. Furthermore. Missing in this measure is health outcome data. Thus. With the exception of two studies [19. If a firm is self insured. Tompa E. The stakeholder advisory evidence base on the financial merits of such interventions. and adding a gray literature search would have made the task unmanageable with the References resources available. 11. DeRango K. 2003. et al. 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