Compensation, whether through workers’ compensation or through
litigation, has been associated with poor outcome after surgery; however,
this association has not been examined by meta-analysis.
To investigate the association between compensation status and outcome
We searched MEDLINE (1966-2003), EMBASE (1980-2003), CINAHL, the Cochrane
Controlled Trials Register, and reference lists of retrieved articles and
textbooks, and we contacted experts in the field.
The review included any trial of surgical intervention in which compensation
status was reported and results were compared according to that status. No
restrictions were placed on study design, language, or publication date. Studies
were selected by 2 unblinded independent reviewers.
Two reviewers independently extracted data on study type, study quality,
surgical procedure, outcome, country of origin, length and completeness of
follow-up, and compensation type.
Two hundred eleven studies satisfied the inclusion criteria. Of these,
175 stated that the presence of compensation (workers’ compensation
with or without litigation) was associated with a worse outcome, 35 found
no difference or did not describe a difference, and 1 described a benefit
associated with compensation. A meta-analysis of 129 studies with available
data (n = 20 498 patients) revealed the summary odds ratio for an unsatisfactory
outcome in compensated patients to be 3.79 (95% confidence interval, 3.28-4.37
by random-effects model). Grouping studies by country, procedure, length of
follow-up, completeness of follow-up, study type, and type of compensation
showed the association to be consistent for all subgroups.
Compensation status is associated with poor outcome after surgery. This
effect is significant, clinically important, and consistent. Because data
were obtained from observational studies and were not homogeneous, the summary
effect should be interpreted with caution. Compensation status should be considered
a potential confounder in all studies of surgical intervention. Determination
of the mechanism for this association requires further study.