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Original Investigation
October 28, 2020

Association of Severe Trauma With Work and Earnings in a National Cohort in Canada

Author Affiliations
  • 1Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
  • 2Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  • 3Statistics Canada, Ottawa, Ontario, Canada
  • 4Department of Economics, Massachusetts Institute of Technology, Cambridge, Massachusetts
  • 5Manitoba Centre for Health Policy, University of Manitoba Winnipeg, Manitoba, Canada
  • 6Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor
  • 7Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
JAMA Surg. 2021;156(1):51-59. doi:10.1001/jamasurg.2020.4599
Key Points

Question  How is severe traumatic injury associated with individuals’ ability to work and earn income?

Findings  In this population-based cohort study of 5167 adults who had employment and were hospitalized with severe traumatic injury, 79.3% were employed 3 years after injury, compared with 91.7% of matched control participants, with a resultant mean earnings loss of 19.0%. Those in the lowest tercile of preinjury income were 3-fold less likely than those in the highest tercile to be employed 3 years after injury.

Meaning  Substantial loss in employment and earnings persists for at least 3 years after severe traumatic injury among adults who were previously employed.


Importance  Traumatic injury disproportionately affects adults of working age. The ability to work and earn income is a key patient-centered outcome. The association of severe injury with work and earnings appears to be unknown.

Objective  To evaluate the association of severe traumatic injury with subsequent employment and earnings in long-term survivors.

Design, Setting, and Participants  This is a retrospective, matched, national, population-based cohort study of adults who had employment and were hospitalized with severe traumatic injury in Canada between January 2008 and December 2010. All acute care hospitalizations for severe injury were included if they involved adults aged 30 to 61 years who were hospitalized with severe traumatic injury, working in the 2 years prior to injury, and alive through the third calendar year after their injury. Patients were matched with unexposed control participants based on age, sex, marital status, province of residence, rurality, baseline health characteristics, baseline earnings, self-employment status, union membership, and year of the index event. Data analysis occurred from March 2019 to December 2019.

Main Outcomes and Measures  Changes in employment status and annual earnings, compared with unexposed control participants, were evaluated in the third calendar year after injury. Weighted multivariable probit regression was used to compare proportions of individuals working between those who survived trauma and control participants. The association of injury with mean yearly earnings was quantified using matched difference-in-difference, ordinary least-squares regression.

Results  A total of 5167 adults (25.6% female; mean [SD] age, 47.3 [8.8] years) with severe injuries were matched with control participants who were unexposed (25.6% female; mean [SD] age, 47.3 [8.8] years). Three years after trauma, 79.3% of those who survived trauma were working, compared with 91.7% of control participants, a difference of −12.4 (95% CI, −13.5 to −11.4) percentage points. Three years after injury, patients with injuries experienced a mean loss of $9745 (95% CI, −$10 739 to −$8752) in earnings compared with control participants, representing a 19.0% difference in annual earnings. Those who remained employed 3 years after injury experienced a 10.8% loss of earnings compared with control participants (−$6043 [95% CI, −$7101 to −$4986]). Loss of work was proportionately higher in those with lower preinjury income (lowest tercile, −18.5% [95% CI, −20.8% to −16.2%]; middle tercile, −11.5% [95% CI, −13.2% to −9.9%]; highest tercile, −6.0% (95% CI, −7.8% to −4.3%]).

Conclusions and Relevance  In this study, severe traumatic injury had a significant association with employment and earnings of adults of working age. Those with lower preinjury earnings experienced the greatest relative loss of employment and earnings.

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