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Anna Hobman,1 William MM Levack,1 Bernadette Jones,1 Tristram R Ingham,1 James Fingleton,2 Mark Weatherall,1 Amanda A McNaughton,3 Harry K McNaughton3 1Department of Medicine, University of Otago, Wellington, New Zealand; 2Te Whatu Ora Capital, Coast and Hutt Valley, Wellington, New Zealand; 3Medical Research Institute of New Zealand, Wellington, New ZealandCorrespondence: Anna Hobman, Department of Medicine, University of Otago Wellington, PO Box 7343, Wellington, 6242, New Zealand, Tel +64 21 918 627, Email ahobman@gmail.comPurpose: Current guidelines for prevention of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) reflect clinical understanding of the causes of exacerbations but with a limited recognition of person-specific contributing factors. As part of a randomized trial of a person-centered intervention aiming to promote self-determination, we describe personal perspectives of those with chronic obstructive pulmonary disease (COPD) on what they saw as the causes and best ways to stay well and prevent rehospitalization after an AECOPD.Patients and Methods: Twelve participants (mean age 69.3 years, six female, six male; eight New Zealand European, two Māori, one Pacific, and one other) were interviewed about their experiences of staying well and out of hospital. Data were collected via individual semi-structured interviews one year following an index hospital admission for AECOPD and focused on the participants’ views and experiences of their health condition, their beliefs about staying well, and the causes of and factors preventing further exacerbations and hospitalizations. Data were analyzed using constructivist grounded theory methods.Results: Three main themes were identified that described participants’ views on what helped or hindered them to stay well and out of hospital: 1) Being Positive: The importance of having a positive mindset; 2) Being Proactive: Practical steps to reduce the risk of, and consequences from, episodes of AECOPD; and 3) Being in Control: Feeling in command of one’s life and health. Each of these was affected by Being Connected: The influence of significant others, particularly close family.Conclusion: This research expands our understanding of how patients manage COPD and adds patient perspectives to current knowledge on how to prevent recurrent AECOPD. Programs which promote self-efficacy and positivity would be beneficial additions to AECOPD prevention strategies, as could the inclusion of family or significant others in wellbeing plans.Keywords: COPD, lived experience, self-management, rehospitalization, self-efficacy, taking charge

William MM Levack,1 Mark Weatherall,1 Harry K McNaughton,2 Amanda A McNaughton,2 Anna Hobman,1 Bernadette Jones,1 Tristram R Ingham,1 James Fingleton3 1Department of Medicine, University of Otago, Wellington, New Zealand; 2Medical Research Institute of New Zealand, Wellington, New Zealand; 3Te Whatu Ora Capital, Coast and Hutt Valley, Wellington, New ZealandCorrespondence: William MM Levack, Department of Medicine, University of Otago Wellington, PO Box 7343, Wellington, 6242, New Zealand, Tel +64 21 918 627, Email william.levack@otago.ac.nzPurpose: Few interventions improve outcomes for people with Chronic Obstructive Pulmonary Disease (COPD), particularly higher risk groups such as those admitted to hospital with an acute exacerbation of COPD (AECOPD). The aim of the study was to test the feasibility and acceptability of a modified version of the Take Charge program in people after AECOPD and to determine the potential to improve self-reported limitations, health-related quality of life and reduce future hospitalizations.Patients and Methods: A prospective, parallel group randomized trial with blinded endpoint assessment. Participants had been discharged from hospital with a diagnosis of AECOPD and were randomized to receive either a single 60– 90 minute session of “Take Charge for COPD” from a trained facilitator in their own home or usual care. Take Charge is a “talking therapy” that encourages a sense of purpose, autonomy, mastery, and connectedness with others. The primary outcome was the rate of moderate or severe episodes of AECOPD in the subsequent 12 months.Results: Fifty-six people were randomized (study target 60): predominantly European (71%), female (61%), older (mean [SD] age 70 [11] years), and non-smokers (89%). Charlson Comorbidity Index mean (SD) score was 2.3 (1.6) indicating mild to moderate comorbidity severity. There were 85 moderate or severe AECOPD episodes in the 12 months after the index admission for the Take Charge participants and 84 episodes in the control group (relative rate 0.93; 95% confidence interval (CI) 0.69 to 1.26). COPD Clinical Questionnaire (CCQ) scores were significantly lower (better) in the Take Charge group (mean difference − 1.26; 95% CI − 2.06 to − 0.45).Conclusion: The Take Charge intervention proved feasible with a population of people recently discharged from hospital with AECOPD. The direction of change in the primary outcome and some secondary outcomes suggest that an adequately powered study is justified.Keywords: COPD, self-management, Take Charge, randomized controlled trial

PURPOSE: This study aimed to explore the applicability of a previously derived model of what mattered most to people with arthritis across a number of different disabling conditions. METHOD: A qualitative study using interviews with 30 participants from three out-patient groups (rheumatoid arthritis, stroke and chronic pain) was conducted. Participants were asked to identify and discuss the most important consequences of living with their condition. Narratives were explored for similarities and differences within and across conditions. RESULTS: While diagnostically related differences were clearly evident, particularly in categories within the Intrinsic, Extrinsic and Future Issues themes, a marked level of similarity in view was apparent in two themes, Taking Charge and Perceptions of Normality. CONCLUSIONS: The study identified a shared perspective about a number of issues, but also detailed where there were differences. We suggest explicit consideration of the themes highlighted in this research, and a deeper understanding of the inter-relatedness of seemingly separate issues will help health professionals and researchers re-think ways of working with people who have disabling conditions, and identify different factors to address in measuring the success of rehabilitation. [ABSTRACT FROM AUTHOR]

This review looks at poliomyelitis from the perspective of rehabilitation clinicians, covering issues of pathophysiology, impairments, and problems of functioning. The authors attempt to pick a path through some of the controversy around 'post-polio syndrome' and suggest an overall framework for considering people with problems many years after episodes of poliomyelitis. On the basis of that framework, the authors offer suggestions for the management of this group of people, in the hope that the broad principles apply equally well to many other people with chronic disabling conditions. [ABSTRACT FROM AUTHOR]

Background and Objectives: International evidence shows that patients treated at nonurban hospitals experience poorer access to key stroke interventions. Evidence for whether this results in poorer outcomes is conflicting and generally based on administrative or voluntary registry data. The aim of this study was to use prospective high-quality comprehensive nationwide patient-level data to investigate the association between hospital geography and outcomes of patients with stroke and access to best-practice stroke care in New Zealand., Methods: This is a prospective, multicenter, nationally representative observational study involving all 28 New Zealand acute stroke hospitals (18 nonurban) and affiliated rehabilitation and community services. Consecutive adults admitted to the hospital with acute stroke between May 1 and October 31, 2018, were captured. Outcomes included functional outcome (modified Rankin Scale [mRS] score shift analysis), functional independence (mRS score 0-2), quality of life (EuroQol 5-dimension, 3-level health-related quality of life questionnaire), stroke/vascular events, and death at 3, 6, and 12 months and proportion accessing thrombolysis, thrombectomy, stroke units, key investigations, secondary prevention, and inpatient/community rehabilitation. Results were adjusted for age, sex, ethnicity, stroke severity/type, comorbid conditions, baseline function, and differences in baseline characteristics., Results: Overall, 2,379 patients were eligible (mean [SD] age 75 [13.7] years; 51.2% male; 1,430 urban, 949 nonurban). Patients treated at nonurban hospitals were more likely to score in a higher mRS score category (greater disability) at 3 (adjusted odds ratio [aOR] 1.28, 95% CI 1.07-1.53), 6 (aOR 1.33, 95% CI 1.07-1.65), and 12 (aOR 1.31, 95% CI 1.06-1.62) months and were more likely to have died (aOR 1.57, 95% CI 1.17-2.12) or experienced recurrent stroke and vascular events at 12 months (aOR 1.94, 95% CI 1.14-3.29 and aOR 1.65, 95% CI 1.09-2.52). Fewer nonurban patients received recommended stroke interventions, including endovascular thrombectomy (aOR 0.25, 95% CI 0.13-0.49), acute stroke unit care (aOR 0.60, 95% CI 0.49-0.73), antiplatelet prescriptions (aOR 0.72, 95% CI 0.58-0.88), ≥60 minutes of daily physical therapy (aOR 0.55, 95% CI 0.40-0.77), and community rehabilitation (aOR 0.69, 95% CI 0.56-0.84)., Discussion: Patients managed at nonurban hospitals experience poorer stroke outcomes and reduced access to key stroke interventions across the entire care continuum. Efforts to improve access to high quality stroke care in nonurban hospitals should be a priority., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.)

Aim: The aim of this study was to explore the perspectives of people with stroke and their whānau on barriers to accessing best practice care across Aotearoa, and to brainstorm potential solutions., Method: We conducted ten focus groups nationwide and completed a thematic analysis., Results: Analysis of the data collected from the focus groups identified five themes: (1) inconsistencies in stroke care; (2) importance of effective communication; (3) the role of whānau support; (4) the need for more person rather than stroke centred processes; and (5) experienced inequities. Participants also identified potential solutions., Conclusion: Key recommendations include the need for improved access to stroke unit care for rural residents, improved post-discharge support and care coordination involving the whānau, improved communication across the patient journey, and a concerted effort to improve culturally safe care. Next step is to implement and monitor these recommendations., Competing Interests: The study was funded by the Health Research Council of New Zealand (HRC 17/037). Some of the authors receive other grant funding, but none that relates to this study, and report no competing interests.

Background: Stroke systems of care differ between larger urban and smaller rural settings and it is unclear to what extent this may impact on patient outcomes. Ethnicity influences stroke risk factors and care delivery as well as patient outcomes in nonstroke settings. Little is known about the impact of ethnicity on poststroke care, especially in Māori and Pacific populations., Objective: Our goal is to describe the protocol for the Reducing Ethnic and Geographic Inequities to Optimise New Zealand Stroke Care (REGIONS Care) study., Methods: This large, nationwide observational study assesses the impact of rurality and ethnicity on best practice stroke care access and outcomes involving all 28 New Zealand hospitals caring for stroke patients, by capturing every stroke patient admitted to hospital during the 2017-2018 study period. In addition, it explores current access barriers through consumer focus groups and consumer, carer, clinician, manager, and policy-maker surveys. It also assesses the economic impact of care provided at different types of hospitals and to patients of different ethnicities and explores the cost-efficacy of individual interventions and care bundles. Finally, it compares manual data collection to routine health administrative data and explores the feasibility of developing outcome models using only administrative data and the cost-efficacy of using additional manually collected registry data. Regarding sample size estimates, in Part 1, Study A, 2400 participants are needed to identify a 10% difference between up to four geographic subgroups at 90% power with an α value of .05 and 10% to 20% loss to follow-up. In Part 1, Study B, a sample of 7645 participants was expected to include an estimated 850 Māori and 419 Pacific patients and to provide over 90% and over 80% power, respectively. Regarding Part 2, 50% of the patient or carer surveys, 40 provider surveys, and 10 focus groups were needed to achieve saturation of themes. The main outcome is the modified Rankin Scale (mRS) score at 3 months. Secondary outcomes include mRS scores; EQ-5D-3L (5-dimension, 3-level EuroQol questionnaire) scores; stroke recurrence; vascular events; death; readmission at 3, 6, and 12 months; cost of care; and themes around access barriers., Results: The study is underway, with national and institutional ethics approvals in place. A total of 2379 patients have been recruited for Part 1, Study A; 6837 patients have been recruited for Part 1, Study B; 10 focus groups have been conducted and 70 surveys have been completed in Part 2. Data collection has essentially been completed, including follow-up assessment; however, primary and secondary analyses, data linkage, data validation, and health economics analysis are still underway., Conclusions: The methods of this study may provide the basis for future epidemiological studies that will guide care improvements in other countries and populations., International Registered Report Identifier (irrid): DERR1-10.2196/25374., (©Annemarei Ranta, Stephanie Thompson, Matire Louise Ngarongoa Harwood, Dominique Ann-Michele Cadilhac, Peter Alan Barber, Alan John Davis, John Henry Gommans, John Newton Fink, Harry Karel McNaughton, Hayley Denison, Marine Corbin, Valery Feigin, Virginia Abernethy, William Levack, Jeroen Douwes, Jacqueline Girvan, Andrew Wilson. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 12.01.2021.)

Objective: To explore the impact of a complex community environment on gait parameters (speed, step length and cadence) for community-dwelling participants with a previous stroke, and compare outcome measures commonly used in a clinical environment., Design: Repeated measurement of participants in different environments., Setting: One clinic and two community environments (suburban street and shopping mall)., Subjects: Thirty community-dwelling stroke participants with chronic stroke who were classified according to gait speed (20-50 m/min on 10-metre timed walk) as marginal community walkers., Outcome Measures: During a six-minute walk test (6MWT) a step activity monitor (SAM) and odometer were used to calculate gait speed, step length and cadence. The 10-metre timed walk (10MTW) was measured in a clinic environment., Analysis: A mixed linear model examined differences in gait measurements in the different environments. Bland-Altman analysis illustrated agreement between gait speed measures (6MWT and 10MTW)., Results: A statistically significant, but not a clinically significant difference in gait speed between some environments was found. Gait speed was slowest in the mall and fastest in the street with a difference of only 2.1 m/min between these environments (95% confidence interval (CI) -3.8 to -0.5, P<0.01). Comparison of clinic 10MTW and street 6MWT showed wide limits of agreement (-18.5 to 16.9 m/min) which improved for clinic 6MWT and street 6MWT comparisons (-5.7 to 8.9 m/min)., Conclusion: Despite residual gait deficit, the gait parameters of these chronic stroke survivors did not deteriorate markedly under challenging conditions. The 6MWT is recommended as a clinical measure for community ambulation.

Objective: This pilot randomized controlled trial evaluated an assistant-led, community-based intervention to improve community mobility and participation after stroke, and examined the potential for independent community ambulation in people with subacute stroke who present with moderate gait deficit., Design: A multicentre, pilot randomized controlled trial., Setting: Three hospitals and three community settings in New Zealand., Subjects: Thirty post-acute, home-dwelling stroke survivors were randomly allocated to receive intervention in the community (n = 14) or as hospital outpatients (n = 16) twice a week for seven weeks., Interventions: The community intervention involved practice of functional gait activities in community environments relevant to each participant. Hospital-based physiotherapy was based upon a Motor Relearning approach., Main Measures: The primary outcome measure was gait speed (m/min). Secondary outcomes included endurance (six-minute walk time), Activities-specific Confidence Balance Scale, and the Subjective Index of Physical and Social Outcomes measured at baseline, post intervention and six months., Results: Large gains in gait speed were obtained for participants in both groups: community group mean (SD) 16 (16.1) m/min; physiotherapy group mean (SD) 15.9 (16.1) m/min, maintained at six months. There were no significant differences between groups for primary and secondary outcomes after treatment (P = 0.86 ANOVA) or at six months (P = 0.83 ANOVA). Only 11 participants reported independent community ambulation. Levels of social integration were low to moderate., Conclusions: A community-based gait recovery programme appears a practicable alternative to routine physiotherapy, however independent community ambulation is a challenging rehabilitation goal.

Objectives: To assess the effect of environment and a secondary task on gait parameters in community ambulant stroke survivors and to assess the contribution of clinical symptoms to gait performance., Design: A 2x3 randomized factorial design with 2 main factors: task (no task, motor task, cognitive task) and environment (clinic, suburban street, shopping mall)., Setting: Subjects were assessed in 1 of 3 settings: 2 in the community (a suburban street and shopping mall) and 1 clinical environment., Participants: Twenty-seven people with stroke (mean age, 61+/-11.6y; mean time since stroke onset, 45.8+/-34.2mo), living at home, were recruited from community stroke groups and from a local rehabilitation unit. Selection criteria included the following: ability to give informed consent, unilateral first ever or recurrent stroke at least 6 months previously, walking independently in the community, a gait speed between 24 and 50 m/min, Mini-Mental State Examination score of 24 or higher, and no severe comorbidity., Interventions: Not applicable., Main Outcome Measures: Gait speed (in m/min), cadence, and step length were assessed by using an accelerometer with adjustable thresholds. Clinical measures hypothesized to influence gait parameters in community environments were also assessed including fatigue, anxiety and depression, and attentional deficit., Results: Twenty-seven people with a mean baseline gait speed of 42.2+/-5.9 m/min were randomly allocated to 1 of 9 conditions in which the setting and distraction were manipulated. Analysis of variance showed a significant main effect for environment (P = .046) but not for task (P = .37). The interaction between task and environment was not significant (P = .73). Adjusting for baseline gait speed, people walked on average 8.8m/min faster in the clinic (95% confidence interval, 0.3-17.3m/min) than in the mall. Scores for fatigue, anxiety and depression, and attentional deficit were higher than normative values but did not influence gait performance., Conclusions: This study suggests that people with chronic stroke cope well with the challenges of varied environments and can maintain their gait speed while performing a secondary task. Despite moderate levels of gait impairment, gait automaticity may be restored over time to a functional level.

Background: Organised stroke care saves lives and reduces disability. A clinical pathway might be a form of organised stroke care, but the evidence for the effectiveness of this model of care is limited., Methods: This study was a retrospective audit study of consecutive stroke admissions in the setting of an acute general medical unit in a district general hospital. The case-notes of patients admitted with stroke for a 6-month period before and after introduction of the pathway, were reviewed to determine data on length of stay, outcome, functional status, (Barthel Index, BI and Modified Rankin Scale, MRS), Oxfordshire Community Stroke Project (OCSP) sub-type, use of investigations, specific management issues and secondary prevention strategies. Logistic regression was used to adjust for differences in case-mix., Results: N = 77 (prior to the pathway) and 76 (following the pathway). The median (interquartile range, IQR) age was 78 years (67.75-84.25), 88% were European NZ and 37% were male. The median (IQR) BI at admission for the pre-pathway group was less than the post-pathway group: 6 (0-13.5) vs. 10 (4-15.5), p = 0.018 but other baseline variables were statistically similar. There were no significant differences between any of the outcome or process of care variables, except that echocardiograms were done less frequently after the pathway was introduced. A good outcome (MRS < 4) was obtained in 66.2% prior to the pathway and 67.1% after the pathway. In-hospital mortality was 20.8% and 23.1%. However, using logistic regression to adjust for the differences in admission BI, it appeared that admission after the pathway was introduced had a significant negative effect on the probability of good outcome (OR 0.29, 95%CI 0.09-0.99)., Conclusion: A clinical pathway for acute stroke management appeared to have no benefit for the outcome or processes of care and may even have been associated with worse outcomes. These data support the conclusions of a recent Cochrane review.

Objective: To describe the underlying dimensions for a range of functional measures across 3 neurologic diseases at different time points., Design: Multiple cohort study., Setting: Combination of public hospital wards and community., Participants: Patients (N=308) from 3 cohorts: paralytic poliomyelitis (n=38), mean of 25 years previously, assessed once; acute stroke admitted to hospital and followed up for 12 months postdischarge (n=181); and traumatic brain injury (TBI), admitted to hospital and followed up for 12 months postdischarge (n=89)., Interventions: Not applicable., Main Outcome Measures: The Barthel Index, FIM instrument, Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical component score (PCS) and mental component score (MCS), Community Integration Questionnaire (CIQ), and the London Handicap Score (LHS). Measures were compared at 2 time points: pre-event status for stroke, TBI and the polio cohort, and 12-month postdischarge status for stroke and TBI., Results: The different measures generally correlated highly within disease states at each time point. Principal components analysis revealed 2 underlying dimensions, a physical dimension onto which loaded the Barthel Index, FIM, PCS, and LHS and a cognitive/emotional dimension onto which loaded the MCS and, for subjects with polio, the CIQ. These 2 dimensions accounted for 69% of the variance in measures at the pre-event time point and 85% of the variance at the 12-month time point., Conclusions: These data suggest 2 basic underlying dimensions across a wide range of measures in 3 different neurologic conditions even at different time points. Most of the variation in the measures can be captured using the 2 component summary scores (PCS, MCS) of the SF-36.

Objectives: We sought to determine the relationship between self-reported ratings of health-related quality of life (HRQoL) by people with 3 chronic and disabling conditions and population estimates of those health states and to model factors that might explain the disagreement between these 2 ratings., Research Design: A cross-sectional postal survey was sent in which each participant completed a set of questionnaires addressing HRQoL. Data from self-valuation on a visual analog scale (VAS) was compared with a population-based VAS-equivalent valuation, using the EQ-5D instrument. Different ways of scaling the 2 VAS scores were also explored. Data were analyzed using descriptive statistics and analysis of covariance., Subjects: A community sample of 1036 people took part in the study (rheumatoid arthritis n = 142, stroke n = 585, multiple sclerosis n = 309). MEASUREMENT INSTRUMENT: The EQ-5D health state profile and accompanying visual analog scale were used., Results: Self-ratings were significantly different than the population-based ratings, and agreement was poor, both on the original scale of the data and by analyses of rescaled data. On the original scales the mean difference was 0.13 (95% confidence interval 0.117-0.143). Diagnosis, health state severity, and its square explained 35.3% of the variation in the differences between self and population ratings with a curvilinear relationship suggesting that the differences increased as the health state worsened, but at a decreasing rate as health state severity increased., Conclusions: This study provides evidence that EQ-5D population valuation estimates of treatment benefit for people with disabling and chronic conditions may well be inaccurate representations of the degree of change actually experienced by the individual with the condition. The varying magnitude of difference between the 2 forms of valuation has important implications for interpreting shifts in health status valuation following interventions for these populations.

Objectives: To assess how important community ambulation is to stroke survivors and to assess the relation between the level of community ambulation achieved and other aspects of mobility., Design: A multicenter observational survey., Setting: Community setting in New Zealand., Participants: One hundred fifteen stroke survivors living at home were referred from physical therapy (PT) services at 3 regional hospitals at the time of discharge and were assessed within 1 week after returning home. Another 15 people with stroke who did not require further PT when discharged were assessed within 2 weeks after they returned home to provide insight into community ambulation status for those without mobility impairment, as recognized by health professionals., Interventions: Not applicable., Main Outcome Measures: Self-reported levels of community ambulation ascertained by questionnaire, gait velocity (m/min), Functional Ambulation Categories (FAC) score, and Rivermead Mobility Index (RMI) score., Results: Mean gait velocity for the participants was 53.9 m/min (95% confidence interval [CI], 52.3-61.1); mean treadmill distance was 165.5 m (95% CI, 141.6-189.5); median RMI score was 14; and median FAC score was 6. Mobility scores for the 15 people who did not require PT were within the normal range. Based on self-reported levels of ambulation, 19 (14.6%) participants were unable to leave the home unsupervised, 22 (16.9%) were walking as far as the letterbox, 10 (7.6%) were limited to walking within their immediate environment, and 79 (60.7%) could access shopping malls and/or places of interest. Participants with different levels of community ambulation showed a significant difference in gait velocity (P<.001). The ability to "get out and about" in the community was considered to be either essential or very important by 97 subjects (74.6%)., Conclusions: Community ambulation is a meaningful outcome after stroke. However, despite good mobility outcomes on standardized measures for this cohort of home-dwelling stroke survivors, nearly one third were not getting out unsupervised in the community. Furthermore, gait velocity may be a measure that discriminates between different categories of community ambulation. These findings may have implications for PT practice for people with mobility problems after stroke.

Objective: To determine whether health valuations, such as those used in economic evaluation, are affected by duration of a health condition. People with disabling health conditions tend to value health more highly than members of the general population, and one explanation for this is that over time their experience of living with a disabling illness changes the way in which they value health. If this is so, a relationship between the duration of an individual's disabling health condition and the valuation they assign to their health-state might reasonably be expected., Design: A postal survey using the EuroQoL (EQ-5D) instrument to collect descriptions and valuations for health from people who reported a diagnosis of either stroke or multiple sclerosis. Contact with participants was made through national support organizations and questionnaires were returned by mail., Results: Eight hundred and ninety-four people completed the survey. One hundred (11 %) had one health-state indicating moderate problems in all five dimensions of the EQ-5D descriptive profile. For people with this health-state, analysis of covariance showed no relationship between valuation of health-state and time from onset of illness (F = 0.38, p = 0.54). This finding applied irrespective of the diagnosis, and for some other less frequently reported health-states., Conclusion: Clinical experience suggests that over time people adapt to long-term disability. However we found no evidence to support the proposition that higher health-state valuations by people with disabling conditions are explained by the actual duration of their condition.

Study Design: A retrospective descriptive casenote review of consecutive back pain claimants assessing claim outcome at 12 months from onset., Objective: To assess prognosis for back pain claimants in a no-fault 24-hour-cover accident compensation system., Background: New Zealand has a unique accident compensation system that may provide incentives for health professionals to classify people with backache as having a back injury and incentives for back pain claimants to continue claims longer than would be the case in other compensation systems., Methods: One hundred consecutive back pain claimants were identified from a single office of New Zealand's sole accident compensation insurer (Accident Rehabilitation and Compensation Insurance Corporation; ACC), who were still receiving compensation payments 4 weeks after the initial date of the claim. The study end point was case closure in the subsequent 12 months. Case closure rate was analyzed in relation to several potential prognostic variables., Results: Of the 100 cases identified in which the claimant was receiving compensation 4 weeks from the initial date of the claim, 43 cases were not closed by 6 months, and 30 cases were not closed at 12 months. The variable most strongly associated with case nonclosure was whether the claimant was receiving earnings-related compensation (equal to 80% of previous income), with 41% of this group still receiving compensation at 12 months versus 16% of the group not receiving earnings-related compensation (chi2 = 8.55, P = 0.003). These results compare unfavorably with those from previous published studies from The Netherlands and Jersey in the United Kingdom., Conclusion: New Zealand's unique accident compensation environment may discourage return to work for people with back pain. New Zealand legislators should assess the impact of the ACC scheme on people with back pain, particularly in light of the recent recommendations of the International Association for the Study of Pain Task Force on Back Pain in the Workplace, that compensation cover for workers with back pain be limited to 6 weeks.