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Blind Faith? The Effects of Promoting Active Sick Leave for Back Pain Patients
Abstract
Study Design. A cluster-randomized controlled trial. Objective. To evaluate the effects of two strategies to increase the use of active sick leave (ASL) among patients with low back pain (LBP) on improved return to work and quality of life. Summary of Background Data. Active sick leave is an option provided by the Norwegian National Insurance Administration that enables employees to return to modified duties at the workplace with 100% of normal wages. A proactive implementation strategy increased the use of ASL for LBP patients from 11.5% to 17.7% compared with a passive intervention and a control group (P = 0.006). Methods. Sixty-five municipalities were randomly assigned to a passive intervention, a proactive intervention, or a control group. The interventions, which were designed to improve the use of ASL, were targeted at patients on sick leave for LBP for more than 16 days (n = 6179), their general practitioners, employers, and local insurance officers. The main outcome measures were the average number of days off work, the proportion of patients returning to work within 1 year, and self-reported quality of life while on sick leave. Results. The median number of days on sick leave was similar in the proactive intervention group (70 days), the passive intervention group (68 days), and the control group (71 days) (P = 0.8). The proportion of patients returning to work before 50 weeks was also similar in the proactive (89%), passive (89.5%), and control groups (89.1%). Response rates for the questionnaires that were sent to patients were low (38%), and no significant differences were observed across the three groups for quality of life or patient satisfaction. Conclusions. It is not likely that efforts to increase the use of ASL will result in measurable economic benefits or improved health outcomes at the population level. The benefits of ASL for individual patients with LBP are not known.
... In the majority of both intervention trials and program evaluations, RTW coordination was only one of several elements included within a larger RTW intervention arm or institutional program. Other program components included medical case management [22-26, 54-56, 58-61], multidisciplinary rehabilitation [21,[30][31][32][33][34][35][36][37], physiotherapy [16-19, 48, 65, 66], early medical management by a rehabilitation specialist [28], physician recommendations to stay active [29,[62][63][64], improvements in employer safety practices [38][39][40][41][42][43][44][45][46][62][63][64], adoption of a managed care approach to medical care [39][40][41][42][43][44][45][46][49][50][51], and improved database tracking of claims costs and lost time claims [47,53]. Thus, benefits of RTW coordination were difficult to distinguish from other program benefits. ...
... In the majority of both intervention trials and program evaluations, RTW coordination was only one of several elements included within a larger RTW intervention arm or institutional program. Other program components included medical case management [22-26, 54-56, 58-61], multidisciplinary rehabilitation [21,[30][31][32][33][34][35][36][37], physiotherapy [16-19, 48, 65, 66], early medical management by a rehabilitation specialist [28], physician recommendations to stay active [29,[62][63][64], improvements in employer safety practices [38][39][40][41][42][43][44][45][46][62][63][64], adoption of a managed care approach to medical care [39][40][41][42][43][44][45][46][49][50][51], and improved database tracking of claims costs and lost time claims [47,53]. Thus, benefits of RTW coordination were difficult to distinguish from other program benefits. ...
... One study assessing cost-benefit found a net savings of CAN$16,000 per case [34], while another showed improved outcomes with no significant increase in overall treatment cost [18]. Only 2 of the 22 studies reported no improvement in disability outcomes after intervention [29,[62][63][64]. ...
Return-to-work (RTW) coordination has been suggested as an effective strategy for preventing workplace disability, but the scope of these services is not well described. The objective of this study was to describe the activities of RTW coordinators in published trials to provide a basis for establishing necessary competencies.
A keyword search of MEDLINE and CINAHL databases was conducted to identify intervention studies with a RTW coordinator providing direct, on-site workplace liaison to reduce work absences associated with physical health ailments. This search yielded 2,383 titles that were inspected by two examiners. Using a stepwise process that allowed for assessment of inter-observer agreement, 90 full articles were selected and reviewed, and 40 articles (22 studies) met criteria for inclusion.
All but two studies (of traumatic brain injury) focused on musculoskeletal conditions or work injuries. Twenty-nine RTW coordinator activities were identified, but there was variation in the training background, workplace activities, and contextual setting of RTW coordinators. Based on reported RTW coordinator activities, six preliminary competency domains were identified: (1) ergonomic and workplace assessment; (2) clinical interviewing; (3) social problem solving; (4) workplace mediation; (5) knowledge of business and legal aspects; and (6) knowledge of medical conditions.
Principal activities of RTW coordination involve workplace assessment, planning for transitional duty, and facilitating communication and agreement among stakeholders. Successful RTW coordination may depend more on competencies in ergonomic job accommodation, communication, and conflict resolution than on medical training.
... Findings from a Norwegian cluster-randomized controlled trial (28) indicated that increased use of so-called active sick leave (return to work to modified duties) did not affect the average number of days on sick leave, long-term disability, or quality of life. The results may, however, be partly explained by the minor use of active sick leave among the intervention groups. ...
... It is ethically problematic to carry out a randomized study to compare two existing types of benefits, for example, partial and full sick leave. The only randomized study carried out so far looked at whether an enhancement of the use of so-called active sick leave in municipalities affected the length of sick leave and disability (28). An on-going study (44) is assessing the effects of early part-time sick leave in Finland, where the statutory benefit so far is available only after a longer period of full sick leave. ...
Partial sick leave and partial sickness benefits are currently available in Sweden, Norway, Denmark, and Finland. The literature was reviewed to determine their use, describe their recipients, find evidence of their effects, and explore attitudes towards and experiences with their use. Eight databases were searched. National sickness absence statistics and other relevant sources were also reviewed. Of the sickness benefits, partial benefits accounted for approximately one-fifth in Norway, less than 10% in Denmark, and over a third in Sweden. In Finland, partial sick leave was seldom used during the first year (2007) of benefit availability. Few peer-reviewed studies on its effects were identified, and scientific evidence was scarce. Its acceptance was good in all four countries. Most of the recipients were women and over 45 years of age. Studies of its feasibility seem congruent in reporting hindrances due to inflexible work arrangements and poor collaboration between actors. More research and more rigorous study designs are needed to determine whether partial sick leave is feasible and beneficial in keeping those with reduced work ability in worklife.
... Sexton studier omfattande totalt 26 268 deltagare redovisade effekter av insatser som gjordes mot vårdgivare, men där effekten mättes på patientnivå [74, 77, 90, 93, 96, 97, 103, 106-108, 125, 126, 128, 143-145]. Sex av studierna var klusterrandomiserade [74,93,97,107,108,126]. Alla studier hade uppföljningstider på 12 månader eller kortare, utom en studie med uppföljning på två år [106] och en studie som rapporterade resultat på både kort och längre tid [103]. ...
This is an HTA report that includes a systematic review of the effects of health care interventions in case of long-term sick leave for common health problems. The report also includes health economic evaluations and an evaluation of ethical aspects. The report is in Swedish and was performed by SBU, The Swedish Agency for Health Technology Assessment and Assessment of Social Services. Link to report: https://www.sbu.se/359
... The development and resultant adoption of evidence-based clinical guidelines has been shown to reduce costs and may lead to improved patient outcomes: randomised controlled trials have reported either significant [6][7][8] or non-significant [9][10][11] reductions in costs favouring guideline adherent approaches. Patient outcomes have been seen to improve in some [10,12,13], but not all [14,15] randomised controlled studies trialling guidelineconsistent approaches. ...
Purpose
Examine the effectiveness of interventions to approach guideline-adherent surgical referrals for low back pain assessed via systematic review and meta-analysis.
Methods
Five databases (10 September 2021), Google Scholar, reference lists of relevant systematic reviews were searched and forward and backward citation tracking of included studies were implemented. Randomised controlled/clinical trials in adults with low back pain of interventions to optimise surgery rates or referrals to surgery or secondary referral were included. Bias was assessed using the Cochrane ROB2 tool and evidence certainty via Grading of Recommendations Assessment, Development and Evaluation (GRADE). A random effects meta-analysis with a Paule Mandel estimator plus Hartung–Knapp–Sidik–Jonkman method was used to calculate the odds ratio and 95% confidence interval, respectively.
Results
Of 886 records, 6 studies were included ( N = 258,329) participants; cluster sizes ranged from 4 to 54. Five studies were rated as low risk of bias and one as having some concerns. Two studies reporting spine surgery referral or rates could only be pooled via combination of p values and gave evidence for a reduction ( p = 0.021, Fisher’s method, risk of bias: low). This did not persist with sensitivity analysis ( p = 0.053). For secondary referral, meta-analysis revealed a non-significant odds ratio of 1.07 (95% CI [0.55, 2.06], I ² = 73.0%, n = 4 studies, Grading of Recommendations Assessment, Development and Evaluation [GRADE] evidence certainty: very low).
Conclusion
Few RCTs exist for interventions to improve guideline-adherent spine surgery rates or referral. Clinician education in isolation may not be effective. Future RCTs should consider organisational and/or policy level interventions.
PROSPERO registration
CRD42020215137.
... Finally, it is important to stress that some studies show no effect of sick-leave. For instance, a Norwegian cluster-randomized study on "active sick leave", which implies returning to an adjusted work environment with the assistance of social security, showed no beneficial effects [55]. These studies point out potential weaknesses that need to be better understood. ...
Due to low employment rates associated to chronic conditions in Europe, it is essential to foster effective integration and re-integration into work strategies. The objective of this systematic review is to summarize the evidence on the effectiveness of strategies for integration and re-integration to work for persons with chronic diseases or with musculoskeletal disorders, implemented in Europe in the past five years. A systematic search was conducted in MedLine, PsycINFO, CDR-HTA, CDR-DARE and Cochrane Systematic Reviews. Overall, 32 relevant publications were identified. Of these, 21 were considered eligible after a methodological assessment and included. Positive changes in employment status, return to work and sick leave outcomes were achieved with graded sickness-absence certificates, part-time sick leave, early ergonomic interventions for back pain, disability evaluation followed by information and advice, and with multidisciplinary, coordinated and tailored return to work interventions. Additionally, a positive association between the co-existence of active labour market policies to promote employment and passive support measures (e.g., pensions or benefits) and the probability of finding a job was observed. Research on the evaluation of the effectiveness of strategies targeting integration and re-integration into work for persons with chronic health conditions needs, however, to be improved and strengthened.
... 7 No effect of active sick leave (RTW to modified duties) on the average number of sick leave days or long-term disability had been detected in a Norwegian cluster randomised controlled trial. 8 There is some discrepancy in the findings on the effectiveness of partial sick leave in mental disorders. A Danish study 9 found no effect, whereas a Swedish study 10 reported a weak effect of partial sick leave on full recovery in the beginning of work disability due to mental disorders, and a stronger effect when partial sick leave was assigned after 60 days of full sick leave. ...
To examine the effect of the new legislation on partial sickness benefit on subsequent work participation of Finns with long-term sickness absence. Additionally, we investigated whether the effect differed by sex, age or diagnostic category.
A register-based quasi-experimental study compared the intervention (partial sick leave) group with the comparison (full sick leave) group regarding their pre-post differences in the outcome. The preintervention and postintervention period each consisted of 365 days.
Nationwide, individual-level data on the beneficiaries of partial or full sickness benefit in 2008 were obtained from national sickness insurance, pension and earnings registers.
1738 persons in the intervention and 56 754 persons in the comparison group.
Work participation, measured as the proportion (%) of time within 365 days when participants were gainfully employed and did not receive either partial or full ill-health-related or unemployment benefits.
Although work participation declined in both groups, the decline was 5% (absolute difference-in-differences) smaller in the intervention than in the comparison group, with a minor sex difference. The beneficial effect of partial sick leave was seen especially among those aged 45-54 (5%) and 55-65 (6%) and in mental disorders (13%). When the groups were rendered more exchangeable (propensity score matching on age, sex, diagnostic category, income, occupation, insurance district, work participation, sickness absence, rehabilitation periods and unemployment, prior to intervention and their interaction terms), the effects on work participation were doubled and seen in all age groups and in other diagnostic categories than traumas.
The results suggest that the new legislation has potential to increase work participation of the population with long-term sickness absence in Finland. If applied in a larger scale, partial sick leave may turn out to be a useful tool in reducing withdrawal of workers from the labour market due to health reasons.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
... One review states that the workers offered modified work return to work twice as often as others (Krause et al 1998), while a randomised trial from 2006 could not confirm this (Seenstra et al 2006). The "active sick leave" program in Norway that enabled the employees to return to a modified work during their sick leave period could not document any economic benefits from this (Scheel et al. 2002). ...
... So far, studies on the effects of partial sick leave on RTW or work retention are limited in number. [2][3][4][5][6][7] Although the indicators of outcome are inconsistent across these studies, they suggest that the use of partial sick leave enhances RTW. Little evidence exists on the effects of partial sick leave on transition to disability pension. ...
To support sustainability of the welfare society enhanced work retention is needed among those with impaired work ability. Partial health-related benefits have been introduced for this target. The aim was to estimate the effects of partial sick leave on transition to disability pension applying propensity score methods.
Register-based cohort study.
Sample from the national sickness insurance registers representative of the Finnish working population (full-time workers) with long-term sickness absence due to musculoskeletal disorders, mental disorders, traumas or tumours.
All recipients of partial or full sickness benefit whose sick leave period had ended between 1 May and 31 December 2007 were included. The sample was limited to four most prevalent diagnostic groups-mental and musculoskeletal disorders, traumas and tumours. The total sample consisted of 1047 subjects on partial sick leave (treatment group) and 28 380 subjects on full sick leave (control group). A subsample (1017 and 25 249 subjects, respectively) was formed to improve the comparability of the two groups.
A three-category measure and a binary measure for the occurrence of disability pension on the last day of 2008 were computed.
Partial sickness benefit reduced the risk (change in absolute risk) of full disability pension by 6% and increased the risk of partial disability pension by 8% compared with full sick leave. The effects did not differ markedly for the two main diagnostic groups of musculoskeletal and mental disorders. In men, the use of full disability pension was reduced by 10% with a 5% increase in the use of partial disability pension, while in women the effects were close to those of the total sample.
Our findings suggest that combining work with partial sick leave may provide one means to increase work retention at population level. The use of partial sick leave could be encouraged among men.
... When adjusted for background factors, the use of partial sick leave was associated with a lower risk of full disability pension. The latter finding is incompatible with Norwegian studies which report no association between the increased use of partial sick leave and long-term disability , or the use of disability benefits [13,14] . In agreement with previous studies on predictors of disability pensions345151617181920, we found that higher age, a mental or musculoskeletal disorder, and a higher number of sickness absence days were associated with subsequent partial or full disability pension. ...
Timely return to work after longterm sickness absence and the increased use of flexible work arrangements together with partial health-related benefits are tools intended to increase participation in work life. Although partial sickness benefit and partial disability pension are used in many countries, prospective studies on their use are largely lacking. Partial sickness benefit was introduced in Finland in 2007. This register study aimed to investigate the use of health-related benefits by subjects with prolonged sickness absence, initially on either partial or full sick leave.
Representative population data (13 375 men and 16 052 women either on partial or full sick leave in 2007) were drawn from national registers and followed over an average of 18 months. The registers provided information on the study outcomes: diagnoses and days of payment for compensated sick leaves, and the occurrence of disability pension. Survival analysis and multinomial regression were carried out using sociodemographic variables and prior sickness absence as covariates.
Approximately 60% of subjects on partial sick leave and 30% of those on full sick leave had at least one recurrent sick leave over the follow up. A larger proportion of those on partial sick leave (16%) compared to those on full sick leave (1%) had their first recurrent sick leave during the first month of follow up. The adjusted risks of the first recurrent sick leave were 1.8 and 1.7 for men and women, respectively, when subjects on partial sick leave were compared with those on full sick leave. There was no increased risk when those with their first recurrent sick leave in the first month were excluded from the analyses. The risks of a full disability pension were smaller and risks of a partial disability pension approximately two-fold among men and women initially on partial sick leave, compared to subjects on full sick leave.
This is the first follow up study of the newly adopted partial sickness benefit in Finland. The results show that compared to full sick leave, partial sick leave - when not followed by lasting return to work - is more typically followed by partial disability pension and less frequently by full disability pension. It is anticipated that the use of partial benefits in connection with part-time participation in work life will have favourable effects on future disability pension rates in Finland.
... Yet, the effectiveness of part-time sick leave has been poorly studied. A Norwegian cluster-randomised study on "active sick leave" (return to adjusted work supported by social security after conventional sick leave had lasted 16 days or more) showed no beneficial effects, partly because part-time sick leave system was so seldom used [9]. Users' contentment seems to be, however, high; 92% of employees on part-time sick leave in a Swedish survey were satisfied with the arrangement [10]. ...
The importance of staying active instead of bed rest has been acknowledged in the management of musculoskeletal disorders (MSDs). This emphasizes the potential benefits of adjusting work to fit the employee's remaining work ability. Despite part-time sick leave being an official option in many countries, its effectiveness has not been studied yet. We have designed a randomized controlled study to assess the health effects of early part-time sick leave compared to conventional full-day sick leave. Our hypothesis is that if work time is temporarily reduced and work load adjusted at the early stages of disability, employees with MSDs will have less disability days and faster return to regular work duties than employees on a conventional sick leave.
The study population will consist of 600 employees, who seek medical advice from an occupational physician due to musculoskeletal pain. The inclusion requires that they have not been on a sick leave for longer than 14 days prior to the visit. Based on the physician's judgement, the severity of the symptoms must indicate a need for conventional sick leave, but the employee is considered to be able to work part-time without any additional risk. Half of the employees are randomly allocated to part-time sick leave group and their work time is reduced by 40-60%, whereas in the control group work load is totally eliminated with conventional sick leave. The main outcomes are the number of days from the initial visit to return to regular work activities, and the total number of sick leave days during 12 and 24 months of follow-up. The costs and benefits as well as the feasibility of early part-time sick leave will also be evaluated.
This is the first randomised trial to our knowledge on the effectiveness of early part-time sick leave compared to conventional full-time sick leave in the management of MSDs. The data collection continues until 2011, but preliminary results on the feasibility of part-time sick leave will be available already in 2008. The increased knowledge will assist in better decision making process regarding the management of disability related to MSDs.
International Standard Randomised Controlled Trial Number Register, register number ISRCTN30911719.
Background
Effectiveness of implementing interventions to optimise guideline-recommended medical prescription in low back pain is not well established.
Methods
A systematic review and random-effects meta-analyses for dichotomous outcomes with a Paule-Mandel estimator. Five databases and reference lists were searched from inception to 4th August 2021. Randomised controlled/clinical trials in adults with low back pain to optimise medication prescription were included. Cochrane Risk of Bias 2 tool and GRADE were implemented. The review was registered prospectively with PROSPERO (CRD42020219767).
Findings
Of 3352 unique records identified in the search, seven studies were included and five were eligible for meta-analysis (N=11339 participants). Six of seven studies incorporated clinician education, three studies included audit/feedback components and one study implemented changes in medical records systems. Via meta-analysis, we estimated a non-significant odds-ratio of 0·94 (95% CI (0·77; 1.16), I² = 0%; n=5 studies, GRADE: low) in favour of the intervention group. The main finding was robust to sensitivity analyses.
Interpretation
There is low quality evidence that existing interventions to optimise medication prescription or usage in back pain had no impact. Peer-to-peer education alone does not appear to lead to behaviour change. Organisational and policy interventions may be more effective.
Funding
This work was supported by internal institutional funding only.
Quantitative designs should be used within a sequence of evaluation building on preceding theoretical, qualitative, and modeling work. While an uncontrolled evaluation design can generate insight in how far the targeted change has reached, a controlled evaluation design can shed light on the causal relationship between the implementation strategy and the improvement. There are a range of more or less complex randomized designs available for evaluating the effects of implementation projects. This chapter focuses primarily on the setting of research to evaluate the effectiveness of specific quality improvement and implementation strategies where the main aim is to make internally valid statements on their value and generalizability to a wider population or to other settings. A range of research designs and methodological considerations are presented for studies where the researcher has a level of control with regard to the allocation of practices, hospitals, professionals, or patients to experimental or control condition.
Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits-for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
Background:
Work disability has serious consequences for individuals as well as society. It is possible to facilitate resumption of work by reducing barriers to return to work (RTW) and promoting collaboration with key stakeholders. This review was first published in 2009 and has now been updated to include studies published up to February 2015.
Objectives:
To determine the effectiveness of workplace interventions in preventing work disability among sick-listed workers, when compared to usual care or clinical interventions.
Search methods:
We searched the Cochrane Work Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO databases on 2 February 2015.
Selection criteria:
We included randomised controlled trials (RCTs) of workplace interventions that aimed to improve RTW for disabled workers. We only included studies where RTW or conversely sickness absence was reported as a continuous outcome.
Data collection and analysis:
Two review authors independently extracted data and assessed risk of bias of the studies. We performed meta-analysis where possible, and we assessed the quality of evidence according to GRADE criteria. We used standard methodological procedures expected by Cochrane.
Main results:
We included 14 RCTs with 1897 workers. Eight studies included workers with musculoskeletal disorders, five workers with mental health problems, and one workers with cancer. We judged six studies to have low risk of bias for the outcome sickness absence.Workplace interventions significantly improved time until first RTW compared to usual care, moderate-quality evidence (hazard ratio (HR) 1.55, 95% confidence interval (CI) 1.20 to 2.01). Workplace interventions did not considerably reduce time to lasting RTW compared to usual care, very low-quality evidence (HR 1.07, 95% CI 0.72 to 1.57). The effect on cumulative duration of sickness absence showed a mean difference of -33.33 (95% CI -49.54 to -17.12), favouring the workplace intervention, high-quality evidence. One study assessed recurrences of sick leave, and favoured usual care, moderate-quality evidence (HR 0.42, 95% CI 0.21 to 0.82). Overall, the effectiveness of workplace interventions on work disability showed varying results.In subgroup analyses, we found that workplace interventions reduced time to first and lasting RTW among workers with musculoskeletal disorders more than usual care (HR 1.44, 95% CI 1.15 to 1.82 and HR 1.77, 95% CI 1.37 to 2.29, respectively; both moderate-quality evidence). In studies of workers with musculoskeletal disorders, pain also improved (standardised mean difference (SMD) -0.26, 95% CI -0.47 to -0.06), as well as functional status (SMD -0.33, 95% CI -0.58 to -0.08). In studies of workers with mental health problems, there was a significant improvement in time until first RTW (HR 2.64, 95% CI 1.41 to 4.95), but no considerable reduction in lasting RTW (HR 0.79, 95% CI 0.54 to 1.17). One study of workers with cancer did not find a considerable reduction in lasting RTW (HR 0.88, 95% CI 0.53 to 1.47).In another subgroup analysis, we did not find evidence that offering a workplace intervention in combination with a cognitive behavioural intervention (HR 1.93, 95% CI 1.27 to 2.93) is considerably more effective than offering a workplace intervention alone (HR 1.35, 95% CI 1.01 to 1.82, test for subgroup differences P = 0.17).Workplace interventions did not considerably reduce time until first RTW compared with a clinical intervention in workers with mental health problems in one study (HR 2.65, 95% CI 1.42 to 4.95, very low-quality evidence).
Authors' conclusions:
We found moderate-quality evidence that workplace interventions reduce time to first RTW, high-quality evidence that workplace interventions reduce cumulative duration of sickness absence, very low-quality evidence that workplace interventions reduce time to lasting RTW, and moderate-quality evidence that workplace interventions increase recurrences of sick leave. Overall, the effectiveness of workplace interventions on work disability showed varying results. Workplace interventions reduce time to RTW and improve pain and functional status in workers with musculoskeletal disorders. We found no evidence of a considerable effect of workplace interventions on time to RTW in workers with mental health problems or cancer.We found moderate-quality evidence to support workplace interventions for workers with musculoskeletal disorders. The quality of the evidence on the effectiveness of workplace interventions for workers with mental health problems and cancer is low, and results do not show an effect of workplace interventions for these workers. Future research should expand the range of health conditions evaluated with high-quality studies.
Purpose:
This study sought to provide an overview of the main topics and trends in contemporary research on successful non-clinical interventions for preventing prolonged work disability in workers compensated for work-related musculoskeletal disorders (WRMSDs).
Methods:
A systematic electronic search (English and French) was performed in ten scientific databases using keywords and descriptors. After screening the identified titles and abstracts using specific sets of criteria, categorical and thematic analyses were performed on the retained articles.
Results:
Five main topics appear to dominate the research: (1) risk factors and determinants; (2) effectiveness of interventions (programmes, specific components, strategies and policies); (3) viewpoints, experiences and perceptions of specific actors involved in the intervention process; (4) compensation issues; and (5) measurement issues. A currently widespread trend is early screening to identify risks factors for appropriate intervention and multidisciplinary, multimodal approaches. Morover, workplace-related psychosocial and ergonomic factors are considered vital to the success and sustainability of return-to-work (RTW) interventions. Finally, involving workplace actors, and more specifically, affected workers, in the RTW process appears to be a powerful force in improving the chances of moving workers away from disabled status.
Conclusions:
The findings of this literature review provide with information about the main topics and trends in research on rehabilitation interventions, revealing some successful modalities of intervention aimed at preventing prolonged work disability.
Implications for rehabilitation:
Successful intervention for preventing prolonged work disability in workers compensated for WRMSDs address workplace issues: physical and psychosocial demands at work, ability of the workers to fill these demands, work organization and support of the worker, and worker' beliefs and attitudes related to work. Successful intervention promotes collaboration, coordination between all actors and stakeholders involved in the process of rehabilitation. Strategies able to mobilize the employees, employers, insurers and health care providers are still needed to be implemented.
There is increasing evidence that staying active is an important part of a recovery process for individuals on sick leave due to musculoskeletal disorders (MSDs). It has been suggested that using part-time sick-leave rather than full-time sick leave will enhance the possibility of full recovery to the workforce, and several countries actively favor this policy. The aim of this paper is to examine if it is beneficial for individuals on sick leave due to MSDs to be on part-time sick leave compared to full-time sick leave.
A sample of 1,170 employees from the RFV-LS (register) database of the Social Insurance Agency of Sweden is used. The effect of being on part-time sick leave compared to full-time sick leave is estimated for the probability of returning to work with full recovery of lost work capacity. A two-stage recursive bivariate probit model is used to deal with the endogeneity problem.
The results indicate that employees assigned to part-time sick leave do recover to full work capacity with a higher probability than those assigned to full-time sick leave. The average treatment effect of part-time sick leave is 25 percentage points.
Considering that part-time sick leave may also be less expensive than assigning individuals to full-time sick leave, this would imply efficiency improvements from assigning individuals, when possible, to part-time sick leave.
Many factors affect worker return to work (RTW) after occupational injury, among which effective case management strategies play a particularly vital role in prompting workers for a successful RTW. Objectives This study aimed at predicting the RTW outcome and optimizing the intervention scheme of a case management program initiated in China.
A retrospective cohort was formed with 523 injured workers treated at a rehabilitation center for work injuries in southern China. The social demographic information, medical data and intervention process were extracted from the medical records of the rehabilitation center. A Cox Regression Model was used to examine the predictors of RTW case management.
261 patients (77.9%) out of the 335 valid subjects successfully returned to work after median absence duration of 36.0 days. A computer skills training program was a positive factor for RTW outcomes (hazard ratio 1.5, P < 0.001). Psychological counseling was possibly an important measure to improve RTW with a hazard ratio of 3.4 (95% CI 0.94-16, P > 0.05). Disability adjustment accommodations did not specifically benefit RTW. Education level, family's attitude to RTW, personal perceptions about social support for RTW, and injury severity were significantly associated with outcomes of RTW.
It was implied that RTW intervention should be focused on a specific skill reconstruction and training which was presumably related with labor market needs. However, tailored psychological counseling and disability adjustment activity should not be ignored in RTW.
OECD countries over the past two decades have implemented a range of labour market integration initiatives to improve the employment chances of disabled and chronically ill individuals. This article presents a systematic review and evidence synthesis on effectiveness of government interventions to influence employers' employment practices concerning disabled and chronically ill individuals in five OECD countries. A separate paper reports on interventions to influence the behaviour of employees.
Electronic and grey literature searches to identify all empirical studies reporting employment effects and/or process evaluations of government policies aimed at changing the behaviour of employers conducted between 1990 and 2008 from Canada, Denmark, Norway, Sweden and the UK.
Few studies provided robust evaluations of the programmes or their differential effects and selection of participants into programmes may distort the findings of even controlled studies. A population-level effect of legislation to combat discrimination by employers could not be detected. Workplace adjustments had positive impacts on employment, but low uptake. Financial incentives such as wage subsidies can work if they are sufficiently generous. Involving employers in return-to-work planning can reduce subsequent sick leave and be appreciated by employees, but this policy has not been taken up with the level of intensity that is likely to make a difference. Some interventions favour the more advantaged disabled people and those closer to the labour market.
Future evaluations need to pay more attention to differential impact of interventions, degree of take-up, non-stigmatizing implementation and wider policy context in each country.
To assess the effectiveness of interventions in community and workplace settings to reduce sickness absence and job loss in workers with musculoskeletal disorders (MSDs).
Relevant randomized controlled trials (RCTs) and cohort studies, published since 1990, were identified by screening citations from 35 earlier systematic reviews and by searching MEDLINE and Embase until April 2010. Effects were estimated by intervention category and other features, including study quality.
Among 42 studies (including 34 RCTs), 27 assessed return to work (RTW), 21 duration of sickness absence and 5 job loss. Interventions included exercise therapy, behavioural change techniques, workplace adaptations and provision of additional services. Studies were typically small {median sample 107 [inter-quartile range (IQR) 77-148]} and limited in quality. Most interventions appeared beneficial: the median relative risk (RR) for RTW was 1.21 (IQR 1.00-1.60) and that for avoiding MSD-related job loss was 1.25 (IQR 1.06-1.71); the median reduction in sickness absence was 1.11 (IQR 0.32-3.20) days/month. However, effects were smaller in larger and better-quality studies, suggesting publication bias. No intervention was clearly superior, although effort-intensive interventions were less effective than simple ones. No cost-benefit analyses established statistically significant net economic benefits.
As benefits are small and of doubtful cost-effectiveness, employers' practice should be guided by their value judgements about the uncertainties. Expensive interventions should be implemented only with rigorous cost-benefit evaluation planned from the outset. Future research should focus on the cost-effectiveness of simple, low-cost interventions, and further explore impacts on job retention.
Six randomized controlled trials involving 749 workers were included in this systematic review. In five studies the workers had musculoskeletal disorders and in one study they had mental health problems. The results of this review show that there is moderate-quality evidence to support the use of workplace interventions to reduce sickness absence among workers with musculoskeletal disorders when compared to usual care. However, workplace interventions were not effective to improve health outcomes among workers with musculoskeletal disorders. Considering all the types of work disability together, the results showed low-quality evidence that workplace interventions are more effective than usual care in reducing absence from work because of sickness. Unfortunately, no conclusions could be drawn regarding interventions for people with mental health problems and other health conditions due to a lack of studies. In conclusion, care providers could implement workplace interventions in guiding workers disabled with musculoskeletal disorders if the main goal is return to work.
A controlled randomized clinical trial was performed.
To investigate the effect of a light mobilization program on the duration of sick leave for patients with subacute low back pain.
Early intervention with information, diagnostics, and light mobilization may be a cost-effective method for returning patients quickly to normal activity. In this experiment, patients were referred to a low back pain clinic and given this simple and systematic program as an outpatient treatment.
In this study, 457 patients sick-listed 8 to 12 weeks for low back pain, as recorded by the National Insurance Offices, were randomized into two groups: an intervention group (n = 237) and a control group (n = 220). The intervention group was examined at a spine clinic and given information and advice to stay active. The control group was not examined at the clinic, but was treated with conventional primary health care.
At 12-month follow-up assessment, 68.4% in the intervention group had returned to full-duty work, as compared with 56.4% in the control group.
Early intervention with examination, information, and recommendations to stay active showed significant effects in reducing sick leave for patients with low back pain.
A randomized clinical trial.
To evaluate long-term clinical and economical effects of a light mobilization program on the duration of sick leave for patients with subacute low back pain.
Twelve-month follow-up results from a previous study showed that early intervention with examination at a spine clinic, giving the patients information, reassurance, and encouragement to engage in physical activity as normal as possible had significant effect in reducing sick leave. At 12-month follow-up, 68.4% in the intervention group were off sick leave, as compared with 56.4% in the control group. Patients in this study were followed-up for a period of 3 years to investigate possible long-term effects.
Four hundred fifty-seven patients placed on a sick list for 8 to 12 weeks for low back pain were randomized into two groups: an intervention group (n = 237) and a control group (n = 220). The intervention group was examined at a spine clinic and given information and advice to stay active. The control group was not examined at the clinic but was treated within the primary health care.
Over the 3 years of observation, the intervention group had significantly fewer days of sickness compensation (average 125.7 d/person) than the control group (169.6 d/person). This difference is mainly caused by a more rapid return to work during the first year. There was no significant difference for the second or third year. In particular, there is no increased risk for reoccurrence of illness from early return to work. At 6-month follow-up, patients in the intervention group were less likely to use bed rest and more likely to use stretching and walking to cope with their back pain compared with the control group. This effect diminished. At 12-month follow-up, the only significant difference between the groups was in the use of stretching. Economic returns of the intervention were calculated in terms of increases in the net present value of production for the society because of the reduction in number of days on sick leave. Net benefits accumulated over 3 years of treating the 237 patients in the intervention group amount to approximately 2,822 dollars per person.
For patients with subacute low back pain, a brief and simple early intervention with examination, information, reassurance, and encouragement to engage in physical activity as normal as possible had economic gains for the society. The effect occurred during the first year after intervention. There were no significant long-term effects of the intervention. The initial gain obtained during the first year does not lead to any increased costs or increased risks for reoccurrence of illness over the next 2 years.
The objective of this study was to determine the effectiveness of a training to increase collaboration between general practitioners and occupational health physicians in the treatment of patients with low back pain (LBP) because more collaboration might improve a patient's recovery and shorten sick leave.
In a controlled trial, the intervention in one region was compared with usual care in a control region. Participating physicians enrolled patients with LBP on sick leave for 3-12 weeks. Patients filled out three questionnaires: at inclusion, at 3 months, and at 6 months. Information on sick leave was gathered from occupational health services. All analyses were performed on an intention-to-treat basis.
Fifty-six patients with LBP were enrolled in each region. There was little collaboration between physicians during the project. Patients in the intervention region returned to work significantly later (P=.005) but were significantly more satisfied with their occupational health physician (P=.01). No differences were found between the intervention and control patients for pain, disability, quality of life, and medical consumption.
Our study does not show a positive effect of the training to increase collaboration between general practitioners and occupational health physicians. The training may not have improved collaboration enough to influence the prognosis of LBP.
This chapter summarizes the European Guidelines for Prevention in Low Back Pain, which consider the evidence in respect of the general population, workers and children. There is limited scope for preventing the incidence (first-time onset) of back pain and, overall, there is limited robust evidence for numerous aspects of prevention in back pain. Nevertheless, there is evidence suggesting that prevention of various consequences of back pain is feasible. However, for those interventions where there is acceptable evidence, the effect sizes are rather modest. The most promising approaches seem to involve physical activity/exercise and appropriate (biopsychosocial) education, at least for adults. Owing to its multidimensional nature, no single intervention is likely to be effective at preventing the overall problem of back pain, although there is likely to be benefit from getting all the players onside. However, innovative studies are required to better understand the mechanisms and delivery of prevention in low back pain.
A systematic review was conducted to review the effectiveness of workplace-based return-to-work (RTW) interventions.
Seven databases were searched, in English and French, between January 1990 and December 2003 for peer-reviewed studies of RTW interventions provided at the workplace to workers with work disability associated with musculoskeletal or other pain-related conditions. Methodological quality appraisal and data extraction were conducted by pairs of reviewers.
Of a total of 4124 papers identified by the search, 10 studies were of sufficient quality to be included in the review. There was strong evidence that work disability duration is significantly reduced by work accommodation offers and contact between healthcare provider and workplace; and moderate evidence that it is reduced by interventions which include early contact with worker by workplace, ergonomic work site visits, and presence of a RTW coordinator. For these five intervention components, there was moderate evidence that they reduce costs associated with work disability duration. Evidence for sustainability of these effects was insufficient or limited. Evidence regarding the impact of supernumerary replacements was insufficient. Evidence levels regarding the impact of the intervention components on quality-of-life was insufficient or mixed.
Our systematic review provides the evidence base supporting that workplace-based RTW interventions can reduce work disability duration and associated costs, however the evidence regarding their impact on quality-of-life outcomes was much weaker.
The process of returning disabled workers to work presents numerous challenges. In spite of the growing evidence regarding work disability prevention, little uptake of this evidence has been observed. One reason for limited dissemination of evidence is the complexity of the problem, as it is subject to multiple legal, administrative, social, political, and cultural challenges.
A literature review and collection of experts' opinion is presented, on the current evidence for work disability prevention, and barriers to evidence implementation. Recommendations are presented for enhancing implementation of research results.
The current evidence regarding work disability prevention shows that some clinical interventions (advice to return to modified work and graded activity programs) and some non-clinical interventions (at a service and policy/community level but not at a practice level) are effective in reducing work absenteeism. Implementation of evidence in work disability is a major challenge because intervention recommendations are often imprecise and not yet practical for immediate use, many barriers exist, and many stakeholders are involved. Future studies should involve all relevant stakeholders and aim at developing new strategies that are effective, efficient, and have a potential for successful implementation. These studies should be based upon a clearer conceptualization of the broader context and inter-relationships that determine return to work outcomes.
Literature review.
To review the literature about the performance of physicians as mediators of temporary and permanent disability for patients with chronic musculoskeletal complaints. To assess specifically the nature and variance of recommendations from physicians, factors influencing physician performance, and efforts to influence physician behavior in this area.
While caring for patients with musculoskeletal injuries, physicians are often asked to recommend appropriate levels of activity and work. These recommendations have significant consequences for patients' general health, employment, and financial well-being.
Medical literature search.
Physician recommendations limiting activity and work after injury are highly variable, often reflecting their own pain attitudes and beliefs. Patients' desires strongly predict disability recommendations (i.e., physicians often acquiesce to patients' requests). Other influences include jurisdiction, employer, insurer, and medical system factors. The most successful efforts to influence physician recommendations have used mass communication to influence public attitudes, while reinforcing the current standard of practice for physicians.
Physician recommendations for work and activity have important health and financial implications. Systemic, multidimensional approaches are necessary to improve performance.
Patient work resumption after sickness absence varies even among patients with similar pathologies and characteristics. Explanations remain uncertain. One newly investigated field is "information asymmetry", a situation in which critical information is not appropriately exchanged between stakeholders in disability management. It is hypothesised that information asymmetry between social insurance physicians and occupational physicians prolongs sickness absence.
To assess the influence of enhanced information exchange between these physicians on patient outcome.
Non-randomised controlled intervention study. The setting was the work inability assessment consultation of social insurance physicians in Belgium. Inclusion criteria were: employee, age 18-50, and subacute (more than one month) sickness absence. The intervention was a structured information exchange (through the use of a communication form) between the patient's social insurance physician and occupational physician. The intervention started when the patient's sickness absence reached the subacute stage, and ended when the sickness absence benefit was ceased or the duration exceeded one year. The primary outcome measure was the sickness absence benefit status of the patient assessed one year after benefit onset.
Of the 1883 patients asked to enroll in the study, 1564 (84%) participated; 505 (32%) of 1564 patients were assigned to the intervention group and 1059 (68%) to the control group; 1553 (99%) of 1564 patients completed the study. In the intervention group, 86% received no sickness absence benefit at the end of the study, versus 84% in the control group (95% CI 0.91-1.15). No significant differences in other outcome parameters were obtained.
Information exchange between physicians may not be enough to influence work resumption among patients on sickness absence. Further research on stakeholders' information asymmetry and its effect on the outcome of patients are necessary. The complexity of information asymmetry in disability management cannot be underestimated.
The lack of efficient medical interventions for combating increasing sickness absence rates has lead to the introduction of alternative measures initiated by the Norwegian National Insurance Service or at workplaces.
To determine whether minimal postal intervention had any effect on the length of sick leave.
Randomised, controlled trial with a one year follow up in Northern Norway in 1997 and 1998; 990 consecutive newly sick-listed persons with musculoskeletal or mental disorders were studied. Within the intervention group, 495 eligible sick-listed persons received a general information letter and a questionnaire as their sick leave passed 14 days. Possible intervention effects were analysed by survival analysis of the probability of returning to work within one year, and logistic regressions with benefits at one year as the dependent variable.
The overall reduction of 8.3 (95% CI -22.5 to 6.0) calendar days in mean length of sick leaves in the intervention group compared to controls, was not statistically significant. However, intervention significantly reduced length of sick leaves in subgroups with mental disorders, and with rheumatic disorders and arthritis, and overall for sick leaves lasting 12 weeks or more. Young people with low back pain showed an adverse effect to intervention. The overall relative risk of receiving benefits due to sickness after one year in the intervention group was 0.69 (95% CI 0.51 to 0.93) compared to controls.
The results should encourage employers, insurance institutions, and authorities to initiate challenges as questions on the length of sick leave and possible modified work measures, during the first few weeks of sick leave, for at least some groups of sick-listed persons.
One of the key players in the return-to-work (RTW) and work accommodation process is the healthcare provider (HCP). This study examines the association between RTW approximately one month post injury and early, proactive HCP communication with the patient and workplace.
In this cross-sectional study 187 Ontario workers completed a telephone survey 17-43 days post injury. All had accepted or pending lost-time claims for back, neck or upper extremity occupational musculoskeletal injuries. Logistic regression was used to analyze the effects of three self-reported items "your HCP told you the date you could RTW," "your HCP advised you on how to prevent re-injury or recurrence," "your HCP made contact with your workplace" on self-reported RTW. Fourteen potential confounders were also tested in the model including sex, age, income, education, occupational classification, worksite size, co-morbidity, psycho-physical work demands, pain, job satisfaction, depression, and time from injury to interview.
The HCP giving a patient a RTW date (adjusted OR=3.33, 95% CI=1.62-6.87) and giving a patient guidance on how to prevent recurrence and re-injury (adjusted OR=2.71, 95% CI=1.24-5.95) were positively associated with an early RTW. Contact by the HCP with the workplace was associated with RTW, however, this association became weaker upon adjusting for confounding variables (crude OR=2.11, 95% C1=1.09-4.09; adjusted OR=1.72, 95% CI=0.83-3.58).
Our study lends support to the HCP playing an active role early in the RTW process, one that includes direct contact with the workplace and proactive communication with the patient.
To quantify the influence that workers' satisfaction with the firm's treatment of their disability claim and their health care provider has on workers' return to work (RTW) following onset of occupational LBP.
Using a prospective survey on back pain, medical treatment, and workers' satisfaction, we employ nonparametric and logistic analyses to see how satisfaction affects RTW.
Workers' satisfaction with their employer's treatment of their disability claim is more important in explaining RTW than satisfaction with health care providers or expectations about recovery. Dissatisfied workers have worse return to work outcomes because they are more likely to have time lost claims and are more likely to have multiple spells of joblessness.
Workers' RTW is more responsive to their satisfaction with how the firm treated their disability claim than with their satisfaction with the health care provider. Satisfaction of both types plays an important role in determining RTW.
Limited knowledge precludes evidence-based interventions targeting return to work among employees on sick leave. The objective of this study was to examine the vocational effect of an intervention focused on motivation, goal setting, and planning of return to work.
A total of 2,795 people, across 6 municipalities, on sick leave for at least 21 days received a questionnaire; 1,256 with a self-assessed poor prognosis for fast return to work were eligible for the study. An examination by a specialist in social medicine, followed by additional counselling by a social worker, was offered to 510 residents in two municipalities and accepted by 264 (52%). The goal was to enhance motivation, goal setting, and planning of return to work. Residents in the remaining municipalities (n=746) received the standard case management offered by the municipalities; 845 (67%) persons completed a follow-up questionnaire gathering data on general health and employment status. The duration of the sick leave was analysed by Cox regression, and the chance of being gainfully employed was analysed by logistic regression analysis, both adjusted for several covariates.
The intervention neither shortened sick leave periods nor increased the likelihood of gainful employment after one year (OR 0.76; 95% CI 0.45-1.28).
A low-cost counselling programme addressing motivation, goal setting, and planning of return to work did not improve vocational outcomes or reduce the duration of sick leave.
Relationship-centred care stresses the importance of taking both patients' and health-care providers' values, expectations and preferences into account to improve health outcomes. The aim of this qualitative study was to identify patients' and providers' views and experiences of skin disease and topical treatment.
Two types of focus group were used: (i) patients with chronic dermatological diseases and (ii) doctors, nurses and pharmacists working in dermatological care.
Three major categories emerged: (i) problems related to the disease, (ii) problems related to the treatment and (iii) strategies for improving everyday life for patients.
Patients and providers made several suggestions for improving everyday life. Future research needs to focus on how to achieve preference-matched shared decision-making, or concordance, between patients and health-care providers, taking different perspectives into account and how to evaluate the effect of the final, clinical, economical and humanistic outcomes of care and treatment. More seamless care and an increasingly shared understanding between patients and providers of their values, expectations and preferences for care and treatment may contribute to better health and better daily lives for patients.
Low back pain (LBP) is among the most frequent causes of sickness absence in Norway, and it is thought that it could be reduced by 30-50% if present day knowledge was implemented in the workplace. Evidence-based interventions in occupational settings to prevent sickness absence are still lacking.
To evaluate whether peer support would be able to modify general beliefs about LBP, pain experiences, health care utilization and sickness absence due to back pain.
In addition to a media campaign in two Norwegian counties in 2002-05, aiming at improving beliefs about LBP in the general public, the 'Active Back' project trained a peer adviser in six participating workplaces. The task of this peer adviser was to provide information aimed at reducing fear of the pain, supportive advice and arrange for modifications of workloads, etc., for a limited period of time.
The prevalence of back pain remained constant throughout the study period, but self-reported intensity of LBP decreased at the end. There was a small decline in use of health care professionals and significant improvements in beliefs, in line with the messages of the campaign. Total sickness absence decreased by 27% and the LBP-related sickness absence by 49%.
The combination of peer support and modified workload seemed to have additional effects to the general media campaign, and resulted in decline in sickness absence and improvements in beliefs about back pain.
To describe return-to-work services for employees on sick leave offered by Finnish occupational health services (OHS).
Finnish OHS are surveyed every 3 years. Respondents are asked if they offer services to facilitate return to work (RTW), and if so, to describe them. The description was qualitatively analysed using the Atlas-ti programme to find the themes that best describe the services. We also studied characteristics of OHS predicting a return-to-work policy.
Of the total sample of 969 occupational health units, 95% responded to the survey. Forty-one per cent reported offering services for facilitating RTW after sick leave. The service usually consisted of occupational physician examination of employees on sick leave for approximately 6 weeks. This was followed by a joint discussion between employee, physician and supervisor, which could result in work accommodation or a work trial period. There was a substantial variation, with only 10% mentioning a joint meeting and 13% mentioning a work trial period or work accommodation. Return-to-work policies were more frequently found in the OHS that served only a few employers, provided more group activities and collaborated more with employers and research institutes.
Less than half of Finnish OHS offer return-to-work services of which the contents show wide variation that is not in line with current scientific evidence. A guideline project for return-to-work practices is needed to fill the gap. More research is needed to best define monitoring and screening practices for workers on sick leave.
A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
The International Classification for Primary Care (ICPC) has been the standard classification for diagnoses on sickness certificates and bills for services to the National Insurance Administration in Norway since 1992. Coding according to ICPC is compulsory for all general practitioners.
The objective of the present study was to describe the introduction of ICPC in Norway, to comment on introduction problems, and to examine the compliance and validity of coding.
The study was based on statistics for episodes of sickness certification in the National Benefit Absence Register.
In 1994, the underlying medical diagnosis was coded in 98% of the sickness absence episodes lasting more than 2 weeks. Component 1 codes (symptom codes) were used in 23% of episodes, compared with 26-31% in practice studies.
ICPC-coded data in a large Norwegian register appear promising. Most doctors do accurate and careful work in coding, and data appear to be of acceptable quality for further analysis. It is a matter of concern, however, that as many as 23% of episodes had component 1 codes, since these certificates were issued during follow-up encounters. The introduction of ICPC coding has enabled researchers to use diagnoses in the analyses of sickness absence. The growing use of ICPC in general practice has made multi-practice studies possible. The introduction of criteria is mandatory for the improvement of validity in diagnostic coding.
The objective of health technology assessment (HTA) is to support decision making in health care. HTA does not claim to provide a definite solution to a health care problem, but to assist decision makers with evidence-based information about the clinical, ethical, social, and economic implications of the development, diffusion, and use of health care technology.
Study Design. Semistructured interviews, group discussions, and a mailed survey. Objective. To identify barriers to the use of active sick leave (ASL) and to design an intervention to improve the use of ASL by patients with low back pain. Summary of Background Data. ASL was introduced in Norway in 1993 to encourage people on sick leave to return to modified work. With ASL the National Insurance Administration (NIA) pays 100% of wages, thereby allowing the employer to engage a substitute worker at no extra cost, in addition to the worker on ASL. Arranging ASL requires cooperation between the general practitioner (GP), employer, local NIA staff, and the patient, which may explain why ASL was used in less than 1% of the eligible sick leave cases in 1995, despite strong support from all players. Methods. The authors conducted five in-depth interviews at a workplace where ASL was successfully implemented. Questionnaires were sent to 89 GPs, 102 workplace representatives, and 22 local NIA officers in three counties. Five patients with back pain who had used ASL were interviewed in a focus group, and 10 patients with back pain who had not used ASL were interviewed using a structured guide. Five workplaces participated in a dialogue conference. Data collection and analysis were iterative, and new data were constantly compared with the previously analyzed materials. Results. About 80% of the GPs, employers, and NIA officers believed ASL is effective in reducing long-term sick leave. Among the barriers identified were lack of information, lack of time, and work flow barriers such as poor communication and coordination of activities between the players required to carry out ASL. Two strategies were designed to improve the workflow between them. A passive implementation strategy was designed to require a minimum amount of economic and administrative support. It included targeted information, clinical guidelines for low back pain, a reminder to GPs in the sick leave form, and a standardized agreement. A proactive strategy included the same four elements plus a kick-off continuing education seminar for GPs and a trained resource person to facilitate the use of ASL. Conclusions. Having all the players onside may be essential, but it is not sufficient to bring about action in workplace strategies for patients with low back pain. If early return to modified work is effective, implementing it may require interventions targeted at identified barriers.
Study Design. Cluster randomized controlled trial. Objective. To evaluate the effectiveness of two strategies to improve the use of active sick leave (ASL) for patients with low back pain. Summary of Background Data. ASL is a public sickness benefit scheme offered to promote early return to modified work for temporarily disabled workers. It was poorly used, and the authors designed two community interventions to strengthen the implementation of ASL based on the results of a study of barriers to use among back pain patients, employers, general practitioners (GPs), and local National Insurance Administration staff. Methods. Sixty-five municipalities in three counties in Norway, randomly assigned to a passive intervention, a proactive intervention, or a control group. The interventions were targeted at patients on sick leave for low back pain for more than 16 days (n = 6176), their GPs, employers, and local insurance officers. The passive intervention included reminders about ASL on the sick leave form that GPs must complete, a standard agreement to facilitate ASL, targeted information, and a desktop summary for GPs of clinical practice guidelines for low back pain, emphasizing the importance of advice to stay active. The proactive intervention included these elements plus a resource person to facilitate the use of ASL and a continuing education workshop for GPs. The main outcome measure reported here is the proportion of eligible patients that used ASL. Results. ASL was used significantly more in the proactive intervention municipalities (17.7%) compared with the passive intervention and control municipalities (11.5%, P = 0.018). Conclusions. A passive intervention that addressed identified barriers to the use of ASL did not increase its use. Although modest, a proactive intervention did increase its use. The main impact of the intervention was through direct contact and motivating telephone calls to patients. To the extent that GPs’ practice was changed, it was either patient mediated or by patients bypassing their GP.
This is the seventh in a series of eight articles analysing the gap between research and practiceSeries editors: Andrew Haines and Anna DonaldDespite the considerable amount of money spent on clinical research relatively little attention has been paid to ensuring that the findings of research are implemented in routine clinical practice.1 There are many different types of intervention that can be used to promote behavioural change among healthcare professionals and the implementation of research findings. Disentangling the effects of intervention from the influence of contextual factors is difficult when interpreting the results of individual trials of behavioural change.2 Nevertheless, systematic reviews of rigorous studies provide the best evidence of the effectiveness of different strategies for promoting behavioural change. 3 4 In this paper we examine systematic reviews of different strategies for the dissemination and implementation of research findings to identify evidence of the effectiveness of different strategies and to assess the quality of the systematic reviews.
Summary points
Systematic reviews of rigorous studies provide the best evidence on the effectiveness of different strategies to promote the implementation of research findings
Passive dissemination of information is generally ineffective
It seems necessary to use specific strategies to encourage implementation of research based recommendations and to ensure changes in practice
Further research on the relative effectiveness and efficiency of different strategies is required
Identification and inclusion of systematicreviews
We searched Medline records dating from 1966 to June 1995 using a strategy developed in collaboration with the NHS Centre for Reviews and Dissemination. The search identified 1139 references. No reviews from the Cochrane Effective Practice and Organisation of Care Review Group4 had been published during this time. In addition, we searched the Database of Abstracts of Research Effectiveness (DARE) (http://www.york.ac.uk/inst/crd) but did not identify any other review meeting the inclusion criteria.
We searched for any review …
Workplace injuries which result in lost time from work can have considerable financial repercussions for employer and employee alike, not to mention their physical and emotional impact on the employee. In order to lessen workers' compensation costs and facilitate the rehabilitation process, some employers offer modified work to their injured employees in order to allow an earlier return to work than would ordinarily be possible. Although modified work is regarded by many as a cornerstone in the job rehabilitation process, little is known about the structure, effectiveness, and efficiency of such programs. This report is a systematic review of the scientific literature on modified work published since 1975. Its objective is to synthesize and critically appraise the research on modified work, and, specifically, to assess the effectiveness of modified work programs. Using a systematic keyword search in three online libraries, 29 empirical studies of modified work programs were selected for review. The studies were evaluated for methodological quality, from which 13 higher quality studies were identified. On the basis of these 13 studies, the effectiveness of modified work programs was evaluated. The main finding of this review is that modified work programs facilitate return to work for temporarily and permanently disabled workers. Injured workers who are offered modified work return to work about twice as often as those who are not. Similarly, modified work programs cut the number of lost work days in half. The available evidence also suggests that modified work programs are cost-effective. Comprehensive cost-benefit analyses are needed to confirm this finding.
Population-based randomized clinical trial.
To develop and test a model of management of subacute back pain, to prevent prolonged disability.
The present management of back pain seems inadequate, and development of innovative models has been urged.
A model for the treatment of subacute work-related back pain has been developed and evaluated in a population-based randomized clinical trial. Workers (n = 130) from eligible workplaces in the Sherbrooke area (N = 31), who had been absent from work for more than 4 weeks for back pain, were randomized, based on their workplace, in one of four treatment groups: usual care, clinical intervention, occupational intervention, and full intervention (a combination of the last two). The duration of absence from regular work and from any work was evaluated using survival analysis. Functional status and pain were compared at study entry and after 1 year of follow-up.
The full intervention group returned to regular work 2.41 times faster than the usual care intervention group (95% confidence interval 1.19-4.89; P < 0.01). The specific effect of the occupational intervention accounted for the most important part of this result, with a rate ratio of return to regular work of 1.91 (95% confidence interval = 1.18-3.10; P < 0.01). Pain and disability scales demonstrated either a statistically significant reduction or a trend toward reduction in the three intervention groups, compared with the trend in the usual care intervention group.
Close association of occupational intervention with clinical care is of primary importance in impeding progression toward chronicity of low back pain.
The performance of the SF-36 was compared with disease-specific health status instruments (Arthritis Impact Measurements Scales [AIMS2], Modified Health Assessment Questionnaire [MHAQ] and visual analogue scales) in 1030 patients with rheumatoid arthritis (mean age 62.3 years, 79% females, mean disease duration 12.9 years, 48% rheumatoid factor positive). The scales performed similarly in known group comparisons (age cohorts, disease severity, disease activity, comorbidity). The SF-36 physical functioning scale correlated -0.69 and -0.73 with the MHAQ and AIMS2 physical scales, respectively. A strong negative correlation was found with the walking and bending subscale of AIMS2 (r = -0.80), a substantial negative correlation with mobility (r = -0.65), and moderate correlations with the scales for hand/finger and arm function (r = -0.52 and r = -0.53). Frequency distributions of scores revealed more skewed distributions of the AIMS2 physical scale and the MHAQ scale than the physical functioning scale of the SF36, whereas the pain and mental health scales were distributed similarly. In conclusion, the SF-36 performs well in patients with rheumatoid arthritis. The physical functioning scale of the SF-36 does not seem to capture all aspects of physical health in rheumatoid arthritis patients, but may be more sensitive than disease-specific measures to low levels of physical disability.
The use of multi-level logistic regression models was explored for the analysis of data from a cluster randomized trial investigating whether a training programme for general practitioners' reception staff could improve women's attendance at breast screening. Twenty-six general practices were randomized with women nested within them, requiring a two-level model which allowed for between-practice variability. Comparisons were made with fixed effect (FE) and random effects (RE) cluster summary statistic methods, ordinary logistic regression and a marginal model based on generalized estimating equations with robust variance estimates. An FE summary statistic method and ordinary logistic regression considerably understated the variance of the intervention effect, thus overstating its statistical significance. The marginal model produced a higher statistical significance for the intervention effect compared to that obtained from the RE summary statistic method and the multi-level model. Because there was only a moderate number of practices and these had unbalanced cluster sizes, reliable asymptotic properties for the robust standard errors used in the marginal model may not have been achieved. While the RE summary statistic method cannot handle multiple covariates easily, marginal and multi-level models can do so. In contrast to multi-level models however, marginal models do not provide direct estimates of variance components, but treat these as nuisance parameters. Estimates of the variance components were of particular interest in this example. Additionally, parametric bootstrap methods within the multi-level model framework provide confidence intervals for these variance components, as well as a confidence interval for the effect of intervention which allows for the imprecision in the estimated variance components. The assumption of normality of the random effects can be checked, and the models extended to investigate multiple sources of variability.
Increasing recognition of the failure to translate research findings into practice has led to greater awareness of the importance of using active dissemination and implementation strategies. Although there is a growing body of research evidence about the effectiveness of different strategies, this is not easily accessible to policy makers and professionals.
To identify, appraise, and synthesize systematic reviews of professional educational or quality assurance interventions to improve quality of care.
An overview was made of systematic reviews of professional behavior change interventions published between 1966 and 1998.
Forty-one reviews were identified covering a wide range of interventions and behaviors. In general, passive approaches are generally ineffective and unlikely to result in behavior change. Most other interventions are effective under some circumstances; none are effective under all circumstances. Promising approaches include educational outreach (for prescribing) and reminders. Multifaceted interventions targeting different barriers to change are more likely to be effective than single interventions.
Although the current evidence base is incomplete, it provides valuable insights into the likely effectiveness of different interventions. Future quality improvement or educational activities should be informed by the findings of systematic reviews of professional behavior change interventions.
New Hampshire René Schmidt Mannheim, Germany Michael Schneier Marina Del Rey, California Atsushi Seichi Tochigi
- Luiz Pimenta
- São Paulo
- Timothy A Puckett Oklahoma
- Oklahoma City
- M Robert
- Quencer
- Florida Miami
- R Glenn
- Ii Rechtine
- H Rochester Japan Francis
- Virginia Shen Charlottesville
- L Harry
- Florida Shuffl Ebarger Miami
- P Dhaval
- Shukla
- India Bangalore
- H Edward
- Georgia Simmons Buffalo Andrew Simpson Atlanta
- L Richard
- Skolasky
- Maryland Baltimore
- J Paul
- Jr Slosar
- Daly
- City
Luiz Pimenta
São Paulo, Brazil
Timothy A. Puckett
Oklahoma City, Oklahoma
Robert M. Quencer
Miami, Florida
Glenn R. Rechtine II
Rochester, New York
Charles A. Reitman
Houston, Texas
Sally Roberts
Shropshire, United Kingdom
Peter Robertson
Aukland, New Zealand
Michel Rossignol
Montreal, Canada
Jeffrey A. Saal
Redwood City, California
Joel S. Saal
Redwood City, California
Koichi Sairyo
Tokushima, Japan
Harvinder S. Sandhu
New York, New York
Richard Saunders
Lebanon, New Hampshire
René Schmidt
Mannheim, Germany
Michael Schneier
Marina Del Rey, California
Atsushi Seichi
Tochigi, Japan
Francis H. Shen
Charlottesville, Virginia
Harry L. Shuffl ebarger
Miami, Florida
Dhaval P. Shukla
Bangalore, India
Edward H. Simmons
Buffalo, New York
Andrew Simpson
Atlanta, Georgia
Richard L. Skolasky
Baltimore, Maryland
Paul J. Slosar, Jr.
Daly City, California
Gary L. Smidt
Lakeville, Minnesota
William D. Smith
Las Vegas, Nevada
Tomislav Smoljanovic
Zagreb, Croatia
Paul D. Sponseller
Baltimore, Maryland
Jeffrey Stambough
Cincinnati, Ohio
Bjorn N. Stromqvist
Lund, Sweden
Fred Sweet
Rockford, Illinois
Katsushi Takeshita
Tokyo, Japan
Eeric Truumees
Austin, Texas
Dennis Turk
Seattle, Washington
Judith A. Turner
Seattle, Washington
Vidyadhar V. Upasani
San Diego, California
Howard Vernon
Ontario, Canada
Barrie Vernon-Roberts
Adelaide, Australia
Tapio Videman
Alberta, Canada
Michael R. Von Korff
Seattle, Washington
Robert G. Watkins
Los Angeles, California
H. Randal Woodward
Omaha, Nebraska
Karin Wuertz
Zurich, Switzerland
Hiroshi Yamada
Wakayama, Japan
Narayan Yoganandan
Milwaukee, Wisconsin
Kazuo Yonenobu
Osaka, Japan
Takashi Yurube
Hyogo, Japan
Yin-gang Zhang
Shaanxi, China
Michael R. Zindrick
Hinsdale, Illinois
Dewei Zou
Beijing, China
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