Return-to-work coordination programmes for improving return to work in workers on sick leave

Elements of Return-to-Work Interventions for Workers on Long-Term Sick Leave: A Systematic Literature Review

PURPOSE

The aim of this systematic review is to identify vocational rehabilitation (VR) interventions that are effective to enhance return-to-work (RTW) for people on long-term sick leave (> 90 days) and to identify main elements of these interventions.

METHODS

Six electronic databases were searched for peer-reviewed studies published up to February 2022. Each article was screened independently by two different reviewers. Thereafter, one author performed the data-extraction which was checked by another author. The EPHPP quality assessment tool was used to appraise the methodological quality of the studies.

RESULTS

11.837 articles were identified. 21 articles were included in the review, which described 25 interventions. Results showed that ten interventions were more effective than usual care on RTW. Two interventions had mixed results. The effective interventions varied widely in content, but were often more extensive than usual care. Common elements of the effective interventions were: coaching, counseling and motivational interviewing, planning return to work, placing the worker in work or teaching practical skills and advising at the workplace. However, these elements were also common in interventions that were not effective on RTW compared to usual care and can therefore not explain why certain interventions are effective and others are not.

CONCLUSION

The effective interventions included in this study were often quite extensive and aimed at multiple phases of the RTW-process of the worker. In the future, researchers need to describe the population and the content of the investigated interventions more elaborate to be able to better compare VR interventions and determine what elements make interventions effective.

What is the volume, quality and characteristics of evidence relating to the effectiveness and cost-effectiveness of multi-disciplinary occupational health interventions aiming to improve work-related outcomes for employed adults? An evidence and gap map of systematic reviews

Background

In the UK, tens of millions of working days are lost due to work-related ill health every year, costing billions of pounds. The role of Occupational Health (OH) services is vital in helping workers to maintain employment when they encounter injury or illness. OH providers traditionally rely on a clinical workforce to deliver these services, particularly doctors and nurses with OH qualifications. However, the increasing demand for OH services is unlikely to be met in the future using this traditional model, due to the declining number of OH-trained doctors and nurses in the UK. Multi-disciplinary models of OH delivery, including a more varied range of healthcare and non-healthcare professionals, could provide a way to meet this new demand for OH services. There is a need to identify collaborative models of OH service delivery and review their effectiveness on return-to work outcomes. There is an existing pool of systematic review evidence evaluating workplace based, multi-disciplinary OH interventions, but it is difficult to identify which aspects of the content and/or delivery of these interventions may be associated with improved work-related outcomes.

Objectives

The aim of this evidence and gap map (EGM) was to provide an overview of the systematic review evidence that evaluates the effectiveness and cost-effectiveness of multi-disciplinary OH interventions intending to improve work-related outcomes.

Search Methods

In June 2021 we searched a selection of bibliographic databases and other academic literature resources covering a range of relevant disciplines, including health care and business studies, to identify systematic review evidence from a variety of sectors of employment. We also searched Google Search and a selection of topically relevant websites and consulted with stakeholders to identify reports already known to them. Searches were updated in February 2023.

Selection Criteria

Systematic reviews needed to be about adults (16 years or over) in employment, who have had absence from work for any medical reason. Interventions needed to be multi-disciplinary (including professionals from different backgrounds in clinical and non-clinical professions) and designed to support employees and employers to manage health conditions in the workplace and/or to help employees with health conditions retain and/or return to work following medical absence. Effectiveness needed to be measured in terms of return to work, work retention or measures of absence, or economic evaluation outcomes. These criteria were applied to the title and abstract and full text of each systematic review independently by two reviewers, with disagreements resolved through discussion. We awarded each systematic review a rating of 'High', 'Medium' or 'Low' relevance to indicate the extent to which the populations, interventions and their contexts synthesised within the review were consistent with our research question. We also recorded the number of primary studies included within each of the 'High' and 'Medium' reviews that were relevant to research question using the same screening process applied at review level.

Data Collection and Analysis

Summary data for each eligible review was extracted. The quality of the systematic reviews, rated as 'High' or 'Medium' relevance following full text screening, was appraised using the AMSTAR-2 quality appraisal tool. All data were extracted by one reviewer and checked by a second, with disagreements being settled through discussion. Summary data for all eligible systematic reviews were tabulated and described narratively. The data extracted from reviews of 'High' and 'Medium' relevance was imported into EPPI-Mapper software to create an EGM.

Stakeholder Involvement

We worked alongside commissioners and policy makers from the Department of Health and Social Care (DHSC) and Department of Work and Pensions (DWP), OH personnel, and people with lived experience of accessing OH services themselves and/or supporting employees to access OH services. Individuals contributed to decision making at all stages of the project. This ensured our EGM reflects the needs of individuals who will use it.

Main Results

We identified 98 systematic reviews that contained relevant interventions, which involved a variety of professionals and workplaces, and which measured effectiveness in terms of return to work (RTW). Of these, we focused on the 30 reviews where the population and intervention characteristics within the systematic reviews were considered to be of high or medium relevance to our research questions. The 30 reviews were of varying quality, split evenly between High/Moderate quality and Low/Critically-Low quality ratings. We did not identify any relevant systematic review evidence on any other work-related outcome of interest. Interventions were heterogenous, both within and across included systematic reviews. The EGM is structured according to the health condition experienced by participants, and the effectiveness of the interventions being evaluated, as reported within the included systematic reviews. It is possible to view (i) the quality and quantity of systematic review evidence for a given health condition, (ii) how review authors assessed the effectiveness or cost-effectiveness of the interventions evaluated. The EGM also details the primary studies relevant to our research aim included within each review.

Authors’ Conclusions

This EGM map highlights the array of systematic review evidence that exists in relation to the effectiveness or cost-effectiveness of multi-disciplinary, workplace-based OH interventions in supporting RTW. This evidence will allow policy makers and commissioners of services to determine which OH interventions may be most useful for supporting different population groups in different contexts. OH professionals may find the content of the EGM useful in identifying systematic review evidence to support their practice. The EGM also identifies where systematic review evidence in this area is lacking, or where existing evidence is of poor quality. These may represent areas where it may be particularly useful to conduct further systematic reviews.

Success rate and predictors of return to work after implementation of a formal return-to-work trajectory: A retrospective cohort study

BACKGROUND

Long term sick leave (SL) is increasing in Europe, several countries have legislative initiatives to reduce long-term absenteeism.

OBJECTIVE

We evaluated the impact of a legally defined return-to-work (RTW) trajectory on the RTW of employees on sick leave in Belgium.

METHODS

This was a retrospective register-based cohort study of employees (n = 1416) who followed an RTW trajectory in 2017. We linked workers' data from a prevention service with social security data. By multinomial logistic regression, we analysed which characteristics predicted the RTW with the same or another employer.

RESULTS

One year after their RTW trajectory, 69.2% of the 1416 employees did not RTW; 10.7% returned to work with the same employer and 20.1% with a new employer. Duration of SL was an important predictor for the RTW with both the same employer and another employer. The odds of RTW were lower when the SL duration was >  6 months compared to <  6 months. Marital status, organization-size, and the occupational physician decision had a significant impact on the RTW with the same employer. Age and who initiated the RTW-trajectory were important predictors on the RTW with another employer.

CONCLUSIONS

Overall, 30.8% of employees returned to work after their RTW trajectory. A one-size-fits-all approach is not recommended. A stepped approach with an early, informal start of the RTW process is advised. When employees or employers fail to initiate the RTW on their own, a legally defined RTW trajectory could be useful. In particular, RTW with another employer seemed a positive effect of the RTW-trajectory.

Getting an outsider's perspective - sick-listed workers' experiences with early follow-up sessions in the return to work process: a qualitative interview study

PURPOSE

The aim of this study was to explore how early follow-up sessions (after 14 and 16 weeks of sick leave) with social insurance caseworkers was experienced by sick-listed workers, and how these sessions influenced their return-to-work process.

METHODS

A qualitative interview study with sick-listed workers who completed two early follow-up sessions with caseworkers from the Norwegian Labor and Welfare Administration (NAV). Twenty-six individuals aged 30 to 60 years with a sick leave status of 50-100% participated in semi-structured interviews. The data was analyzed with thematic analysis.

RESULTS

Participants' experiences of the early follow-up sessions could be categorized into three themes: (1) Getting an outsider's perspective, (2) enhanced understanding of the framework for long term sick-leave, and (3) the empathic and personal face of the social insurance system. Meeting a caseworker enabled an outsider perspective that promoted critical reflection and calibration of their thoughts. This was experienced as a useful addition to the support many received from their informal network, such as friends, family, and co-workers. The meetings also enabled a greater understanding of their rights and duties, possibilities, and limitations regarding welfare benefits, while also displaying an unexpected empathic and understanding perspective from those working in the social insurance system.

CONCLUSION

For sick-listed individuals, receiving an early follow-up session from social insurance caseworkers was a positive experience that enhanced their understanding of their situation, and promoted reflection towards RTW. Thus, from the perspective of the sick-listed workers, early sessions with social insurance caseworkers could be a useful addition to the overall sickness absence follow-up.

Effects of Inpatient Occupational Rehabilitation vs. Outpatient Acceptance and Commitment Therapy on Sick Leave and Cost of Lost Production: 7-Year Follow-Up of a Randomized Controlled Trial

OBJECTIVES

Previously, we reported that an inpatient multimodal occupational rehabilitation program (I-MORE) was more effective than outpatient Acceptance and Commitment Therapy (O-ACT) in reducing sickness absence and was cost-effective over a 24-month period. Here we present 7-years of follow-up on sick leave and the cost of lost production.

METHODS

We randomized individuals aged 18-60, sick-listed due to musculoskeletal or mental health disorders to I-MORE (n = 82) or O-ACT (n = 79). I-MORE, lasting 3.5 weeks, integrated ACT, physical training, and work-related problem-solving. In contrast, O-ACT mainly offered six weekly 2.5 h group sessions of ACT. We measured outcomes using registry data for days on medical benefits and calculated costs of lost production. Our analysis included regression analyses to examine differences in sickness absence days, logistic general estimating equations for repeated events, and generalized linear models to assess differences in costs of lost production.

RESULTS

Unadjusted regression analyses showed 80 fewer days of sickness absence in the 7-year follow-up for I-MORE compared to O-ACT (95% CI - 264 to 104), with an adjusted difference of 114 fewer days (95% CI - 298 to 71). The difference in costs of production loss in favour of I-MORE was 27,048 euros per participant (95% CI - 35,009 to 89,104).

CONCLUSIONS

I-MORE outperformed O-ACT in reducing sickness absence and production loss costs during seven years of follow-up, but due to a limited sample size the results were unprecise. Considering the potential for substantial societal cost savings from reduced sick leave, there is a need for larger, long-term studies to evaluate return-to-work interventions.

Tailored vocational rehabilitation for people with a work disability pension in The Netherlands; an in-depth data analysis of the content and outcomes of vocational rehabilitation trajectories of the Social Security Institute

PURPOSE

People with a work disability pension receive vocational rehabilitation (VR) services from the Dutch Social Security Institute (SSI) in order to facilitate return-to-work (RTW). The SSI offers tailored VR existing of two trajectories (aimed at getting fit for work or aimed at returning to work). The purpose of this study is to describe the current practice of VR. This includes a description of client characteristics, RTW barriers and the intensity, duration, content and the outcomes of the offered trajectories.

MATERIALS AND METHODS

We analyzed data from 197 clients that were randomly selected from clients who attended a VR trajectory between 1 January t 2017 and 31 December 2018. Data were obtained from the SSI registration databases and client files.

RESULTS

Both VR trajectories at the SSI have a different aim, but in practice the content of the VR interventions often overlaps. Around half of both trajectories reached their goal. Reasons for unsuccessful trajectories were that the client did not find work or barriers were more complex than initially assessed.

CONCLUSIONS

The SSI delivers tailored VR to the specific needs of the client, however substantiations for why a certain VR intervention is offered are limited. Guidelines are needed to support professionals.

Return-to-Work Experiences in Ontario Policing: Injured But Not Broken

PURPOSE

Police officers and others working in police services are exposed to challenging and traumatic situations that can result in physical and/or psychological injuries requiring time off work. Safely returning to work post-injury is critical, yet little is known about current return-to-work (RTW) practices in police services. This study examines RTW practices and experiences in police services from the perspective of RTW personnel and workers with physical and/or psychological health conditions.

METHODS

We used a purposive sampling approach to recruit sworn and civilian members from several police services in Ontario, Canada. The recruited members had experienced RTW either as a person in a RTW support role or as a worker with a work-related injury/illness. We conducted and transcribed interviews for analysis and used qualitative research methods to identify themes in the data.

RESULTS

Five overarching themes emerged. Two pointed to the context and culture of police services and included matters related to RTW processes, injury/illness complexity, the hierarchical nature of police organizations, and a culture of stoicism and stigma. The remaining three themes pointed to the RTW processes of accommodation, communication and trust-building. They included issues related to recovery from injury/illness, meaningful accommodation, timely and clear communication, malingering and trust.

CONCLUSIONS

Our findings point to potential areas for improving RTW practices in police services: greater flexibility, more clarity, stricter confidentiality and reduced stigma. More research is needed on RTW practices for managing psychological injuries to help inform policy and practice.

A Mega-Ethnography of Qualitative Meta-Syntheses on Return to Work in People with Chronic Health Conditions

PURPOSE

The aim of this study was to synthesize the findings of qualitative meta-syntheses (QMS) on return to work (RTW) of people with different chronic illnesses and to develop a generic RTW model that can provide advice on how to improve RTW interventions and strategies.

METHODS

We conducted a systematic literature search in PubMed, Epistemonikos, CENTRAL, and PsycARTICLES to find relevant QMS, published in English or German between 2000 and 2021, and adapted the meta-ethnographic approach of Noblit and Hare to synthesize their findings.

RESULTS

Nineteen QMS (five focusing on musculoskeletal disorders or chronic pain, four on acquired or traumatic brain injuries, four on cancer, two on mental disorders, one on spinal cord injury, and three on mixed samples) met our inclusion criteria for the meta-ethnographic synthesis. Through systematic comparison and reciprocal translation of the single QMS findings, we could identify a set of key cross-cutting themes/concepts, which formed the basis for four RTW principles and a generic RTW model.

CONCLUSIONS

RTW is a multifactorial and highly interactive multistakeholder process, embedded in an individual's life and working history, as well as in a determined social and societal context. It runs parallel and interdependently to the process of coping with the disease and realigning one's own identity, thus emphasizing the significance of RTW for the person. Besides symptoms and consequences of the disease, individual coping strategies, and RTW motivation, the course and success of RTW are strongly affected by the adaptability of the person's working environment and the social support in their private and working life. Thus, RTW is not only a problem of the individual, but also a matter of the social environment, especially the workplace, requiring a holistic, person-centered, and systemic approach, coordinated by a designated body, which considers the interests of all actors involved in the RTW process.

Evaluation of an Innovative Case Management Strategy to Improve Rehabilitation Coverage for People at High Risk of Permanent Work Disability: a Feasibility Study

PURPOSE

Our process evaluation (trial registration: DRKS00022468) monitored the implementation of a multi-component strategy including case management aiming to improve rehabilitation coverage and work participation of people with a high risk of permanent work disability.

METHODS

A risk score using administrative data, particularly on employment and welfare benefits, was employed to identify individuals with higher probability of receiving disability pension and therefore potentially needing support. These individuals were contacted by post and encouraged to phone their regional case manager if they needed assistance. Content for the intervention components was developed collaboratively with the case managers. We examined the sample reached, dose delivered, fidelity, dose received and satisfaction with the intervention.

RESULTS

Out of 1074 individuals with high-risk scores were contacted, there were 57 case managements. The participants reached were in poor health, and 42.1% reported at least four diagnosed conditions, mostly musculoskeletal and mental disorders. About two-thirds (63.0%) reported poor work ability at baseline. On average, 72.5% of the content of the initial telephone contacts, 88.7% of the content of the face-to-face interviews and 45.2% of the content of the case management were delivered. The participants were highly satisfied with the various components and content of the intervention. Knowledge about rehabilitation improved significantly, with 43 of the 57 participants (75.4%) applying for rehabilitation, mainly medical rehabilitation. At the end of the case management intervention, most participants (91.7%) were still employed.

CONCLUSION

The risk score offers an opportunity to screen for people with a high risk of permanent work disability. Case management participants found participation worthwhile and were significantly better informed about participation services after completing case management. More than every second participant received medical or vocational rehabilitation.

Effectiveness of 'motivational interviewing' on sick leave: a randomized controlled trial in a social insurance setting

OBJECTIVE

This study aimed to evaluate the effectiveness of motivational interviewing (MI) - a counselling approach offered by caseworkers at the Norwegian Labor and Welfare Administration (NAV) - on return to work (RTW) for individuals sick-listed for ≥8 weeks due to any diagnoses. MI was compared to usual case management and an active control during 12 months of follow-up.

METHODS

In a randomized clinical trial with three parallel arms, participants were randomized to MI (N=257), usual case management (N=266), or an active control group (N=252). MI consisted of two MI sessions while the active control involved two sessions without MI, both were offered in addition to usual case management. The primary outcome was number of sickness absence days based on registry data. Secondary outcomes included time to sustainable RTW, defined as four consecutive weeks without medical benefits.

RESULTS

The median number of sickness absence days for the MI group was 73 days [interquartile range (IQR) 31-147], 76 days (35-134) for usual care, and 75 days (34-155) for active control. In total 89%, 88% and 86% of the participants, respectively, achieved sustainable RTW. The adjusted hazard ratio (HR) for time to sustainable RTW was 1.12 (95% CI 0.90-1.40) for MI compared to usual case management and HR 1.16 (95% CI 0.93-1.44) compared to the active control.

CONCLUSIONS

This study did not provide evidence that MI offered by NAV caseworkers to sick-listed individuals was more effective on RTW than usual case management or an active control. Providing MI in this context could be challenging as only half of the MI group received the intervention.

Economic Evaluation of Inpatient Multimodal Occupational Rehabilitation vs. Outpatient Acceptance and Commitment Therapy for Sick-Listed Workers with Musculoskeletal- or Common Mental Disorders

PURPOSE

To evaluate the cost-effectiveness and cost-benefit of inpatient multimodal occupational rehabilitation (I-MORE) compared to outpatient acceptance and commitment therapy (O-ACT) for individuals sick listed due to musculoskeletal- or common mental disorders during two-years of follow-up.

METHODS

We conducted an economic evaluation with a societal perspective alongside a randomized controlled trial with 24 months follow-up. Individuals sick listed 2 to 12 months were randomized to I-MORE (n = 85) or O-ACT (n = 79). The outcome was number of working days. Healthcare use and sick leave data were obtained by registry data.

RESULTS

Total healthcare costs during the 24 months was 12,057 euros (95% CI 9,181 to 14,933) higher for I-MORE compared to O-ACT, while the difference in production loss was 14,725 euros (95% CI -1,925 to 31,375) in favour of I-MORE. A difference of 43 (95% CI -6 to 92) workdays, in favour of I-MORE, gave an incremental cost-effectiveness ratio of 278 euros for one workday, less than the cost of one day production (339 euros). Net societal benefit was 2,667 euros during two years of follow-up.

CONCLUSION

Despite considerable intervention costs, the lower production loss resulted in I-MORE being cost-effective when compared to O-ACT. Based on economic arguments, I-MORE should be implemented as a treatment alternative for individuals on long-term sick leave. However, more research on subgroup effects and further follow-up of participants' permanent disability pension awards are warranted.

The impact of disease changes and mental health illness on readapted return to work after repeated sick leaves among Brazilian public university employees

Introduction

Health affects work absenteeism and productivity of workers, making it a relevant marker of an individual's professional development.

Objectives

The aims of this article were to investigate whether changes in the main cause of the sick leaves and the presence of mental health illnesses are associated with return to work with readaptation.

Materials and methods

A historical cohort study was carried out with non-work-related illnesses suffered by statutory workers of university campuses in a medium-sized city in the state of São Paulo, Brazil. Two exposures were measured: (a) changes, throughout medical examinations, in the International Classification of Diseases (ICD-10) chapter regarding the main condition for the sick leave; and (b) having at least one episode of sick leave due to mental illness, with or without change in the ICD-10 chapter over the follow-up period. The outcome was defined as return to work with adapted conditions. The causal model was established a priori and tested using a multiple logistic regression (MLR) model considering the effects of several confounding factors, and then compared with the same estimators obtained using Targeted Machine Learning.

Results

Among workers in adapted conditions, 64% were health professionals, 34% had had changes in the ICD-10 chapter throughout the series of sick leaves, and 62% had diagnoses of mental health issues. In addition, they worked for less time at the university and were absent for longer periods. Having had a change in the illness condition reduced the chance of returning to work in another function by more than 30%, whereas having had at least one absence because of a cause related to mental and behavioral disorders more than doubled the chance of not returning to work in the same activity as before.

Conclusion

These results were independent of the analysis technique used, which allows concluding that there were no advantages in the use of targeted maximum likelihood estimation (TMLE), given its difficulties in access, use, and assumptions.

Effectiveness of work-related interventions for return to work in people on sick leave: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Long-term sick leave is a serious concern in developed countries and the cost of sickness absence and disability benefits cause major challenges for both the individual and society as a whole. Despite an increasing body of research reported by existing systematic reviews, there is uncertainty regarding the effect on return to work of workrelated interventions for workers with different diagnoses. The objective of this systematic review was to assess and summarize available research about the effects of work-related interventions for people on long-term sick leave and those at risk of long-term sick leave.

METHODS

We conducted a systematic review in accordance with international guidelines. Campbell Collaboration (Area: Social Welfare), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Embase, Epistemonikos, MEDLINE, PsycINFO, Scopus, and Sociological Abstracts were systematically searched in March 2021. Two authors independently screened the studies. We conducted risk of bias assessments and meta-analyses of the available evidence in randomized controlled trials (RCTs). The remaining comparisons were synthesized narratively. The certainty of evidence for each outcome was assessed.

RESULTS

We included 20 RCTs comprising 5753 participants at baseline from 4 different countries. The studies had generally low risk of bias. Our certainty in the effect estimates ranged from very low to moderate. Eight different interventions were identified. Meta-analysis revealed no statistically significant difference between multidisciplinary rehabilitation (MR) and usual care (US) (Risk Ratio [RR] 1.01; Confidence Interval [CI] 95% 0.70-1.48 at 12 months follow-up) and between MR and other active intervention (Risk Ratio [RR] 1.04; Confidence Interval [CI] 95% 0.86-1.25 at 12 months follow-up). Remaining intervention groups revealed marginal, or no effect compared to the control group. The results for the secondary outcomes (self-efficacy, symptom reduction, function, cost-effectiveness) showed varied and small effects in the intervention groups.

CONCLUSION

Overall, the present data showed no conclusive evidence of which work-related intervention is most effective for return to work. However, a handful of potential interventions exist, that may contribute to a foundation for future research. Our findings support the need for adequately powered and methodologically strong studies.

Social security policy changes in 2013 had a positive impact on work participation for people with reduced work capacity: A regional Danish cohort study

BACKGROUND: In Denmark, people with permanent and significantly reduced work capacity can be assigned to a flexi-job (FJ) scheme. In 2013, the social security policy for FJ was reformed to improve employment possibilities for people with reduced work capacity. OBJECTIVE: To describe work participation in the FJ scheme before and after the reform in the North Denmark Region. METHODS: The study population was assigned to the FJ scheme between 2010 and 2015 and followed for two years. Work participation score (WPS) was defined as the number of working weeks divided by the total number of weeks in the FJ scheme. High WPS was defined as above the median. RESULTS: A total of 4,668 people were included in the study. High WPS was significantly influenced by enrolment after policy changes (odds ratio (OR)) 1.60, 95% CI 1.41–1.81), male sex (OR 1.20, CI 1.06–1.36), age above 50 (OR 0.72, CI 0.58–0.90), peripheral living (OR 0.75, CI 0.63–0.90), contact to both somatic and psychiatric healthcare (OR 0.55, CI 0.43–0.71) and a prior strong association to the labour market (OR 5.70, CI 4.40–7.37). CONCLUSIONS: Policy changes increased work participation in the FJ scheme.

Return to work factors and vocational rehabilitation interventions for long-term, partially disabled workers: a modified Delphi study among vocational rehabilitation professionals

Background

Long-term disability has a great impact on both society and workers with disabilities. Little is known about the barriers which prohibit workers with long-term disabilities from returning to work and which interventions are best suited to counteract these barriers. The main purpose of this study was to obtain consensus among professionals on important return to work (RTW) factors and effective vocational rehabilitation (VR) interventions for long-term (> 2 years), partially disabled workers. Our three research questions were: (1) which factors are associated with RTW for long-term disabled workers?; (2) which factors associated with RTW can be targeted by VR interventions?; and (3) which VR interventions are the most effective to target these factors?

Methods

A modified Delphi Study was conducted using a panel of 22 labour experts, caseworkers, and insurance physicians. The study consisted of several rounds of questionnaires and one online meeting.

Results

The multidisciplinary panel reached consensus that 58 out of 67 factors were important for RTW and that 35 of these factors could be targeted using VR interventions. In five rounds, the expert panel reached consensus that 11 out of 22 VR interventions were effective for at least one of the eight most important RTW factors.

Conclusions

Consensus was reached among the expert panel that many factors that are important for the RTW of short-term disabled workers are also important for the RTW of long-term partially disabled workers and that a substantial number of these factors could effectively be targeted using VR interventions. The results of this study will be used to develop a decision aid that supports vocational rehabilitation professionals in profiling clients and in choosing suitable VR interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13295-6.

An innovative case management intervention for people at high risk of permanent work disability to improve rehabilitation coverage and coordination of health services: a randomized controlled trial (AktiFAME, DRKS00024648)

BACKGROUND

German social law offers services from various providers and agencies for people with chronic disease or disability. Claiming services requires a high level of information and communication. Dealing with a multitude of actors, such as pension insurance agencies, job centers, employers, physicians, and psychotherapists, and coordinating between and with these actors can delay or prevent the utilization of necessary measures like medical or vocational rehabilitation. We developed a case management intervention for people at high risk of receiving a disability pension to address these challenges.

METHODS/DESIGN

Our randomized controlled trial tests the effectiveness of the multi-component AktiFAME strategy (Active access, counseling, and case management for people at high risk of permanent work disability). This strategy is comprised of four modules: screening and postal contact, telephone counseling, an initial one-on-one interview, and case management. The randomized controlled trial is complemented by an observational study that exclusively involves the individuals participating in case management and accompanies the implementation of the case management intervention. We enroll 9000 individuals aged 18 to 65 years who were identified as being at increased risk for receiving a disability pension based on administrative data from the German Pension Insurance North but who have not yet applied for rehabilitation. Half of the individuals are randomly assigned to the intervention group and the other half to the control group. The intervention group is contacted and informed about a case management intervention, whereas the control group is not. The primary outcome of the randomized controlled trial is the utilization of rehabilitation services from the German Pension Insurance North (medical or vocational rehabilitation). Data on rehabilitation will be provided by the German Pension Insurance North 1 year after random allocation. Secondary and tertiary outcomes cover additional administrative data (e.g., employment and welfare benefits) and a range of patient-reported outcome measures.

DISCUSSION

This randomized controlled trial is designed to determine the effectiveness of a newly implemented multi-component strategy to promote participation and rehabilitation coverage among individuals at high risk of receiving a disability pension.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00024648, April 27, 2021).

Effects of a Person-Centered eHealth Intervention for Patients on Sick Leave Due to Common Mental Disorders (PROMISE Study): Open Randomized Controlled Trial

BACKGROUND

Sick leave due to common mental disorders (CMDs) is a public health problem in several countries, including Sweden. Given that symptom relief does not necessarily correspond to return to work, health care interventions focusing on factors that have proven important to influence the return to work process, such as self-efficacy, are warranted. Self-efficacy is also a central concept in person-centered care.

OBJECTIVE

The aim of this study is to evaluate the effects of a person-centered eHealth intervention for patients on sick leave due to CMDs.

METHODS

A randomized controlled trial of 209 patients allocated to either a control group (107/209, 51.2%) or an intervention group (102/209, 48.8%) was conducted. The control group received usual care, whereas the intervention group received usual care with the addition of a person-centered eHealth intervention. The intervention was built on person-centered care principles and consisted of telephone support and a web-based platform. The primary outcome was a composite score of changes in general self-efficacy (GSE) and level of sick leave at the 6-month follow-up. An intention-to-treat analysis included all participants, and a per-protocol analysis consisted of those using both the telephone support and the web-based platform.

RESULTS

At the 3-month follow-up, in the intention-to-treat analysis, more patients in the intervention group improved on the composite score than those in the control group (20/102, 19.6%, vs 10/107, 9.3%; odds ratio [OR] 2.37, 95% CI 1.05-5.34; P=.04). At the 6-month follow-up, the difference was no longer significant between the groups (31/100, 31%, vs 25/107, 23.4%; OR 1.47, 95% CI 0.80-2.73; P=.22). In the per-protocol analysis, a significant difference was observed between the intervention and control groups at the 3-month follow-up (18/85, 21.2%, vs 10/107, 9.3%; OR 2.6, 95% CI 1.13-6.00; P=.02) but not at 6 months (30/84, 35.7%, vs 25/107, 23.4%; OR 1.8, 95% CI 0.97-3.43; P=.06). Changes in GSE drove the effects in the composite score, but the intervention did not affect the level of sick leave.

CONCLUSIONS

A person-centered eHealth intervention for patients on sick leave due to CMDs improved GSE but did not affect the level of sick leave.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03404583; https://clinicaltrials.gov/ct2/show/NCT03404583.

Evidence-informed decision about (de-)implementing return-to-work coordination to reduce sick leave: a case study

BACKGROUND

Coordination of return to work (RtW) is implemented in many countries, but a Cochrane review found no considerable effect on workers' sick leave compared to usual care. The aim of the study is to analyse how the evidence from this review can be used for decisions about (de-)implementing RtW coordination in a country-specific setting, using Finland as an example.

METHODS

We conducted a systematic literature search and online survey with two groups of experts to compare interventions included in the Cochrane review to Finnish RtW practice using content analysis methods. We applied the evidence-to-decision (EtD) framework criteria to draw conclusions about (de-)implementing RtW coordination in Finland, including benefits, harms and costs of the intervention compared to usual care.

RESULTS

We included seven documents from the literature search and received data from 10 of 42 survey participants. RtW coordination included, both in Finland and in the review, at least one face-to-face meeting between the physician and the worker, a workers' needs assessment, and an individual RtW plan and its implementation. Usual care focuses on medical treatment and may include general RtW advice. RtW coordination would be cost-saving if it decreases sick leave with at least 2 days compared to usual care. The evidence in the Cochrane review was mainly of low certainty, and the effect sizes had relatively wide confidence intervals. Only a new, high-quality and large randomized controlled trial (RCT) can decrease the current uncertainty, but this is unlikely to happen. The EtD framework did not provide arguments for further implementation or for de-implementation of the intervention.

CONCLUSIONS

Interventions evaluated in the Cochrane review are similar to RtW coordination and usual care interventions in Finland. Considering all EtD framework criteria, including certainty of the evidence and costs, de-implementation of RtW coordination interventions in Finland seems unnecessary. Better evidence about the costs and stakeholders' values regarding RtW coordination is needed to improve decision-making.

Exploring treatment adherence in long-term sick-listed workers and the impact of coping strategies, illness perceptions and perceived health

Background

Treatment adherence is important to improve return to work in sick-listed workers. Especially in long-term sick-listed workers who apply for a disability benefit and therefore have not (fully) returned to work, it is of great value to gain insight in the adherence to advice of physicians. Non-adherence could be one of the main reasons why they have not returned to work and are sick-listed for a long-term. The aim of the study is to explore treatment adherence and possible associated factors to advice from medical and occupational health physicians in long-term sick-listed workers.

Methods

The study is a cross-sectional survey study among 561 long-term (partly) sick-listed workers applying for a disability benefit. Associations of sociodemographic characteristics, disease related factors, coping strategies (Utrecht Coping List, UCL), illness perception (Illness Cognition Questionnaire, ICQ) and perceived health (Short-Form 12, SF12) with treatment adherence (measured with the Medical Outcomes Study Measures of Patient Adherence, MOS-MPA) were analysed separately for adherence to medical advice (n = 348, mean age 51.3 ± 9.1 years, 55.9% female) and adherence to occupational advice (n = 229, mean age 50.4 ± 9.5 years, 54.1% female).

Results

Among participants, 63.3% to 76.4% reported they were able to do what the physician told them to do. However, about half of the participants found it easy to follow-up and implement the suggestions of the physician (54.3% for medical advice and 50.2% for occupational advice). Having a mental health disorder was negatively associated with adherence to medical advice. An active coping strategy, acceptance of the disease, and perceiving positive long-term consequences of the disease were associated with a higher adherence, whereas focusing on the negative consequences was associated with a lower adherence, both for medical and occupational advice.

Conclusions

The tendency to adhere to medical and occupational advice in long-term sick-listed workers is relatively low. In order to increase return to work in this population, medical and occupational health physicians should especially be aware of the adherence of sick-listed workers with mental health disorders, but also on those who focus on the negative consequences of their (physical or mental health) disorder.

Behavioral Medicine Physiotherapy in the Context of Return to Work for Chronic Pain: A Single-Case Experimental Design Study

Effective interventions are needed for return-to-work (RTW) for individuals with chronic pain on long-term sick leave. In this study, a behavioral medicine physiotherapy protocol was systematically replicated and added to workplace components. The intervention was evaluated for fidelity and effects on target activities and work ability. A single-case experimental design was used with five participants. Daily and weekly ratings of personalized target activities at work as well as work ability were carried out throughout the study period of 26-28 weeks. Effects of the behavioral medicine physiotherapy intervention were evaluated for each individual using visual analysis of displayed graphs and quantitative non-overlap methods. Goal achievement for target activities was reviewed. Three participants completed the intervention. The results indicated an effect from the behavioral medicine physiotherapy intervention on task-specific self-efficacy for target activities, but no consistent effect on experience of target activities or work ability. All three participants had increased function in target activities in line with pre-defined goals. Fidelity to the intervention manual was good. Behavioral medicine physiotherapy can be successfully adapted to work disability and was here replicated in an RTW context for individuals with chronic pain. The intervention protocol should be further evaluated in large-scale studies.

Role of social benefits for future long-term sickness absence, disability pension and unemployment among individuals on sickness absence due to mental diagnoses: a competing risk approach

Purpose

To investigate associations between social benefits and disability pension (DP), long-term sickness absence (LTSA, ≥ 90 days), or unemployment among Swedish twins with sickness absence (SA) due to mental diagnoses.

Methods

This population-based prospective twin study included register data on first incident SA spell (< 90 days) due to mental diagnoses (ICD 10 codes F00-F99) during the follow-up 2005–2016. SA < 90 days due to other diagnoses than mental diagnoses or any other social insurance benefit was identified for the preceding year of the first incident SA spell due to mental diagnoses (coded yes/no). Comparing those with any previous social benefits vs without, cumulative incidence curve to compare time to an event, and Cox proportional hazards models for cause-specific hazard ratios (HR, 95% confidence intervals, CI) treating first incident DP, LTSA and unemployment as competing risks were modeled.

Results

During follow-up, 21 DP, 1619 LTSA, and 808 unemployment events took place. Compared to those without, those with at least one benefit had a higher risk for DP (HR 5.03; 95%CI 1.80, 14.01), LTSA (1.67; 1.50, 1.84) and unemployment (1.24; 1.03, 1.50). The cumulative incidence for DP was very low, < 1%, for LTSA 80% with any previous social benefits vs. 60% without, and for unemployment ≤ 5%.

Conclusion

Social benefits received during the preceding year of SA due to mental diagnoses (< 90 days) predict DP, LTSA, and unemployment. Hence, previous social benefits may provide means for early identification of persons at risk for exit from labor market.

'Return to Work' Coordinator Model and Work Participation of Employees: A Natural Intervention Study in Finland

Purpose Employers increasingly use 'return to work' (RTW) coordinators to support work ability and extend working careers, particularly among employees with reduced work ability. We examined whether applying this model was associated with changes in employee sickness absence and disability retirements. Methods We used data from the Finnish Public Sector study from 2009 until 2015. Employees where the model was introduced in 2012 constituted the cases (n = 4120, one municipality) and employees where the model was not in use during the follow-up, represented the controls (n = 5600, two municipalities). We analysed risk of disability retirement in 2013-2015 and risk of sickness absence after (2013-2015) vs. before (2009-2011) intervention by case-control status. Results The incidence of disability retirement after the intervention was lower in cases compared to controls both in the total population (hazard ratio HR = 0.49, 95% CI 0.30-0.79) and in the subgroup of participants with reduced work ability (HR = 0.34, 95% CI 0.12-0.99). The risk of sickness absence increased from pre-intervention to post-intervention period both among cases and controls although the relative increase was greater among cases (RR_{post- vs. pre-intervention} = 1.26, 95% CI 1.14-1.40) than controls (RR_{post- vs. pre-intervention} = 1.03, 95% CI 0.97-1.08). In the group of employees with reduced work ability, no difference in sickness absence trends between cases and controls was observed. Conclusions These findings suggest that RTW-coordinator model may increase employee sickness absence, but decrease the risk of disability retirement, i.e., permanent exclusion from the labour market.

Two-Year Follow-Up of a Randomized Clinical Trial of Inpatient Multimodal Occupational Rehabilitation Vs Outpatient Acceptance and Commitment Therapy for Sick Listed Workers with Musculoskeletal or Common Mental Disorders

Purpose There is a lack of results on long-term effects of return to work interventions. We previously reported that an inpatient multimodal occupational rehabilitation program (I-MORE) was more effective in reducing sickness absence and facilitating return to work (RTW) at 12 months follow-up compared to an outpatient program that consisted mainly of Acceptance and Commitment Therapy (O-ACT). We now report the 2-year outcome data. Methods A randomized clinical trial with parallel groups. Participants were 18-60 years old, sick listed with musculoskeletal, common mental or general/unspecified disorders. I-MORE lasted 3.5 weeks and consisted of ACT, physical training and work-related problem solving. O-ACT consisted mainly of 6 weekly sessions (2.5 h. each) of ACT in groups. Outcomes were cumulated number of days on medical benefits and time until sustainable RTW (1 month without medical benefits) during 2-years of follow-up, measured by registry data. Results For the 166 randomized participants, the median number of days on medical benefits was 159 (IQR 59-342) for I-MORE vs 249 days (IQR 103-379; Mann-Whitney U test, p = 0.07), for O-ACT. At 2 years, 40% in I-MORE received long-term benefits (work assessment allowance) vs 51% in O-ACT. The crude hazard ratio (HR) for sustainable RTW was 1.59 (95% CI 1.04-2.42, p = 0.03) and the adjusted HR 1.77 (95% CI 1.14-2.75, p = 0.01), in favor of I-MORE. Conclusions The 2-year outcomes show that I-MORE had long-term positive effects on increasing work participation for individuals sick listed with musculoskeletal and mental disorders. Further follow-up and economic evaluations should be performed.

Evaluating the Impact of Intensive Case Management for Severe Vocational Injuries on Work Incapacity and Costs

Purpose This study investigates the impact of an intensive case management program on sick leave days, permanent work incapacity levels and treatment costs for severe vocational injuries set up by the French National Insurance Fund in five health insurance districts. Methods The method employed relies on a four-step matching procedure combining Coarsened Exact Matching and Propensity Score Matching, based on an original administrative dataset. Average Treatment effects on the Treated were estimated using a parametric model with a large set of covariates. Results After one-year follow-up, workers in the treatment group had higher sickness absence rates, with 22 extra days, and the program led to 2.7 (95% CI 2.3-3.1) times more diagnoses of permanent work incapacity in the treatment group. With an estimated yearly operational cost of 2,722 € per treated worker, the average total extra treatment cost was 4,569 € for treated workers, which corresponds to a cost increase of 29.2% for the insurance fund. Conclusions The higher costs found for the treatment group are mainly due to longer sick leave duration for the moderate severity group, implying higher cash transfers in the form of one-off indemnities. Even though workers in the treated group have more diagnoses of permanent work incapacity, the difference of severity between groups is small. Our results on longer sick leave duration are partly to be explained by interactions between the case managers and the occupational physicians that encouraged patients to stay longer off-work for better recovery, despite the higher costs that this represented for the insurance fund and the well-documented adverse side effects of longer periods off-work.

Systematic Review of the Impact on Return to Work of Return-to-Work Coordinators

Purpose We conducted a systematic review to understand the impact that return-to-work coordinators (RTWCs) have on return to work (RTW) outcomes for sick/injured workers. Methods MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and ABI Inform were searched from January 1, 2000 to September 16, 2020. Of 2,927 retrieved and screened citations, 14 quantitative articles fulfilled the eligibility and quality criteria. Quality assessment, data extraction, and evidence synthesis followed article screening. Results We focused on the impact of RTWCs for outcomes of work absence, RTW rates, quality of life, and cost-benefit. Our final synthesis included 14 articles. We found strong evidence that work absence duration was reduced when workers had face-to-face contact with a RTWC. As well, there was strong evidence linking face-to-face RTWC interventions with higher RTW rates and moderate evidence that this reduced intervention costs. RTWC interventions involving the identification of barriers and facilitators to RTW also showed promising results. However, only limited evidence was found that RTWCs improved quality of life for workers. Conclusions Our synthesis identifies key features of RTW interventions that improve RTW outcomes. Future high-quality research should measure long-term outcomes of RTWC interventions to evaluate sustainability and consider the nature of work. They should also focus on RTWC impact on worker quality of life assessments and for older workers and workers with chronic health conditions.

Barriers and Facilitators for Implementing Motivational Interviewing as a Return to Work Intervention in a Norwegian Social Insurance Setting: A Mixed Methods Process Evaluation

Purpose The aim of this study was to evaluate potential barriers and facilitators for implementing motivational interviewing (MI) as a return to work (RTW) intervention in a Norwegian social insurance setting. Methods A mixed-methods process evaluation was conducted alongside a randomized controlled trial involving MI sessions delivered by social insurance caseworkers. The study was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework using focus groups with the caseworkers. MI fidelity was evaluated through audio-recordings of MI sessions and questionnaires to sick-listed participants. Results Lack of co-worker and managerial support, time and place for practicing to further develop MI skills, and a high workload made the MI intervention challenging for the caseworkers. The MI method was experienced as useful, but difficult to master. MI fidelity results showed technical global scores over the threshold for "beginning proficiency" whereas the relational global score was under the threshold. The sick-listed workers reported being satisfied with the MI sessions. Conclusions Despite caseworker motivation for learning and using MI in early follow-up sessions, MI was hard to master and use in practice. Several barriers and facilitators were identified; these should be addressed before implementing MI in a social insurance setting.Trial registration ClinicalTrials.gov: NCT03212118 (registered July 11, 2017).

Determining what constitutes an effective psychosocial 'return to work' intervention: a systematic review and narrative synthesis

PURPOSE

Work can offer a myriad of social and health benefits. Long-term sick leave can be detrimental to employers, individuals, families, and societies. The burden of long-term sick leave has motivated the development of return to work (RTW) interventions. This study sought to determine what constitutes an effective psychosocial RTW intervention, which included exploring whether the level of intervention intensity and intervention characteristics matter to RTW outcomes.

METHODS

A systematic review and narrative synthesis were undertaken. Studies were identified through six databases (Ovid Medline, CINAHL (EBSCOhost), PsycInfo (Ovid), ProQuest, Scopus, and Google Scholar) between 2011 and 3 September 2019. Randomised controlled trials (RCTs) or reviews published in English were eligible for inclusion if they targeted adults who were on sick leave/unemployed trying to return to full-capacity employment, had at least one structured psychosocial RTW intervention, and assessed RTW. Study quality was assessed using checklists from the Joanna Briggs Institute.

RESULTS

Database searching yielded 12,311 records. Eighteen RCTs (comprising 42 intervention/comparison groups), seven reviews (comprising 153 studies), and five grey literature documents were included. Included studies were of moderate-to-high quality. Research was primarily conducted in Europe and focused on psychological or musculoskeletal problems. RTW outcomes included RTW status, time until RTW, insurance claims, and sick days. Participating in a RTW program was superior to care-as-usual. RTW outcomes were similar between diverse interventions of low, moderate, and high intensity. Common foundational characteristics seen across effective RTW interventions included a focus on RTW, psychoeducation, and behavioural activation.

CONCLUSIONS

Evidence suggests that a low intensity approach to RTW interventions may be an appropriate first option before investment in high intensity, and arguably more expensive interventions, as the latter appear to provide limited additional benefit. More high-quality RCTs, from diverse countries, are needed to provide stronger evidence.

A Cross-Provider Healthcare Management Program for Musculoskeletal Disorders: Results of a Randomized Controlled Trial in 22 German Companies

Musculoskeletal disorders (MSDs) are among the most common cause for reduced work capacity and sick leave. Workplace health promotion programs are often neither tailored to the workplace nor the individual needs of the employees. To counteract lacking intersectional care, this four-year randomized controlled trial (RCT) aimed to investigate the effects of modular coordinating case management (treatment group) compared to supported self-management (control group) on MSD specific sick leave days (routine data), workability (WAI), self-efficacy (self-efficacy scale), and pain (German pain questionnaire, GPQ). The study network comprised 22 companies, 15 company health insurance funds, and 12 pension funds in Germany. Overall, 852 participants (Module A/early intervention: n = 651, Module B/rehabilitation: n = 190, Module C/reintegration: n = 10) participated. Both groups achieved fewer sick leave days, higher workability, and less pain (p < 0.0001) at follow-up compared to baseline. At follow-up, the coordinating case management group showed fewer disability days (GPQ), lower disability scores (GPQ), and lower pain intensities (GPQ) than the supported self-management group (p < 0.05), but no superiority regarding MSD specific sick leave days, workability, nor self-efficacy. Module A showed more comprehensive differences. The accompanying process evaluation shows barriers and facilitators for the implementation of the program, especially in a RCT setting.

Fidelity of a Motivational Interviewing Intervention for Improving Return to Work for People with Musculoskeletal Disorders

The objective of this study was to conduct a fidelity evaluation of a motivational interviewing (MI) intervention delivered by social insurance caseworkers, in a three-arm randomized controlled trial (RCT) for improving return to work for people on sick leave with musculoskeletal disorders. The caseworkers received six days of MI training, including an intervention manual prior to the trial onset, as well as supervision throughout the trial. The caseworkers recorded 21 MI sessions at regular intervals during the trial. An independent MI analysis center scored the recordings using the MI treatment integrity code (MITI 4). In addition, three experienced MI trainers assessed the adherence to the MI intervention manual on a 1–4 Likert scale and MI competence. Total MITI 4 mean scores were at beginning proficiency levels for two components (global technical, mean 3.0; SD 0.6 and the reflections/questions ratio, mean 1.1; SD 0.2) and under beginning proficiency for two components (global relational, mean 3.2; SD 0.7 and complex question, mean 34.0; SD 21.2). The MI trainers’ assessment showed similar results. The mean adherence score for the MI sessions was 2.96 (SD 0.9). Despite delivering a thorough course and supervision package, most of the caseworkers did not reach proficiency levels of good MI competence during the study. The fidelity evaluation showed that a large amount of training, supervision and practice is needed for caseworkers to become competent MI providers. When planning to implement MI, it is important that thorough consideration is given regarding the resources and the time needed to train caseworkers to provide MI in a social insurance setting.

Patients' with Multimorbidity and Psychosocial Difficulties and Their Views on Important Professional Competence for Rehabilitation Coordinators in the Return-to-Work Process

Coordinators may play a key role during the return-to-work (RTW) process for people on sickness absence. There are still few studies on the newly implemented rehabilitation coordinators (RECO) within Swedish healthcare, and none focus on their competence. The aim of this study was to explore how persons with multimorbidity and psychosocial difficulties describe the professional competence of the RECO they encountered during their RTW process. The study takes a relational and practical approach in defining professional competence, including both what professionals do and what they possess. Interviews with 12 people with multimorbidity and psychosocial difficulties who had encountered a RECO during their RTW process were analysed using thematic analysis. Six different themes were found: communicative and coordinating skills; advisory and guidance skills; engagement and advocacy skills; being persistent and flexible; being empathic and therapeutic; being professional and trustworthy. Most of these are found in research on RTW coordinators, but being persistent, and having advisory, guidance, advocacy and therapeutic skills have not been recognised as important competences previously. This study adds patients’ views on important professional competence that support the RTW process, which should be regarded in further developments of RECOs’ functions and their competence descriptions.

Développement et tests utilisateurs de l’application Web PRATICAdr : Plateforme de Retour Au Travail axée sur les Interactions et la Communication entre les Acteurs, intégrant un programme Durable favorisant le Rétablissement

Introduction Les troubles mentaux courants (TMC) représentent de 30 % à 50 % des absences maladies toutes confondues. Le succès du retour au travail (RAT) n’est pas dû au seul fait de l’individu, mais plutôt au résultat de l’interaction entre les acteurs impliqués dans le processus. De nombreuses applications en santé mentale ont été développées pour améliorer la prise en charge des patients et optimiser la communication entre les professionnels, sans toutefois être validées. De plus, aucune solution technologique n’a été développée à ce jour pour faciliter à la fois la concertation des acteurs du RAT (p. ex. gestionnaire, professionnels de la santé) et l’accompagnement systématique de l’employé dans son RAT.

Objectif Pour combler ces lacunes, l’objectif de cet article est double : 1) décrire le développement de l’application PRATICAdr, Plateforme de Retour Au Travail axée sur les Interactions et la Communication entre les Acteurs : un programme Durable favorisant le Rétablissement ; 2) documenter les tests utilisateurs de l’application PRATICAdr.

Méthode Le développement de PRATICAdr se décline en 3 phases : 1) l’analyse des besoins ; 2) la conceptualisation des mécanismes internes à l’application et des techniques de programmation ; 3) le test de l’application en situation réelle. L’application est évaluée par des questionnaires et entrevues pour mesurer la satisfaction des utilisateurs.

Résultats PRATICAdr permet de suivre en temps réel le parcours des acteurs impliqués dans l’accompagnement personnalisé de l’employé dans son RAT. La schématisation du processus de RAT et l’inclusion d’outils d’évaluation validés systématisent la concertation et la prise de décision partagée des acteurs, ainsi que le suivi et les actions posées en vue d’entreprendre un RAT favorisant le rétablissement. L’interface de PRATICAdr a été développée pour simplifier l’expérience utilisateur de l’employé en absence maladie et des acteurs du RAT. Les résultats de satisfaction des premiers utilisateurs de PRATICAdr, 16 employés d’une grande organisation dans le domaine de la santé en processus de RAT à la suite d’un TMC, apprécient (moyenne > 9/10) non seulement la Plateforme Web, mais également la participation des acteurs du RAT et les questionnaires inclus dans PRATICAdr. Des éléments d’amélioration sont aussi proposés.

Conclusion PRATICAdr est implantée dans 2 grandes organisations (> 15 000 employés) afin d’évaluer son efficacité auprès d’employés en absence maladie en raison d’un TMC et en processus de RAT. Dans le cadre de cet article, l’objectif était de présenter non seulement le développement de PRATICAdr, mais aussi de mesurer la satisfaction des utilisateurs. Les premiers résultats indiquent une appréciation élevée chez les employés en absence maladie, utilisateurs de PRATICAdr. En termes de pistes futures, l’intégration de l’apprentissage automatique sera abordée dans l’objectif de personnaliser le programme de RAT selon les prédictions de durée d’absence maladie et de RAT durable.

[How do Persons Perceive Rehabilitation Counseling? A Qualitative Study on Experienced Rehabilitation Counseling Implemented by the Federal German Pension Insurance among Persons with Approved Vocational Rehabilitation]

BACKGROUND AND OBJECTIVE

Persons with approved vocational rehabilitation participate in a conversation with a rehabilitation consultant shortly after approval. The aim of the consultation is to select individually suitable services from the available range of services, based on the illness and employment biography of persons with approved vocational rehabilitation. The initial consultation is thus of essential importance for the further rehabilitation process. To date, there has been little research about what characterizes successful counseling from the point of view of persons with approved vocational rehabilitation. The aim of the qualitative study was to examine the perspective on counseling for persons with approved vocational rehabilitation financed by the German Federal Pension Insurance.

METHOD

Telephone interviews based on guidelines were conducted with 16 persons. The interviews were recorded and transcribed. The data was analyzed with MAXQDA using qualitative content analysis and the technique of inductive category development.

RESULTS

Three perceived forms of counseling could be distinguished: a supportive counseling, a passive counseling and an inhibitory counseling. Persons with experienced passive and inhibitory counseling reported uncertainty and withdrawal in the further rehabilitation process.

CONCLUSION

There is an individual perception of the counseling and support provided by the rehabilitation consultant, which can have an impact on the attitude and behaviour of persons in the further course of vocational rehabilitation. The challenge is to enable supportive experiences within the time-limited framework of the initial consultation.

Cohort profile: the Ontario Life After Workplace Injury Study (OLAWIS)

PURPOSE

The substantial economic burden of work-related injury and illness, borne by workers, employers and social security programmes, is primarily attributed to the durations of work disability among workers whose recovery requires a period of absence from work, with the majority of costs arising from the minority of workers with the longest duration absences. The objective of the Ontario Life After Workplace Injury Study is to describe the long-term health and labour market outcomes of workers disabled by work injury or illness after they are no longer receiving benefits or services from the work disability insurance authority.

PARTICIPANTS

Workers disabled by a work-related injury or illness were recruited from a sample frame of disability benefit claimants with oversampling of claimants with longer benefit durations. Characteristics of workers, their employers and claimant benefits were obtained from baseline administrative data. Interviews completed at 18 months post injury (T1) and to be completed at 36 months (T2) measure return-to-work and work status; income; physical and mental health; case manager and healthcare provider interactions and employer accommodations supporting return-to-work and sociodemographic characteristics. Of eligible claimants, 40% (1132) participated in the T1 interview, with 96% consenting to participate in the T2 interview.

FINDINGS TO DATE

Preliminary descriptive analyses of T1 data have been completed. The median age was 50 years and 56% were male. At 18 months following injury, 61% were employed by their at-injury employer, 16% had changed employment and 23% were not working. Past-year prescription opioid use was prevalent (34%), as was past-year cannabis use (31%). Longer duration claimants had poorer function, recovery and health and more adverse labour market outcomes.

FUTURE PLANS

Multivariate analyses to identify modifiable predictors of adverse health and labour market outcomes and a follow-up survey of 96% of participants consenting to follow-up at 36 months are planned.

Subgroups of Long-Term Sick-Listed Based on Prognostic Return to Work Factors Across Diagnoses: A Cross-Sectional Latent Class Analysis

Comorbidity is common among long-term sick-listed and many prognostic factors for return to work (RTW) are shared across diagnoses. RTW interventions have small effects, possibly due to being averaged across heterogeneous samples. Identifying subgroups based on prognostic RTW factors independent of diagnoses might help stratify interventions. The aim of this study was to identify and describe subgroups of long-term sick-listed workers, independent of diagnoses, based on prognostic factors for RTW. Latent class analysis of 532 workers sick-listed for eight weeks was used to identify subgroups based on seven prognostic RTW factors (self-reported health, anxiety and depressive symptoms, pain, self-efficacy, work ability, RTW expectations) and four covariates (age, gender, education, physical work). Four classes were identified: Class 1 (45% of participants) was characterized by favorable scores on the prognostic factors; Class 2 (22%) by high anxiety and depressive symptoms, younger age and higher education; Class 3 (16%) by overall poor scores including high pain levels; Class 4 (17%) by physical work and lack of workplace adjustments. Class 2 included more individuals with a psychological diagnosis, while diagnoses were distributed more proportionate to the sample in the other classes. The identified classes illustrate common subgroups of RTW prognosis among long-term sick-listed individuals largely independent of diagnosis. These classes could in the future assist RTW services to provide appropriate type and extent of follow-up, however more research is needed to validate the class structure and examine how these classes predict outcomes and respond to interventions.

How People with Multimorbidity and Psychosocial Difficulties Experience Support by Rehabilitation Coordinators During Sickness Absence

Purpose

People with multimorbidity face a range of barriers in healthcare, and there is little knowledge about their challenges with regard to return-to-work (RTW). Rehabilitation coordinators, a new function in Swedish healthcare, support people in the RTW process. The present study had two aims: to explore what problems and barriers people with multimorbidity experience during their rehabilitation and RTW process and to explore in which domains the coordinators’ support is perceived to be of importance.

Methods

Interviews were conducted with 12 persons with multimorbidity who had contact with a rehabilitation coordinator during their sickness absence. Thematic analysis was guided by the case-management ecological model; this analysis was revised and adapted to the Swedish context.

Results

The participants experienced problems in all domains of the model, namely: “the healthcare system”, “the labor market and the workplace system”, “the sickness insurance system”, and “the personal system”. Rehabilitation programs that did not accommodate combinations of diseases, social complexities and needs were felt to lead to worse symptoms, thus hindering rather than promoting RTW. An overall finding regarding support by coordinators is that interventions, regardless of domain, were felt to be valuable for people with multimorbidity. The coordinator was perceived to give most support by providing advice about and coordination with healthcare and employers. Sometimes the coordinator gave advice and coordination regarding the Social Insurance Agency, very occasionally the Public Employment Services. The coordinator gave least advice and coordination about social difficulties that hindered rehabilitation and RTW processes.

Conclusion

People with multimorbidity perceive rehabilitation coordinator interventions as important in all domains investigated. Lack of advice and coordination, or rehabilitation programs that were not modified to the complexities of individual’s circumstances, were associated with prolonged sickness absence, worse health, or social risk factors not being recognized.

The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews

BACKGROUND

Policymakers in many countries promote collaboration between health care organizations and other sectors as a route to improving population health. Local collaborations have been developed for decades. Yet little is known about the impact of cross-sector collaboration on health and health equity.

METHODS

We carried out a systematic review of reviews to synthesize evidence on the health impacts of collaboration between local health care and non-health care organizations, and to understand the factors affecting how these partnerships functioned. We searched four databases and included 36 studies (reviews) in our review. We extracted data from these studies and used Nvivo 12 to help categorize the data. We assessed risk of bias in the studies using standardized tools. We used a narrative approach to synthesizing and reporting the data.

RESULTS

The 36 studies we reviewed included evidence on varying forms of collaboration in diverse contexts. Some studies included data on collaborations with broad population health goals, such as preventing disease and reducing health inequalities. Others focused on collaborations with a narrower focus, such as better integration between health care and social services. Overall, there is little convincing evidence to suggest that collaboration between local health care and non-health care organizations improves health outcomes. Evidence of impact on health services is mixed. And evidence of impact on resource use and spending are limited and mixed. Despite this, many studies report on factors associated with better or worse collaboration. We grouped these into five domains: motivation and purpose, relationships and cultures, resources and capabilities, governance and leadership, and external factors. But data linking factors in these domains to collaboration outcomes is sparse.

CONCLUSIONS

In theory, collaboration between local health care and non-health care organizations might contribute to better population health. But we know little about which kinds of collaborations work, for whom, and in what contexts. The benefits of collaboration may be hard to deliver, hard to measure, and overestimated by policymakers. Ultimately, local collaborations should be understood within their macro-level political and economic context, and as one component within a wider system of factors and interventions interacting to shape population health.

Health, Work, and Family Strain - Psychosocial Experiences at the Early Stages of Long-Term Sickness Absence

Background

Knowledge about the psychosocial experiences of sick-listed workers in the first months of sick leave is sparse even though early interventions are recommended. The aim of this study was to explore psychosocial experiences of being on sick leave and thoughts about returning to work after 8–12 weeks of sickness absence.

Methods

Sixteen individuals at 9–13 weeks of sick leave participated in semi-structured individual interviews. Data was analyzed through Giorgi’s descriptive phenomenological method.

Results

Three themes emerged: (1) energy depleted, (2) losing normal life, (3) searching for a solution. A combination of health, work, and family challenges contributed to being drained of energy, which affected both work- and non-work roles. Being on sick leave led to a loss of social arenas and their identity as a contributing member of society. Participants required assistance to find solutions toward returning to work.

Conclusion

Even in this early stage of long-term sick leave, sick listed workers faced complex challenges in multiple domains. Continuing sick leave was experienced as necessary but may challenge personal identity and social life. Those not finding solutions may benefit from additional early follow-up that examine work-related, social and personal factors that influence return to work.

Motivational Interviewing and Return to Work for People with Musculoskeletal Disorders: A Systematic Mapping Review

Purpose There is limited knowledge about motivational interviewing (MI) for people on sick leave with musculoskeletal disorders. Hence, our objective was to investigate what research on MI as a method to facilitate return to work for individuals who are on sick leave due to musculoskeletal disorders exists, and what are the results of the research? Methods We systematically searched MEDLINE, PsycINFO, EMBASE, Cochrane Library, CINAHL, Web of Science, Sociological Abstracts, Epistemonikos, SveMed + and DARE & HTA (covering 1983 to August 2019). We also searched the MINT bulletin and relevant web pages. Eligibility criteria: empirical studies investigating MI and return to work for people with musculoskeletal disorders. Two authors independently screened the records, critically appraised the studies and charted the data using a data extraction form. Results The searches identified 1264 records of which two studies were included. One randomized controlled trial (RCT) found no effect of MI on return to work for disability pensioner with back pain (n = 89, high risk of bias), while a cluster RCT found that MI increased return to work for claimants with chronic musculoskeletal disorders (n = 728, low risk of bias). Conclusions This mapping review identified a huge gap in research on MI to increase return to work for individuals with musculoskeletal disorders. Registration Current Research Information System in Norway, project id: 635823 ( https://app.cristin.no/projects/show.jsf?id=635823 ).

The Prevalence and Determinants of Being Offered and Accepting Operational Management Services-A Cohort Study

In Germany, employers are obliged to offer “operational integration management” (OIM) services to employees returning from long-term sick leave. OIM aims to improve employees’ workability and to prevent future sick leave or early retirement. This study examined (i) to what extent OIM services are offered to eligible employees, (ii) to what extent offers are accepted and (iii) the determinants of both outcomes. We used data from a cohort of employees eligible for OIM. Thirty-four potential determinants were assessed in 2013 (i.e., the baseline) using participant reports. In 2015 (i.e., the follow-up), participants were asked (a) whether they had ever been offered OIM services by their employer, and (b) whether they had accepted that offer (i.e., the outcomes). We estimated relative risks by multivariable binomial regression to identify predictors based on backward elimination. In total, 36.0% of the participants were offered OIM services and 77.2% of them accepted that offer. The likelihood of an OIM offer at follow-up was elevated in participants with mental impairment, cancer or long-term absenteeism and increased with organizational justice, neuroticism, and company size. The likelihood of accepting that OIM offer was positively associated with mental impairment and decreased with increasing company size.

Exploring expected and perceived facilitators and barriers of an indicated prevention strategy to prevent future long-term sickness absence; a qualitative study among employers and employees

BACKGROUND

An indicated prevention strategy (IPS), consisting of a screening questionnaire and early treatment, was found to be effective for the prevention of future long-term sickness absence (LTSA) in two large Dutch RCT's. This IPS aims to detect employees who have a high risk to become absent, and subsequently offer them early treatment. Despite the overall effectiveness, only a few companies have implemented this strategy so far. This suggests that companies may not be convinced of the (cost) effectiveness of this strategy yet. In companies where IPS has been implemented, screenings uptake and adherence to early treatment appeared to be moderate, indicating that both employees and employers might perceive barriers.

METHODS

The aim of this qualitative study was to explore the expected and perceived facilitators and barriers for the implementation of the IPS. Semi-structured interviews were conducted with 9 employers and 11 employees (acquainted and unacquainted with IPS) from large companies. Purposive sampling was used to recruit participants. All interviews were transcribed and analyzed thematically.

RESULTS

The employers believed they were primarily responsible for psychological and work-related health complaints and SA, while the employees felt responsible for health complaints related to their lifestyle. According to the employees, the responsibility of the employer was solely related to work-related health. This finding exposed a relation with the health culture, which was solely based on creating a safe work environment, omitting psychological health issues. The efficacy of this IPS regarding reducing SA was estimated positive, however, the efficacy regarding LTSA was questioned. Fear of a privacy breach was often mentioned by the respondents as an important barrier.

CONCLUSIONS

This study showed that the health culture within a company may be important for the perceived responsibility towards SA and health. A health culture which primarily focuses on physical complaints may raise barriers for the adoption and implementation of this preventive strategy. Participant' perceptions of the nature of LTSA and the fact that not all participants were familiar with the exact content and phasing of IPS may have doubted the efficacy regarding LTSA. This study provides important clues for future and improved implementation of IPS.

Co-operation in the prevention of work disability due to musculoskeletal disorders: A cross-sectional study among occupational health professionals in Finland

BACKGROUND: Occupational health service (OHS) providers and their client organizations are obligated to collaborate in promoting health and work ability. Little is known how this multiprofessional co-operation is implemented in relation to the prevention of musculoskeletal disorders (MSD). OBJECTIVE: The aim of this study was to investigate the working practices of co-operation among OHS professionals, and between the OHSs and workplaces. METHODS: In 2015 a web-based questionnaire was sent to 3900 OHS professionals in Finland. A total of 589 responded: 106 physicians, 322 nurses, 134 physiotherapists and 27 psychologists. RESULTS: The co-operation within OHS personnel was regarded to strengthen the processes to promote work ability of workers with MSD. Despite the positive expectations of co-operation, there is a problem of having enough time to put good ideas into practice. Four main possibilities to develop co-operation were identified: creating proactive working models with defined roles; increasing awareness of importance of early intervention models; implementing the principles of good OH practice; and adopting the knowledge of the latest information to promote work ability. CONCLUSIONS: Despite its recognized importance, co-operation both with OHS colleagues and with the workplaces was not always optimal. There is a need for defined roles and common proactive working models between each stakeholder for more effective co-operation.

Interventions to facilitate return to work in adults with chronic non-malignant pain: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Work absenteeism due to chronic non-malignant pain (CNMP) is a major societal and individual cause of concern that requires effective treatments.

OBJECTIVE

We present a protocol for a systematic review and network meta-analysis (NMA) aiming to compare available interventions for return to work (RTW) in adults with CNMP.

METHODS AND ANALYSIS

PubMed, Embase, PsycINFO, Web of Knowledge and Cochrane Central Register of Controlled Trials databases will be searched till 31 August 2020 for randomised controlled trials (RCTs) examining interventions for RTW outcomes among patients with CNMP. Two independent investigators will search the databases, perform data extraction and assess the methodological quality of the selected RCTs. The primary outcome will be RTW, if possible, full-time or part-time after work absence due to chronic pain from baseline to the last available follow-up. Secondary outcomes will include self-reported workability or work capacity, or self-reported physical functioning and quality of life as measured by any validated scale. Pairwise meta-analysis and NMA will be conducted for each outcome using a random-effects model. For the primary outcomes, we will also obtain the ranking of all competing interventions within each NMA using surface under the cumulative ranking curve. The assumption of coherence (ie, that direct and indirect evidence are in statistical agreement) will be examined using both a local and a global approach. We will also conduct subgroup and meta-regression analyses, whenever feasible, to investigate the unexplained variation in effect size. The comparison-adjusted funnel plot will be used to evaluate small-study effects. The overall quality of evidence will be rated with the Confidence in Network Meta-Analysis tool. Data analysis will be conducted using Stata V.16.0.

ETHICS AND DISSEMINATION

This systematic review does not require ethical approval since it will not disseminate any private patient data. The results of this study will be disseminated through peer-reviewed publication.

PROSPERO REGISTRATION NUMBER

CRD42020171429.

Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review

BACKGROUND

Evidence from disease epidemics shows that healthcare workers are at risk of developing short- and long-term mental health problems. The World Health Organization (WHO) has warned about the potential negative impact of the COVID-19 crisis on the mental well-being of health and social care professionals. Symptoms of mental health problems commonly include depression, anxiety, stress, and additional cognitive and social problems; these can impact on function in the workplace. The mental health and resilience (ability to cope with the negative effects of stress) of frontline health and social care professionals ('frontline workers' in this review) could be supported during disease epidemics by workplace interventions, interventions to support basic daily needs, psychological support interventions, pharmacological interventions, or a combination of any or all of these.

OBJECTIVES

Objective 1: to assess the effects of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic. Objective 2: to identify barriers and facilitators that may impact on the implementation of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic.

SEARCH METHODS

On 28 May 2020 we searched the Cochrane Database of Systematic Reviews, CENTRAL, MEDLINE, Embase, Web of Science, PsycINFO, CINAHL, Global Index Medicus databases and WHO Institutional Repository for Information Sharing. We also searched ongoing trials registers and Google Scholar. We ran all searches from the year 2002 onwards, with no language restrictions.

SELECTION CRITERIA

We included studies in which participants were health and social care professionals working at the front line during infectious disease outbreaks, categorised as epidemics or pandemics by WHO, from 2002 onwards. For objective 1 we included quantitative evidence from randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies, which investigated the effect of any intervention to support mental health or resilience, compared to no intervention, standard care, placebo or attention control intervention, or other active interventions. For objective 2 we included qualitative evidence from studies that described barriers and facilitators to the implementation of interventions. Outcomes critical to this review were general mental health and resilience. Additional outcomes included psychological symptoms of anxiety, depression or stress; burnout; other mental health disorders; workplace staffing; and adverse events arising from interventions.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently applied selection criteria to abstracts and full papers, with disagreements resolved through discussion. One review author systematically extracted data, cross-checked by a second review author. For objective 1, we assessed risk of bias of studies of effectiveness using the Cochrane 'Risk of bias' tool. For objective 2, we assessed methodological limitations using either the CASP (Critical Appraisal Skills Programme) qualitative study tool, for qualitative studies, or WEIRD (Ways of Evaluating Important and Relevant Data) tool, for descriptive studies. We planned meta-analyses of pairwise comparisons for outcomes if direct evidence were available. Two review authors extracted evidence relating to barriers and facilitators to implementation, organised these around the domains of the Consolidated Framework of Implementation Research, and used the GRADE-CERQual approach to assess confidence in each finding. We planned to produce an overarching synthesis, bringing quantitative and qualitative findings together.

MAIN RESULTS

We included 16 studies that reported implementation of an intervention aimed at supporting the resilience or mental health of frontline workers during disease outbreaks (severe acute respiratory syndrome (SARS): 2; Ebola: 9; Middle East respiratory syndrome (MERS): 1; COVID-19: 4). Interventions studied included workplace interventions, such as training, structure and communication (6 studies); psychological support interventions, such as counselling and psychology services (8 studies); and multifaceted interventions (2 studies). Objective 1: a mixed-methods study that incorporated a cluster-randomised trial, investigating the effect of a work-based intervention, provided very low-certainty evidence about the effect of training frontline healthcare workers to deliver psychological first aid on a measure of burnout. Objective 2: we included all 16 studies in our qualitative evidence synthesis; we classified seven as qualitative and nine as descriptive studies. We identified 17 key findings from multiple barriers and facilitators reported in studies. We did not have high confidence in any of the findings; we had moderate confidence in six findings and low to very low confidence in 11 findings. We are moderately confident that the following two factors were barriers to intervention implementation: frontline workers, or the organisations in which they worked, not being fully aware of what they needed to support their mental well-being; and a lack of equipment, staff time or skills needed for an intervention. We are moderately confident that the following three factors were facilitators of intervention implementation: interventions that could be adapted for local needs; having effective communication, both formally and socially; and having positive, safe and supportive learning environments for frontline workers. We are moderately confident that the knowledge or beliefs, or both, that people have about an intervention can act as either barriers or facilitators to implementation of the intervention.

AUTHORS' CONCLUSIONS

There is a lack of both quantitative and qualitative evidence from studies carried out during or after disease epidemics and pandemics that can inform the selection of interventions that are beneficial to the resilience and mental health of frontline workers. Alternative sources of evidence (e.g. from other healthcare crises, and general evidence about interventions that support mental well-being) could therefore be used to inform decision making. When selecting interventions aimed at supporting frontline workers' mental health, organisational, social, personal, and psychological factors may all be important. Research to determine the effectiveness of interventions is a high priority. The COVID-19 pandemic provides unique opportunities for robust evaluation of interventions. Future studies must be developed with appropriately rigorous planning, including development, peer review and transparent reporting of research protocols, following guidance and standards for best practice, and with appropriate length of follow-up. Factors that may act as barriers and facilitators to implementation of interventions should be considered during the planning of future research and when selecting interventions to deliver within local settings.

Interventions to improve return to work in depressed people

BACKGROUND

Work disability such as sickness absence is common in people with depression.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at reducing work disability in employees with depressive disorders.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library), MEDLINE, Embase, CINAHL, and PsycINFO until April 4th 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs of work-directed and clinical interventions for depressed people that included days of sickness absence or being off work as an outcome. We also analysed the effects on depression and work functioning.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and rated the certainty of the evidence using GRADE. We used standardised mean differences (SMDs) or risk ratios (RR) with 95% confidence intervals (CI) to pool study results in studies we judged to be sufficiently similar.  MAIN RESULTS: In this update, we added 23 new studies. In total, we included 45 studies with 88 study arms, involving 12,109 participants with either a major depressive disorder or a high level of depressive symptoms. Risk of bias The most common types of bias risk were detection bias (27 studies) and attrition bias (22 studies), both for the outcome of sickness absence. Work-directed interventions Work-directed interventions combined with clinical interventions A combination of a work-directed intervention and a clinical intervention probably reduces days of sickness absence within the first year of follow-up (SMD -0.25, 95% CI -0.38 to -0.12; 9 studies; moderate-certainty evidence). This translates back to 0.5 fewer (95% CI -0.7 to -0.2) sick leave days in the past two weeks or 25 fewer days during one year (95% CI -37.5 to -11.8). The intervention does not lead to fewer persons being off work beyond one year follow-up (RR 0.96, 95% CI 0.85 to 1.09; 2 studies, high-certainty evidence). The intervention may reduce depressive symptoms (SMD -0.25, 95% CI -0.49 to -0.01; 8 studies, low-certainty evidence) and probably has a small effect on work functioning (SMD -0.19, 95% CI -0.42 to 0.06; 5 studies, moderate-certainty evidence) within the first year of follow-up.  Stand alone work-directed interventions A specific work-directed intervention alone may increase the number of sickness absence days compared with work-directed care as usual (SMD 0.39, 95% CI 0.04 to 0.74; 2 studies, low-certainty evidence) but probably does not lead to more people being off work within the first year of follow-up (RR 0.93, 95% CI 0.77 to 1.11; 1 study, moderate-certainty evidence) or beyond (RR 1.00, 95% CI 0.82 to 1.22; 2 studies, moderate-certainty evidence). There is probably no effect on depressive symptoms (SMD -0.10, 95% -0.30 CI to 0.10; 4 studies, moderate-certainty evidence) within the first year of follow-up and there may be no effect on depressive symptoms beyond that time (SMD 0.18, 95% CI -0.13 to 0.49; 1 study, low-certainty evidence). The intervention may also not lead to better work functioning (SMD -0.32, 95% CI -0.90 to 0.26; 1 study, low-certainty evidence) within the first year of follow-up.   Psychological interventions A psychological intervention, either face-to-face, or an E-mental health intervention, with or without professional guidance, may reduce the number of sickness absence days, compared with care as usual (SMD -0.15, 95% CI -0.28 to -0.03; 9 studies, low-certainty evidence). It may also reduce depressive symptoms (SMD -0.30, 95% CI -0.45 to -0.15, 8 studies, low-certainty evidence). We are uncertain whether these psychological interventions improve work ability (SMD -0.15 95% CI -0.46 to 0.57; 1 study; very low-certainty evidence). Psychological intervention combined with antidepressant medication Two studies compared the effect of a psychological intervention combined with antidepressants to antidepressants alone. One study combined psychodynamic therapy with tricyclic antidepressant (TCA) medication and another combined telephone-administered cognitive behavioural therapy (CBT) with a selective serotonin reuptake inhibitor (SSRI). We are uncertain if this intervention reduces the number of sickness absence days (SMD -0.38, 95% CI -0.99 to 0.24; 2 studies, very low-certainty evidence) but found that there may be no effect on depressive symptoms (SMD -0.19, 95% CI -0.50 to 0.12; 2 studies, low-certainty evidence). Antidepressant medication only Three studies compared the effectiveness of SSRI to selective norepinephrine reuptake inhibitor (SNRI) medication on reducing sickness absence and yielded highly inconsistent results. Improved care Overall, interventions to improve care did not lead to fewer days of sickness absence, compared to care as usual (SMD -0.05, 95% CI -0.16 to 0.06; 7 studies, moderate-certainty evidence). However, in studies with a low risk of bias, the intervention probably leads to fewer days of sickness absence in the first year of follow-up (SMD -0.20, 95% CI -0.35 to -0.05; 2 studies; moderate-certainty evidence). Improved care probably leads to fewer depressive symptoms (SMD -0.21, 95% CI -0.35 to -0.07; 7 studies, moderate-certainty evidence) but may possibly lead to a decrease in work-functioning (SMD 0.5, 95% CI 0.34 to 0.66; 1 study; moderate-certainty evidence). Exercise Supervised strength exercise may reduce sickness absence, compared to relaxation (SMD -1.11; 95% CI -1.68 to -0.54; one study, low-certainty evidence). However, aerobic exercise probably is not more effective than relaxation or stretching (SMD -0.06; 95% CI -0.36 to 0.24; 2 studies, moderate-certainty evidence). Both studies found no differences between the two conditions in depressive symptoms.

AUTHORS' CONCLUSIONS

A combination of a work-directed intervention and a clinical intervention probably reduces the number of sickness absence days, but at the end of one year or longer follow-up, this does not lead to more people in the intervention group being at work. The intervention may also reduce depressive symptoms and probably increases work functioning more than care as usual. Specific work-directed interventions may not be more effective than usual work-directed care alone. Psychological interventions may reduce the number of sickness absence days, compared with care as usual. Interventions to improve clinical care probably lead to lower sickness absence and lower levels of depression, compared with care as usual. There was no evidence of a difference in effect on sickness absence of one antidepressant medication compared to another. Further research is needed to assess which combination of work-directed and clinical interventions works best.

Person-centred eHealth intervention for patients on sick leave due to common mental disorders: study protocol of a randomised controlled trial and process evaluation (PROMISE)

INTRODUCTION

The number of people dealing with common mental disorders (CMDs) is a major concern in many countries, including Sweden. Sickness absence resulting from CMDs is often long-lasting and advancing return to work is a complex process impacted by several factors, among which self-efficacy appears to be an important personal resource. Person-centred care (PCC) has previously shown positive effects on self-efficacy however this needs to be further investigated in relation to patients with CMDs and in an eHealth context.

METHODS AND ANALYSIS

This study is an open randomised controlled trial comparing a control group receiving standard care with an intervention group receiving standard care plus PCC by telephone and a digital platform. The primary outcome measure is a composite score of changes in sick leave and self-efficacy. Participants will include 220 primary care patients on sick leave due to CMDs and data will mainly be collected through questionnaires at baseline and 3, 6, 12 and 24 months from the inclusion date. Inclusion is ongoing and expected to be completed during the fall of 2020. A process and health economic evaluation will also be conducted.

ETHICS AND DISSEMINATION

This study was approved by the Regional Ethical Review Board in Gothenburg, Sweden. Results will be published in peer-reviewed scientific journals and presented at national and international scientific conferences. This project is part of a broader research programme conducted at the Gothenburg Centre for Person-Centred Care (GPCC), where extensive work is undertaken to disseminate knowledge on and implementation of PCC.

TRIAL REGISTRATION NUMBER

NCT03404583.

Stakeholders' Role and Actions in the Return-to-Work Process of Workers on Sick-Leave Due to Common Mental Disorders: A Scoping Review

The lack of knowledge regarding the roles and actions of return to work (RTW) stakeholders create confusion and uncertainty about how and when to RTW after experiencing a common mental disorder (CMD). Purpose The purpose of this scoping review is to disentangle the various stakeholders' role and actions in the RTW process of workers on sick-leave due to CMDs. The research question is: What is documented in the existing literature regarding the roles and actions of the identified stakeholders involved in the RTW process of workers on sick-leave due to CMDs? Methods In conducting this scoping review, we followed Arksey and O'Malley's (Int J Soc Res Methodol 8:19-32, 2005) methodology, consisting of different stages (e.g., charting the data by categorizing key results). Results 3709 articles were screened for inclusion, 243 of which were included for qualitative synthesis. Several RTW stakeholders (n=11) were identified (e.g., workers on sick leave due to CMDs, managers, union representatives, rehabilitation professionals, insurers, return to work coordinators). RTW stakeholders' roles and actions inter- and intra-system were recommended, either general (e.g., know and understand the perspectives of all RTW stakeholders) or specific to an actor (e.g., the return to work coordinator needs to create and maintain a working alliance between all RTW stakeholders). Furthermore, close to 200 stakeholders' actions, spread out on different RTW phases, were recommended for facilitating the RTW process. Conclusions Eleven RTW stakeholders from the work, heath and insurance systems have been identified, as well as their respective roles and actions. Thanks to these results, RTW stakeholders and policy makers will be able to build practical relationships and collaboration regarding the RTW of workers on sick leave due to CMDs.

Occupational advice to help people return to work following lower limb arthroplasty: the OPAL intervention mapping study

BACKGROUND

Hip and knee replacements are regularly carried out for patients who work. There is little evidence about these patients' needs and the factors influencing their return to work. There is a paucity of guidance to help patients return to work after surgery and a need for structured occupational advice to enable them to return to work safely and effectively.

OBJECTIVES

To develop an occupational advice intervention to support early recovery to usual activities including work that is tailored to the requirements of patients undergoing hip or knee replacements. To test the acceptability, practicality and feasibility of this intervention within current care frameworks.

DESIGN

An intervention mapping approach was used to develop the intervention. The research methods employed were rapid evidence synthesis, qualitative interviews with patients and stakeholders, a prospective cohort study, a survey of clinical practice and a modified Delphi consensus process. The developed intervention was implemented and assessed during the final feasibility stage of the intervention mapping process.

SETTING

Orthopaedic departments in NHS secondary care.

PARTICIPANTS

Patients who were in work and intending to return to work following primary elective hip or knee replacement surgery, health-care professionals and employers.

INTERVENTIONS

Occupational advice intervention.

MAIN OUTCOME MEASURES

Development of an occupational advice intervention, fidelity of the developed intervention when delivered in a clinical setting, patient and clinician perspectives of the intervention and preliminary assessments of intervention effectiveness and cost.

RESULTS

A cohort study (154 patients), 110 stakeholder interviews, a survey of practice (152 respondents) and evidence synthesis provided the necessary information to develop the intervention. The intervention included information resources, a personalised return-to-work plan and co-ordination from the health-care team to support the delivery of 13 patient and 20 staff performance objectives. To support delivery, a range of tools (e.g. occupational checklists, patient workbooks and employer information), roles (e.g. return-to-work co-ordinator) and training resources were created. Feasibility was assessed for 21 of the 26 patients recruited from three NHS trusts. Adherence to the defined performance objectives was 75% for patient performance objectives and 74% for staff performance objectives. The intervention was generally well received, although the short time frame available for implementation and concurrent research evaluation led to some confusion among patients and those delivering the intervention regarding its purpose and the roles and responsibilities of key staff.

LIMITATIONS

Implementation and uptake of the intervention was not standardised and was limited by the study time frame. Evaluation of the intervention involved a small number of patients, which limited the ability to assess it.

CONCLUSIONS

The developed occupational advice intervention supports best practice. Evaluation demonstrated good rates of adherence against defined performance objectives. However, a number of operational and implementation issues require further attention.

FUTURE WORK

The intervention warrants a randomised controlled trial to assess its clinical effectiveness and cost-effectiveness to improve rates and timing of sustained return to work after surgery. This research should include the development of a robust implementation strategy to ensure that adoption is sustained.

STUDY REGISTRATION

Current Controlled Trials ISRCTN27426982 and PROSPERO CRD42016045235.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 45. See the NIHR Journals Library website for further project information.

Return to Work for Mental Ill-Health: A Scoping Review Exploring the Impact and Role of Return-to-Work Coordinators

Purpose This scoping review was completed to explore the role and impact of having a return-to-work (RTW) coordinator when dealing with individuals with common mental ill-health conditions. Methods Peer reviewed articles published in English between 2000 and 2018 were considered. Our research team reviewed all articles to determine if an analytic focus on RTW coordinator and mental ill-health was present; consensus on inclusion was reached for all articles. Data were extracted for all relevant articles and synthesized for outcomes of interest. Results Our search of six databases yielded 1798 unique articles; 5 articles were found to be relevant. The searched yielded only quantitative studies. Of those, we found that studies grouped mental ill-health conditions together, did not consider quality of life, and used different titles to describe RTW coordinators. Included articles described roles of RTW coordinators but did not include information on their strategies and actions. Included articles suggest that RTW interventions for mental ill-health that utilize a RTW coordinator may result in delayed time to RTW. Conclusions Our limited findings suggest that interventions for mental ill-health that employ RTW coordinators may be more time consuming than conventional approaches and may not increase RTW rate or worker's self-efficacy for RTW. Research on this topic with long-term outcomes and varied research designs (including qualitative) is needed, as well as studies that clearly define RTW coordinator roles and strategies, delineate results by mental health condition, and address the impact of RTW coordinators on workers' quality of life.

Evaluating the feasibility of ReWork-SCI: a person-centred intervention for return-to-work after spinal cord injury

OBJECTIVES

To evaluate the feasibility of: (1) ReWork-SCI with regard to adherence and acceptability and (2) a study design for evaluating ReWork-SCI with regard to recruitment, retention and outcome measures.

DESIGN

Pre-test and post-test, single group, feasibility study.

SETTING

Spinal cord injury (SCI) unit at a regional rehabilitation centre in Sweden.

PARTICIPANTS

Two women and five men (n=7). Eligible criteria: (1) sustained traumatic or non-traumatic SCI; (2) completed the first acute care episode in a hospital; (3) between 18 to 65 years of age; (4) assessed by a physician as approachable for participation in the intervention; (5) history of permanent or temporary employment; (6) self-reported desire to return to work; and (7) ability to communicate in English or Swedish.

INTERVENTION

ReWork-SCI is a person-centred intervention for return-to-work (RTW), developed and evaluated using the Medical Research Council's guidelines. ReWork-SCI follows a person-centred, structured and coordinated intervention process led by a coordinator within a SCI rehabilitation team.

OUTCOME MEASURES

The feasibility of ReWork-SCI and a study design was evaluated using a set of outcome measurement tools, vocational data, logbooks and semi-structured interviews.

RESULTS

All eligible participants accepted enrolment and follow-up. All participants had a plan for RTW after 3 months and four participants had initiated part-time work or work trial 6 months after commencement of intervention. Adherence and acceptability were overall good. Challenges of the intervention related to the person-centred follow-up, staff shortage and rootedness in the SCI team.

CONCLUSIONS

ReWork-SCI was feasible and can contribute to a systematic design of an individualised plan, facilitate decision-making and build trust in the RTW process after SCI. Core features of the intervention was the systematic structure, use of a person-centred approach and dialogue with the employer. For the effectiveness of ReWork-SCI, modifications and considerations of study design are needed.