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Sullivan V, Wilson MN, Gross DP, Jensen OK, Shaw WS, Steenstra IA, Hayden JA. Expectations for Return to Work Predict Return to Work in Workers with Low Back Pain: An Individual Participant Data (IPD) Meta-Analysis. JOURNAL OF OCCUPATIONAL REHABILITATION 2022; 32:575-590. [PMID: 35152369 DOI: 10.1007/s10926-022-10027-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/01/2022] [Indexed: 06/14/2023]
Abstract
Purpose Low back pain is associated with disability and lost productivity due to inability of workers to return to work. Personal recovery expectation beliefs may be associated with return to work outcomes in those with low back pain at high risk for chronic disability. We aimed to (1) assess whether workers' expectations for return to work, following a low back pain episode, are associated with subsequent return to work; and (2) explore the relationships between return to work expectations and other prognostic factors in their association with work outcomes.Methods We conducted an Individual Participant Data (IPD) meta-analysis using data from five prospective cohort studies identified by a Cochrane prognostic factor review. A one-stage IPD meta-analysis approach was applied. Multi-level mixed effects models were used to determine the unadjusted and adjusted associations between expectations and return to work (logistic regression) and time to return to work (parametric survival models with Weibull distribution).Results The final dataset included 2302 participants. Positive expectations for return to work were associated with return to work at follow-up in both unadjusted (Odds Ratio (OR) 2.95; 95% Confidence Interval (CI) 2.21, 3.95) (n = 2071) and comprehensively adjusted (OR 2.01; 95% CI 1.46, 2.77) (n = 1109) models. Similar findings were identified for shorter length of time to return to work in both unadjusted (HR 2.40; 95% CI 2.09, 2.75) (n = 1156) and minimally adjusted (HR 2.43; 95% CI 2.12, 2.79) (n = 1154) models.Conclusions Results suggest workers with low expectations for return to work are at increased risk for long-term work disability.
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Affiliation(s)
- Victoria Sullivan
- Department of Community Health & Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.
- Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada.
| | - Maria N Wilson
- Department of Community Health & Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Douglas P Gross
- Department of Physical Therapy, University of Alberta, Edmonton, Canada
| | - Ole Kudsk Jensen
- Spine Center, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - William S Shaw
- Division of Occupational and Environmental Medicine, Departments of Medicine and Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Ivan A Steenstra
- Epidemiologist, Director Program Evaluation & Research Outcomes, LifeWorks, Toronto, ON, Canada
| | - Jill A Hayden
- Department of Community Health & Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
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Dillane D, Ramadi A, Nathanail S, Dick BD, Bostick G, Chan K, Douglas C, Goplen G, Green J, Halliday S, Hellec B, Rashiq S, Scharfenberger A, Woolsey G, Beaupre LA, Pedersen ME. Elective surgery in ankle and foot disorders-best practices for management of pain: a guideline for clinicians. Can J Anaesth 2022; 69:1053-1067. [PMID: 35581524 DOI: 10.1007/s12630-022-02267-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 02/14/2022] [Accepted: 03/06/2022] [Indexed: 01/10/2023] Open
Abstract
PURPOSE Complex elective foot and ankle surgeries are often associated with severe pain pre- and postoperatively. When inadequately managed, chronic postsurgical pain and long-term opioid use can result. As no standards currently exist, we aimed to develop best practice pain management guidelines. METHODS A local steering committee (n = 16) surveyed 116 North American foot and ankle surgeons to understand the "current state" of practice. A multidisciplinary expert panel (n = 35) was then formed consisting of orthopedic surgeons, anesthesiologists, chronic pain physicians, primary care physicians, pharmacists, registered nurses, physiotherapists, and clinical psychologists. Each expert provided up to three pain management recommendations for each of the presurgery, intraoperative, inpatient postoperative, and postdischarge periods. These preliminary recommendations were reduced, refined, and sent to the expert panel and "current state" survey respondents to create a consensus document using a Delphi process conducted from September to December 2020. RESULTS One thousand four hundred and five preliminary statements were summarized into 51 statements. Strong consensus (≥ 80% respondent agreement) was achieved in 53% of statements including the following: postsurgical opioid use risk should be assessed preoperatively; opioid-naïve patients should not start opioids preoperatively unless non-opioid multimodal analgesia fails; and if opioids are prescribed at discharge, patients should receive education regarding importance of tapering opioid use. There was no consensus regarding opioid weaning preoperatively. CONCLUSIONS Using multidisciplinary experts and a Delphi process, strong consensus was achieved in many areas, showing considerable agreement despite limited evidence for standardized pain management in patients undergoing complex elective foot and ankle surgery. No consensus on important issues related to opioid prescribing and cessation highlights the need for research to determine best practice.
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Affiliation(s)
- Derek Dillane
- Department of Anesthesia and Pain Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ailar Ramadi
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Stephanie Nathanail
- Collaborative Orthopaedic REsearch (CORe), University of Alberta, Edmonton, AB, Canada
| | - Bruce D Dick
- Department of Anesthesia and Pain Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Geoff Bostick
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Kitty Chan
- Collaborative Orthopaedic REsearch (CORe), University of Alberta, Edmonton, AB, Canada
| | - Chris Douglas
- Department of Anesthesia and Pain Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Gordon Goplen
- Collaborative Orthopaedic REsearch (CORe), University of Alberta, Edmonton, AB, Canada
| | - James Green
- Department of Anesthesia and Pain Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Susan Halliday
- Department of Anesthesia and Pain Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | | | - Saifee Rashiq
- Department of Anesthesia and Pain Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Angela Scharfenberger
- Collaborative Orthopaedic REsearch (CORe), University of Alberta, Edmonton, AB, Canada
| | - Guy Woolsey
- Collaborative Orthopaedic REsearch (CORe), University of Alberta, Edmonton, AB, Canada
| | - Lauren A Beaupre
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.
- Collaborative Orthopaedic REsearch (CORe), University of Alberta, Edmonton, AB, Canada.
- Departments of Physical Therapy and Surgery, University of Alberta, 6-110B Clinical Sciences Building, 8440-112 St., Edmonton, AB, Canada.
| | - M Elizabeth Pedersen
- Collaborative Orthopaedic REsearch (CORe), University of Alberta, Edmonton, AB, Canada
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Hayden JA, Wilson MN, Riley RD, Iles R, Pincus T, Ogilvie R. Individual recovery expectations and prognosis of outcomes in non-specific low back pain: prognostic factor review. Cochrane Database Syst Rev 2019; 2019:CD011284. [PMID: 31765487 PMCID: PMC6877336 DOI: 10.1002/14651858.cd011284.pub2] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Low back pain is costly and disabling. Prognostic factor evidence can help healthcare providers and patients understand likely prognosis, inform the development of prediction models to identify subgroups, and may inform new treatment strategies. Recent studies have suggested that people who have poor expectations for recovery experience more back pain disability, but study results have differed. OBJECTIVES To synthesise evidence on the association between recovery expectations and disability outcomes in adults with low back pain, and explore sources of heterogeneity. SEARCH METHODS The search strategy included broad and focused electronic searches of MEDLINE, Embase, CINAHL, and PsycINFO to 12 March 2019, reference list searches of relevant reviews and included studies, and citation searches of relevant expectation measurement tools. SELECTION CRITERIA We included low back pain prognosis studies from any setting assessing general, self-efficacy, and treatment expectations (measured dichotomously and continuously on a 0 - 10 scale), and their association with work participation, clinically important recovery, functional limitations, or pain intensity outcomes at short (3 months), medium (6 months), long (12 months), and very long (> 16 months) follow-up. DATA COLLECTION AND ANALYSIS We extracted study characteristics and all reported estimates of unadjusted and adjusted associations between expectations and related outcomes. Two review authors independently assessed risks of bias using the Quality in Prognosis Studies (QUIPS) tool. We conducted narrative syntheses and meta-analyses when appropriate unadjusted or adjusted estimates were available. Two review authors independently graded and reported the overall quality of evidence. MAIN RESULTS We screened 4635 unique citations to include 60 studies (30,530 participants). Thirty-five studies were conducted in Europe, 21 in North America, and four in Australia. Study populations were mostly chronic (37%), from healthcare (62%) or occupational settings (26%). General expectation was the most common type of recovery expectation measured (70%); 16 studies measured more than one type of expectation. Usable data for syntheses were available for 52 studies (87% of studies; 28,885 participants). We found moderate-quality evidence that positive recovery expectations are strongly associated with better work participation (narrative synthesis: 21 studies; meta-analysis: 12 studies, 4777 participants: odds ratio (OR) 2.43, 95% confidence interval (CI) 1.64 to 3.62), and low-quality evidence for clinically important recovery outcomes (narrative synthesis: 12 studies; meta-analysis: 5 studies, 1820 participants: OR 1.89, 95% CI 1.49 to 2.41), both at follow-up times closest to 12 months, using adjusted data. The association of recovery expectations with other outcomes of interest, including functional limitations (narrative synthesis: 10 studies; meta-analysis: 3 studies, 1435 participants: OR 1.40, 95% CI 0.85 to 2.31) and pain intensity (narrative synthesis: 9 studies; meta-analysis: 3 studies, 1555 participants: OR 1.15, 95% CI 1.08 to 1.23) outcomes at follow-up times closest to 12 months using adjusted data, is less certain, achieving very low- and low-quality evidence, respectively. No studies reported statistically significant or clinically important negative associations between recovery expectations and any low back pain outcome. AUTHORS' CONCLUSIONS We found that individual recovery expectations are probably strongly associated with future work participation (moderate-quality evidence) and may be associated with clinically important recovery outcomes (low-quality evidence). The association of recovery expectations with other outcomes of interest is less certain. Our findings suggest that recovery expectations should be considered in future studies, to improve prognosis and management of low back pain.
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Affiliation(s)
- Jill A Hayden
- Dalhousie UniversityDepartment of Community Health & Epidemiology5790 University AvenueRoom 403HalifaxNSCanadaB3H 1V7
| | - Maria N Wilson
- Dalhousie UniversityDepartment of Community Health and EpidemiologyHalifaxNova ScotiaCanada
| | - Richard D Riley
- Keele UniversitySchool of Primary, Community and Social CareDavid Weatherall Building, Keele University CampusKeeleStaffordshireUKST5 5BG
| | - Ross Iles
- Monash UniversityDepartment of Physiotherapy, Faculty of Medicine, Nursing and Health SciencesPeninsula CampusFrankstonVictoriaAustralia3199
| | - Tamar Pincus
- Royal Holloway University of LondonDepartment of PsychologyEghamSurreyUKTW20 0EX
| | - Rachel Ogilvie
- Dalhousie UniversityCommunity Health & Epidemiology5760 University AvenueHalifaxCanadaB3H 1V7
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Skarpaas LS, Haveraaen LA, Småstuen MC, Shaw WS, Aas RW. The association between having a coordinator and return to work: the rapid-return-to-work cohort study. BMJ Open 2019; 9:e024597. [PMID: 30782911 PMCID: PMC6398742 DOI: 10.1136/bmjopen-2018-024597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 11/29/2018] [Accepted: 12/05/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess if the reported provision of a coordinator was associated with time to first return to work (RTW) and first full RTW among sick-listed employees who participated in different rapid-RTW programmes in Norway. DESIGN The study was designed as a cohort study. SETTING Rapid-RTW programmes financed by the regional health authority in hospitals and Norwegian Labour and Welfare Administration in Norway. PARTICIPANTS The sample included employees on full-time sick leave (n=326) who participated in rapid-RTW programmes (n=43), who provided information about the coordination of the services they received. The median age was 46 years (minimum-maximum 21-67) and 71% were female. The most common reported diagnoses were musculoskeletal (57%) and mental health disorders (14%). INTERVENTIONS The employees received different types of individually tailored RTW programmes all aimed at a rapid RTW; occupational rehabilitation (64%), treatment for medical or psychological issues, including assessment, and surgery (26%), and follow-up and work clarification services (10%). It was common to be provided with a coordinator (73%). PRIMARY AND SECONDARY OUTCOME MEASURES Outcomes were measured as time to first RTW (graded and 100%) and first full RTW (100%). RESULTS Employees provided with a coordinator returned to work later than employees who did not have a coordinator; a median (95% CI) of 128 (80 to 176) days vs 61 (43 to 79) days for first RTW, respectively. This difference did not remain statistically significant in the adjusted regression analysis. For full RTW, there was no statistically significant difference between employees provided with a coordinator versus those who were not. CONCLUSIONS The model of coordination, provided in the Norwegian rapid-RTW programmes was not associated with a more rapid RTW for sick-listed employees. Rethinking how RTW coordination should be organised could be wise in future programme development.
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Affiliation(s)
- Lisebet Skeie Skarpaas
- Presenter - Making Sense of Science, Stavanger, Norway
- Department of Occupational Therapy, Prosthetics and Orthotics, Oslo Metropolitan University, Oslo, Norway
| | | | | | - William S Shaw
- Division of Occupational & Environmental Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Randi Wågø Aas
- Presenter - Making Sense of Science, Stavanger, Norway
- Department of Occupational Therapy, Prosthetics and Orthotics, Oslo Metropolitan University, Oslo, Norway
- Department of Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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5
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Jordan V. Cochrane Corner: Positive expectations for recovery affects outcomes for patients with low back pain. J Prim Health Care 2019. [DOI: 10.1071/hc15948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Steenstra I, Cullen K, Irvin E, Van Eerd D. A systematic review of interventions to promote work participation in older workers. JOURNAL OF SAFETY RESEARCH 2017; 60:93-102. [PMID: 28160820 DOI: 10.1016/j.jsr.2016.12.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 07/21/2016] [Accepted: 12/12/2016] [Indexed: 06/06/2023]
Abstract
PURPOSE The objective of this systematic review was to synthesize evidence on the effectiveness of interventions aimed at promoting work participation in older workers. METHODS We followed a systematic review process developed by the Institute for Work & Health and a best evidence synthesis that ranked evidence as strong, moderate, limited, or insufficient. RESULTS Seven electronic databases were searched from inception to March 2014. Evidence from 14 studies were synthesized in 4 different intervention categories: multi-component, exercise, medication and other interventions. There was moderate evidence that work participation was improved by multi-component interventions encompassing at least two of three components (health service delivery, coordination of services, and work modifications). There was not enough evidence to recommend the other interventions. CONCLUSIONS Although there is a vast body of research on work participation of older workers, there are only a few high quality intervention studies aimed at improving work participation in this population. We recommend that multi-component interventions could be considered for implementation by practitioners to help improve work participation in older workers. PRACTICAL APPLICATIONS With a moderate level of evidence, multi-component interventions could be considered for use in practice if practitioners deem it suitable for their setting. There is not enough evidence to recommend exercise interventions, pharmaceutical interventions, different types of surgeries, patient education or work accommodation alone to improve work participation. However, the lack of evidence should not be considered, as absence of effect and practitioners should continue to be creative in developing solutions.
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Affiliation(s)
- Ivan Steenstra
- Ted Rogers School of Management, Ryerson University, Toronto, Ontario, Canada; Institute for Work & Health, Toronto, Ontario, Canada.
| | | | - Emma Irvin
- Institute for Work & Health, Toronto, Ontario, Canada.
| | - Dwayne Van Eerd
- Institute for Work & Health, Toronto, Ontario, Canada; School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
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Peters SE, Johnston V, Ross M, Coppieters MW. Expert consensus on facilitators and barriers to return-to-work following surgery for non-traumatic upper extremity conditions: a Delphi study. J Hand Surg Eur Vol 2017; 42:127-136. [PMID: 27655647 DOI: 10.1177/1753193416669263] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED This Delphi study aimed to reach consensus on important facilitators and barriers for return-to-work following surgery for non-traumatic upper extremity conditions. In Round 1, experts ( n = 42) listed 134 factors, which were appraised in Rounds 2 and 3. Consensus (⩾85% agreement) was achieved for 13 facilitators (high motivation to return-to-work; high self-efficacy for return-to-work and recovery; availability of modified/alternative duties; flexible return-to-work arrangements; positive coping skills; limited heavy work exertion; supportive return-to-work policies; supportive supervisor/management; no catastrophic thinking; no fear avoidance to return-to-work; no fear avoidance to pain/activity; return to meaningful work duties; high job satisfaction) and six barriers (mood disorder diagnosis; pain/symptoms at more than one musculoskeletal site; heavy upper extremity exertions at work; lack of flexible return-to-work arrangements; lack of support from supervisor/management; high level of pain catastrophizing). Future prognostic studies are required to validate these biopsychosocial factors to further improve return-to-work outcomes. LEVEL OF EVIDENCE V.
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Affiliation(s)
- S E Peters
- 1 Occupational Therapy, The University of Queensland, St Lucia, Brisbane, Australia.,2 Brisbane Hand and Upper Limb Research Institute, Brisbane Private Hospital, Brisbane, Australia
| | - V Johnston
- 3 Physiotherapy, The University of Queensland, St Lucia, Brisbane, Australia
| | - M Ross
- 2 Brisbane Hand and Upper Limb Research Institute, Brisbane Private Hospital, Brisbane, Australia.,4 Department of Orthopaedic Surgery, Princess Alexandra Hospital, Woolloongabba, Australia.,5 Orthopaedic Surgery, The University of Queensland, St Lucia, Brisbane, Australia
| | - M W Coppieters
- 3 Physiotherapy, The University of Queensland, St Lucia, Brisbane, Australia.,6 MOVE Research Institute Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Cancelliere C, Donovan J, Stochkendahl MJ, Biscardi M, Ammendolia C, Myburgh C, Cassidy JD. Factors affecting return to work after injury or illness: best evidence synthesis of systematic reviews. Chiropr Man Therap 2016; 24:32. [PMID: 27610218 PMCID: PMC5015229 DOI: 10.1186/s12998-016-0113-z] [Citation(s) in RCA: 237] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 07/07/2016] [Indexed: 01/23/2023] Open
Abstract
Background Work disability is a major personal, financial and public health burden. Predicting future work success is a major focus of research. Objectives To identify common prognostic factors for return-to-work across different health and injury conditions and to describe their association with return-to-work outcomes. Methods Medline, Embase, PsychINFO, Cinahl, and Cochrane Database of Systematic Reviews and the grey literature were searched from January 1, 2004 to September 1, 2013. Systematic reviews addressing return-to-work in various conditions and injuries were selected. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria to identify low risk of bias reviews. Results Of the 36,193 titles screened and the 94 eligible studies reviewed, 56 systematic reviews were accepted as low risk of bias. Over half of these focused on musculoskeletal disorders, which were primarily spine related (e.g., neck and low back pain). The other half of studies assessed workers with mental health or cardiovascular conditions, stroke, cancer, multiple sclerosis or other non-specified health conditions. Many factors have been assessed, but few consistently across conditions. Common factors associated with positive return-to-work outcomes were higher education and socioeconomic status, higher self-efficacy and optimistic expectations for recovery and return-to-work, lower severity of the injury/illness, return-to-work coordination, and multidisciplinary interventions that include the workplace and stakeholders. Common factors associated with negative return-to-work outcomes were older age, being female, higher pain or disability, depression, higher physical work demands, previous sick leave and unemployment, and activity limitations. Conclusions Expectations of recovery and return-to-work, pain and disability levels, depression, workplace factors, and access to multidisciplinary resources are important modifiable factors in progressing return-to-work across health and injury conditions. Employers, healthcare providers and other stakeholders can use this information to facilitate return-to-work for injured/ill workers regardless of the specific injury or illness. Future studies should investigate novel interventions, and other factors that may be common across health conditions.
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Affiliation(s)
- Carol Cancelliere
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada ; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
| | - James Donovan
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
| | | | | | - Carlo Ammendolia
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada ; Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario Canada
| | - Corrie Myburgh
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
| | - J David Cassidy
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada ; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada ; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark ; Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
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Tompa E, de Boer H, Macdonald S, Alamgir H, Koehoorn M, Guzman J. Stakeholders' Perspectives About and Priorities for Economic Evaluation of Health and Safety Programs in Healthcare. Workplace Health Saf 2016; 64:163-74; quiz 175. [PMID: 27056937 DOI: 10.1177/2165079915620201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study identified and prioritized resources and outcomes that should be considered in more comprehensive and scientifically rigorous health and safety economic evaluations according to healthcare sector stakeholders. A literature review and stakeholder interviews identified candidate resources and outcomes and then a Delphi panel ranked them. According to the panel, the top five resources were (a) health and safety staff time; (b) training workers; (c) program planning, promotion, and evaluation costs; (d) equipment purchases and upgrades; and (e) administration costs. The top five outcomes were (a) number of injuries, illnesses, and general sickness absences; (b) safety climate; (c) days lost due to injuries, illnesses, and general sickness absences; (d) job satisfaction and engagement; and (e) quality of care and patient safety. These findings emphasize stakeholders' stated priorities and are useful as a benchmark for assessing the quality of health and safety economic evaluations and the comprehensiveness of these findings.
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Affiliation(s)
- Emile Tompa
- Institute for Work & Health McMaster University University of Toronto
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Guzman J, Tompa E, Koehoorn M, de Boer H, Macdonald S, Alamgir H. Economic evaluation of occupational health and safety programmes in health care. Occup Med (Lond) 2015; 65:590-7. [PMID: 26290408 DOI: 10.1093/occmed/kqv114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Evidence-based resource allocation in the public health care sector requires reliable economic evaluations that are different from those needed in the commercial sector. AIMS To describe a framework for conducting economic evaluations of occupational health and safety (OHS) programmes in health care developed with sector stakeholders. To define key resources and outcomes to be considered in economic evaluations of OHS programmes and to integrate these into a comprehensive framework. METHODS Participatory action research supported by mixed qualitative and quantitative methods, including a multi-stakeholder working group, 25 key informant interviews, a 41-member Delphi panel and structured nominal group discussions. RESULTS We found three resources had top priority: OHS staff time, training the workers and programme planning, promotion and evaluation. Similarly, five outcomes had top priority: number of injuries, safety climate, job satisfaction, quality of care and work days lost. The resulting framework was built around seven principles of good practice that stakeholders can use to assist them in conducting economic evaluations of OHS programmes. CONCLUSIONS Use of a framework resulting from this participatory action research approach may increase the quality of economic evaluations of OHS programmes and facilitate programme comparisons for evidence-based resource allocation decisions. The principles may be applicable to other service sectors funded from general taxes and more broadly to economic evaluations of OHS programmes in general.
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Affiliation(s)
- J Guzman
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - E Tompa
- Institute for Work and Health, Toronto, Ontario, Canada
| | - M Koehoorn
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - H de Boer
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - S Macdonald
- Institute for Work and Health, Toronto, Ontario, Canada
| | - H Alamgir
- Division of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, San Antonio, TX, USA.
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Hayden JA, Tougas ME, Riley R, Iles R, Pincus T. Individual recovery expectations and prognosis of outcomes in non-specific low back pain: prognostic factor exemplar review. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2014. [DOI: 10.1002/14651858.cd011284] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jill A Hayden
- Dalhousie University; Department of Community Health & Epidemiology; 5790 University Avenue Room 403 Halifax NS Canada B3H 1V7
| | | | - Richard Riley
- Keele University; Research Institute for Primary Care and Health Sciences; David Weatherall Building, Keele University Campus Staffordshire England UK ST5 5BG
| | - Ross Iles
- Monash University; Department of Physiotherapy, Faculty of Medicine, Nursing and Health Sciences; Peninsula Campus Frankston Victoria Australia 3199
| | - Tamar Pincus
- Royal Holloway University of London; Department of Psychology; Egham Surrey UK TW20 0EX
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Wilkie R, Phillipson C, Hay E, Pransky G. Frequency and predictors of premature work loss in primary care consulters for osteoarthritis: prospective cohort study. Rheumatology (Oxford) 2013; 53:459-64. [PMID: 24136068 PMCID: PMC3930884 DOI: 10.1093/rheumatology/ket336] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective. The objective of this study was to describe the extent of premature work loss (PWL) in OA consulters across a 6-year observation period, and associated factors. Methods. We conducted a population-based prospective cohort study set in primary care. Participants were 1098 adults age 50 years to statutory retirement age at baseline, who completed questionnaires at baseline, 3- and 6-year follow-ups. OA was defined by consultation to primary care (Read code N05) during the study period. PWL was defined as retirement prior to state retirement age (65 years for men, 60 years for women), off work due to health or unemployment. The frequency of PWL was calculated overall and stratified by consultation for OA. Bivariate and multivariate logistic regression was used to investigate the predictors of PWL in consulters for OA. Results. Over the 6-year study period, one in four consulters for OA left the workplace prematurely. Predictors included being male, pain interference with function and lower co-worker support, but not the extent of arthritis, co-morbidity, obesity or psychological or other job factors. Conclusion. PWL in persons consulting primary care general practitioners with OA is common. Those at risk could be identified by brief questions about pain interference with function and workplace support. These results suggest that early identification, treatment strategies focusing on maintaining function and maximizing workplace support should be investigated for their potential to prevent PWL. Good communication with employers may help to improve support for workers with OA.
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Affiliation(s)
- Ross Wilkie
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK.
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Shaw WS, Campbell P, Nelson CC, Main CJ, Linton SJ. Effects of workplace, family and cultural influences on low back pain: What opportunities exist to address social factors in general consultations? Best Pract Res Clin Rheumatol 2013; 27:637-48. [DOI: 10.1016/j.berh.2013.09.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Norder G, Roelen CAM, van Rhenen W, Buitenhuis J, Bültmann U, Anema JR. Predictors of recurrent sickness absence due to depressive disorders--a Delphi approach involving scientists and physicians. PLoS One 2012; 7:e51792. [PMID: 23284768 PMCID: PMC3527456 DOI: 10.1371/journal.pone.0051792] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 11/09/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Depression is a common and highly recurrent mental disorder that is accompanied by poor functioning at home and at work. Not all depressed employees report sick and little is known about variables associated with sickness absence (SA) due to depression. Recurrent SA due to depression tends to marginalize employees from the workforce and exclude them from social participation. Therefore, this study sought group consensus on factors predicting recurrent SA due to depression. METHODOLOGY/PRINCIPAL FINDINGS 23 scientists in the field of work and mental health and 23 physicians with expertise in assessing work disability were invited for a Delphi study. Sixty-seven factors retrieved from the literature were scored for their impact on the recurrence of SA due to depression, range 1 (no impact) to 10 (very high impact) in two Delphi rounds. The third Delphi round addressed the assessability and modifiability of elected predictors. Group consensus was defined as 75% agreement. In the first round (response 78%), group consensus was reached on a high impact of 13 factors on recurrent SA due to depression. The second round (response 79%) added another 8 factors with high impact on recurrent SA due to depression. The panelists were of the opinion that stressful life and work events, age at first diagnosis, duration of the last depressive episode, anxiety, lifetime number of depressive episodes, and psychological work demands were readily assessable in consultation with patients. Furthermore, work factors, particularly decision latitude, psychological job demands, and commitment to work, were recognized as modifiable. CONCLUSIONS/SIGNIFICANCE Although results have to be validated with further quantitative research, physicians may identify employees at risk of recurrent SA due to depression and may support them to adjust their work aimed at increasing commitment to work and preventing future SA due to depression.
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Affiliation(s)
- Giny Norder
- 365/Occupational Health Service Utrecht, Utrecht, The Netherlands.
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15
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Liu MY, Li Y, Lu AP, Han XJ. Feasibility analysis of the value of Q method in the classification and understanding of expert experience. Chin J Integr Med 2012. [PMID: 23207745 DOI: 10.1007/s11655-012-1174-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Q method, combining qualitative and quantitative methods, refers to the qualitative analysis of Q-sorts based on quantitative techniques. It is used to research individual subjective experience, analyzing consensus and divergence to identify and categorize subjects' viewpoints. The sorting process is completely performed by the subjects, independent of study researchers. The Q method in medical research has been applied in many fields, including nursing care, clinical studies, doctor and patient's perceptions, health evaluation and decision making. The authors used the Q method to research Chinese medicine (CM) group decision making, exploring its practical feasibility in this important field. Four primary domains are addressed: (1) integration of expert opinion; (2) expert classification; (3) ascertaining the entire viewpoint orientation of a certain type of expert; and (4) comparison of expert opinion using an additional perspective. The essence of the Q method caters to the CM thinking model and should be introduced into CM and explored more deeply.
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Affiliation(s)
- Meng-yu Liu
- Institute of Basic Theory, China Academy of Chinese Medical Sciences, Beijing, (100700), China
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George SZ, Childs JD, Teyhen DS, Wu SS, Wright AC, Dugan JL, Robinson ME. Predictors of occurrence and severity of first time low back pain episodes: findings from a military inception cohort. PLoS One 2012; 7:e30597. [PMID: 22355317 PMCID: PMC3280257 DOI: 10.1371/journal.pone.0030597] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 12/23/2011] [Indexed: 11/18/2022] Open
Abstract
Primary prevention studies suggest that additional research on identifying risk factors predictive of low back pain (LBP) is necessary before additional interventions can be developed. In the current study we assembled a large military cohort that was initially free of LBP and followed over 2 years. The purposes of this study were to identify baseline variables from demographic, socioeconomic, general health, and psychological domains that were predictive of a) occurrence; b) time; and c) severity for first episode of self-reported LBP. Baseline and outcome measures were collected via web-based surveillance system or phone to capture monthly information over 2 years. The assembled cohort consisted of 1230 Soldiers who provided self-report data with 518 (42.1%) reporting at least one episode of LBP over 2 years. Multivariate logistic regression analysis indicated that gender, active duty status, mental and physical health scores were significant predictors of LBP. Cox regression revealed that the time to first episode of LBP was significantly shorter for Soldiers that were female, active duty, reported previous injury, and had increased BMI. Multivariate linear regression analysis investigated severity of the first episode by identifying baseline predictors of pain intensity, disability, and psychological distress. Education level and physical fitness were consistent predictors of pain intensity, while gender, smoking status, and previous injury status were predictors of disability. Gender, smoking status, physical health scores, and beliefs of back pain were consistent predictors of psychological distress. These results provide additional data to confirm the multi-factorial nature of LBP and suggest future preventative interventions focus on multi-modal approaches that target modifiable risk factors specific to the population of interest.
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Affiliation(s)
- Steven Z George
- Department of Physical Therapy and Center for Pain Research and Behavioral Health, University of Florida, Gainesville, Florida, United States of America.
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Pransky GS, Loisel P, Anema JR. Work disability prevention research: current and future prospects. JOURNAL OF OCCUPATIONAL REHABILITATION 2011; 21:287-92. [PMID: 21858739 DOI: 10.1007/s10926-011-9327-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Work disability prevention has evolved from being a component of disease outcomes studies, to a separate and growing research discipline. In part, this is due to recognition that work outcomes often do not correlate with other health outcomes; the causes of work disability are multiple, complex, and often distinct from associated health conditions or treatments; and that work disability creates an important personal, economic and social burden that is often preventable. Conceptual frameworks, measures, research methods and interventions specific to this area have been developed, many have been validated across different contexts, and an international community of researchers and trainees in work disability prevention has formed. The articles included in this special section exemplify the breadth of current research in this field, and future opportunities for greater cross- disciplinary collaboration and translation of research to practical implementation and policy interventions.
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Affiliation(s)
- G S Pransky
- Center for Disability Research, Liberty Mutual Research Institute for Safety, 71 Frankland Roadd, Hopkinton, MA 01748, USA.
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Cerniauskaite M, Quintas R, Boldt C, Raggi A, Cieza A, Bickenbach JE, Leonardi M. Systematic literature review on ICF from 2001 to 2009: its use, implementation and operationalisation. Disabil Rehabil 2010; 33:281-309. [PMID: 21073361 DOI: 10.3109/09638288.2010.529235] [Citation(s) in RCA: 162] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE To present a systematic literature review on the state of the art of the utilisation of the International Classification of Functioning, Disability and Health (ICF) since its release in 2001. METHOD The search was conducted through EMBASE, MEDLINE and PsychInfo covering the period between 2001 and December 2009. Papers were included if ICF was mentioned in title or abstract. Papers focussing on the ICF-CY and clinical research on children and youth only were excluded. Papers were assigned to six different groups covering the wide scenario of ICF application. RESULTS A total of 672 papers, coming from 34 countries and 211 different journals, were included in the analysis. The majority of publications (30.8%) were conceptual papers or papers reporting clinical and rehabilitation studies (25.9%). One-third of the papers were published in 2008 and 2009. CONCLUSIONS The ICF contributed to the development of research on functioning and on disability in clinical, rehabilitation as well as in several other contexts, such as disability eligibility and employment. Diffusion of ICF research and use in a great variety of fields and scientific journals is a proof that a cultural change and a new conceptualisation of functioning and disability is happening.
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Affiliation(s)
- Milda Cerniauskaite
- Neurology, Public Health and Disability Unit-Scientific Directorate, Neurological Institute C. Besta IRCCS Foundation, Milan, Italy
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What influences positive return to work expectation? Examining associated factors in a population-based cohort of whiplash-associated disorders. Spine (Phila Pa 1976) 2010; 35:E708-13. [PMID: 20535047 DOI: 10.1097/brs.0b013e3181d12432] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cross-sectional study of population-based traffic cohort. OBJECTIVE To determine which factors are associated with both positive and negative expectations for returning to work after vehicle collision resulting in neck pain. SUMMARY OF BACKGROUND DATA Positive expectations predict better outcomes for a variety of health conditions, including return to work from soft-tissue injury (including whiplash-associated disorders [WADs]). However, we know little about those with negative expectations who may be at risk for poor WAD outcomes. METHODS We assessed expectations for return to work in a population-based cohort of 2335 individuals with traffic-related WAD. We used logistic regression analysis to model factors associated with expecting to return to work (compared with not expecting to return to work or being unsure). RESULTS Depressive symptomatology, lower education, lower income, male sex, and greater initial pain (greater percentage of body in pain and greater intensity of neck pain) were associated with lower return-to-work expectation. CONCLUSION A number of demographic, socioeconomic, and injury-related factors were associated with expectations for return to work in WAD. Two of the strongest associated factors were depressive symptomatology and postcollision initial neck pain intensity. These results support using a biopsychosocial approach to evaluate expectancies and their influence on important health outcomes.
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Abstract
Low back pain is a leading cause of work disability and constitutes a significant socioeconomic burden worldwide. In an attempt to stem the serious consequences of long-term disability, a new approach for back pain in primary care is being disseminated. It mainly focusses on identifying the relationship between pain/disability and work, recognising important workplace and psychosocial issues, providing patients reassuring messages about activity, facilitating the return to work process and engaging other resources as needed. This article examines current expert opinion and available evidence on work issues for effective back pain management. In general, return to work, if safe, is beneficial for recovery and well-being. Some cases might require physicians to actively communicate with employers, claims managers and others in order to achieve safe and sustained return to work, while in most instances, simple efforts to identify and discuss work issues directly with the patient can lead to better work outcomes.
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Affiliation(s)
- Kátia M Costa-Black
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Schmidt CO, Chenot JF, Pfingsten M, Fahland RA, Lindena G, Marnitz U, Pfeifer K, Kohlmann T. Assessing a risk tailored intervention to prevent disabling low back pain--protocol of a cluster randomized controlled trial. BMC Musculoskelet Disord 2010; 11:5. [PMID: 20051119 PMCID: PMC2820020 DOI: 10.1186/1471-2474-11-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Accepted: 01/05/2010] [Indexed: 12/01/2022] Open
Abstract
Background Although most patients with low back pain (LBP) recover within a few weeks a significant proportion has recurrent episodes or will develop chronic low back pain. Several mainly psychosocial risk factors for developing chronic LBP have been identified. However, effects of preventive interventions aiming at behavioural risk factors and unfavourable cognitions have yielded inconsistent results. Risk tailored interventions may provide a cost efficient and effective means to take systematic account of the individual risk factors but evidence is lacking. Methods/Design This study will be a cluster-randomised controlled trial comparing screening and a subsequent risk tailored intervention for patients with low back pain to prevent chronic low back pain compared to treatment as usual in primary care. A total of 600 patients from 20 practices in each study arm will be recruited in Berlin and Goettingen. The intervention comprises the following elements: Patients will be assigned to one of four risk groups based on a screening questionnaire. Subsequently they receive an educational intervention including information and counselling tailored to the risk group. A telephone/email consulting service for back pain related problems are offered independent of risk group assignment. The primary outcomes will be functional capacity and sick leave. Discussion This trial will evaluate the effectiveness of screening for risk factors for chronic low back pain followed by a risk tailored intervention to prevent chronic low back pain. This trial will contribute new evidence regarding the flexible use of individual physical and psychosocial risk factors in general practice. Trial registration ISRCTN 68205910
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Affiliation(s)
- Carsten Oliver Schmidt
- Department of General Practice, University of Göttingen, Humboldtallee 38, D-37073 Göttingen, Germany
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Healthy workforce/healthy economy: the role of health, productivity, and disability management in addressing the nation's health care crisis: why an emphasis on the health of the workforce is vital to the health of the economy. J Occup Environ Med 2009; 51:114-9. [PMID: 19136880 DOI: 10.1097/jom.0b013e318195dad2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ozegovic D, Carroll LJ, David Cassidy J. Does expecting mean achieving? The association between expecting to return to work and recovery in whiplash associated disorders: a population-based prospective cohort study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 18:893-9. [PMID: 19343376 DOI: 10.1007/s00586-009-0954-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Revised: 01/14/2009] [Accepted: 03/19/2009] [Indexed: 10/21/2022]
Abstract
To determine the association between expectations to return to work and self-assessed recovery. Positive expectations predict better outcomes in many health conditions, but to date the relationship between expecting to return to work after traffic-related whiplash-associated disorders and actual recovery has not been reported. We assessed early expectations for return to work in a cohort of 2,335 individuals with traffic-related whiplash injury to the neck. Using multivariable Cox proportional hazard analysis we assessed the association between return to work expectations and self-perceived recovery during the first year following the event. After adjusting for the effects of sociodemographic characteristics, initial pain and symptoms, post-crash mood, prior health status and collision-related factors, those who expected to return to work reported global recovery 42% more quickly than those who did not have positive expectations (HRR = 1.42, 95% CI 1.26-1.60). Knowledge of return to work expectation provides an important prognostic tool to clinicians for recovery.
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Affiliation(s)
- Dejan Ozegovic
- Alberta Centre for Injury Control and Research, School of Public Health, University of Alberta, 4075 RTF, Edmonton, AB, Canada, T6G 2E1.
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Diagnostic imaging practice guidelines for musculoskeletal complaints in adults--an evidence-based approach: introduction. J Manipulative Physiol Ther 2008; 30:617-83. [PMID: 18082742 DOI: 10.1016/j.jmpt.2007.10.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2007] [Revised: 09/12/2007] [Accepted: 10/14/2007] [Indexed: 11/22/2022]
Abstract
PURPOSE Imaging technology can improve patient outcomes by allowing greater precision in diagnosing and treating patients. However, there is evidence that overuse, underuse, and misuse of imaging services occur. The purpose of this project was to develop evidence-based diagnostic imaging practice guidelines for musculoskeletal complaints for use by doctors of chiropractic and other primary health care professionals. METHODS An electronic search of the English and French language literature (phase 1) was conducted on several databases. Cross references, and references provided by clinicians, were also used. Independent assessment of the quality of the citations used to support recommendations in the guidelines was performed using the QUADAS, the AGREE,and the SPREAD evaluation tools. A first draft of a diagnostic imaging practice guideline was produced, using the European Commission's Referral Guidelines for Imaging document as a template. Results were sent to 12 chiropractic specialists for a first external review. A modified Delphi process, including 149 international experts, was used to generate consensus on recommendations for diagnostic imaging studies. The reliability of proposed recommendations was further tested on field chiropractors and on a group of specialists both in chiropractic and in medicine in both Canada and the United States. All recommendations were graded according to the strength of the evidence. RESULTS The research procedure resulted in the recommendations for diagnostic imaging guidelines of adult extremity and spine disorders supported by more than 685 primary and secondary citations. High levels of agreement among Delphi panelists were reached for all proposed recommendations. Comments received by specialists were generally very favorable and reflected high levels of agreement with the proposed recommendations, perceived ease of use of guidelines, and implementation feasibility. CONCLUSIONS These evidence-based diagnostic imaging practice guidelines are intended to assist chiropractors and other primary care providers in decision making on the appropriate use of diagnostic imaging for specific clinical presentations. In all cases, the guidelines are intended to be used in conjunction with sound clinical judgment and experience. Application of these guidelines should help avoid unnecessary radiographs, increase examination precision,and decrease health care costs without compromising the quality of care. All guidelines are documents to be refined and modified regularly with new information and experience.
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