Occupational Physicians' Reasoning about Recommending Early Return to Work with Work Modifications

Interrelationships among workload, illness severity, and function on return to work following acute respiratory distress syndrome

BACKGROUND

Inability to return to work (RTW) is common after acute respiratory distress syndrome (ARDS).

OBJECTIVES

The aim of this study is to examine interrelationships among pre-ARDS workload, illness severity, and post-ARDS cognitive, psychological, interpersonal, and physical function with RTW at 6 and 12 months after ARDS.

METHODS

We conducted a secondary analysis using the US multicentre ARDS Network Long-Term Outcomes Study. The US Occupational Information Network was used to determine pre-ARDS workload. The Mini-Mental State Examination and SF-36 were used to measure four domains of post-ARDS function. Analyses used structural equation modeling and mediation analyses.

RESULTS

Among 329 previously employed ARDS survivors, 6- and 12-month RTW rates were 52% and 56%, respectively. Illness severity (standardised coefficients range: -0.51 to -0.54, p < 0.001) had a negative effect on RTW at 6 months, whereas function at 6 months (psychological [0.42, p < 0.001], interpersonal [0.40, p < 0.001], and physical [0.43, p < 0.001]) had a positive effect. Working at 6 months (0.79 to 0.72, P < 0.001) had a positive effect on RTW at 12 months, whereas illness severity (-0.32 to -0.33, p = 0.001) and post-ARDS function (psychological [6 months: 0.44, p < 0.001; 12 months: 0.33, p = 0.002], interpersonal [0.44, p < 0.001; 0.22, p = 0.03], and physical abilities [0.47, p < 0.001; 0.33, p = 0.007]) only had an indirect effect on RTW at 12 months mediated through work at 6 months.

CONCLUSIONS

RTW at 12 months was associated with patients' illness severity; post-ARDS cognitive, psychological, interpersonal, and physical function; and working at 6 months. Among these factors, working at 6 months and function may be modifiable mediators of 12-month post-ARDS RTW. Improving ARDS survivors' RTW may include optimisation of workload after RTW, along with interventions across the healthcare spectrum to improve patients' physical, psychological, and interpersonal function.

Participatory Ergonomics Intervention to Prevent Work Disability Among Workers with Low Back Pain: A Randomized Clinical Trial in Workplace Setting

Purpose In order to support people with low back pain (LBP) to stay at work, work arrangements are regarded important. This study aimed to evaluate the effectiveness of a workplace intervention using a participatory approach on work disability of workers with ongoing or recurrent LBP. Methods A total of 107 workers with LBP, with duration of pain for at least two consecutive weeks or recurrent pain of any duration during the last year, were randomized either to the intervention (n = 51) or control group (n = 56). The intervention included arrangements at the workplace, along with individual guidance provided by an occupational physiotherapist (OPT). The randomized intervention study used standard counselling and guidance by an OPT without workplace intervention as a comparison. Surveys were completed at baseline, and 6 and 12 months after baseline. Results There were no statistically significant differences between the intervention and control groups on the primary outcome measure, i.e. self-assessed work ability. We found no between-group differences in perceived health, self-assessed work productivity, number of sickness absence days and severity of back pain. However, there were significant positive within-group changes in the intervention group in the intensity of LBP, perceived health and the number of sickness absence days due to LBP. Conclusion Workplace arrangements are feasible using participatory ergonomics, but more quantitative and qualitative research is needed on its utilization and effectiveness among workers with LBP.

Analysis of Factors Associated with Return-to-Work After Lumbar Surgery up to 2-Years Follow-up: A Michigan Spine Surgery Improvement Collaborative (MSSIC) Study

STUDY DESIGN

Michigan Spine Surgery Improvement Collaborative (MSSIC) prospectively collects data on all patients undergoing operations for degenerative and/or deformity indications.

OBJECTIVE

We aimed to identify which factors are significantly associated with return-to-work after lumbar surgery at long-term follow-up.

SUMMARY OF BACKGROUND DATA

Prior publications have created a clinically relevant predictive model for return-to-work, wherein education, gender, race, comorbidities, and preoperative symptoms increased likelihood of return-to-work at 3 months after lumbar surgery. We sought to determine if these trends 1) persisted at 1 year and 2 years postoperatively; or 2) differed among preoperatively employed versus unemployed patients.

METHODS

MSSIC was queried for all patients undergoing lumbar operations (2014-2019). All patients intended to return-to-work postoperatively. Patients were followed for up to 2 years postoperatively. Measures of association were calculated with multivariable generalized estimating equations.

RESULTS

Return-to-work increased from 63% (3542/5591) at 90 days postoperatively to 75% (3143/4147) at 1 year and 74% (2133/2866) at 2 years postoperatively. Following generalized estimating equations, neither clinical nor surgical variables predicted return-to-work at all three time intervals: 90 days, 1 year, and 2 years postoperatively. Only socioeconomic factors reached statistical significance at all follow-up points. Preoperative employment followed by insurance status had the greatest associations with return-to-work. In a subanalysis of patients who were preoperatively employed, insurance was the only factor with significant associations with return-to-work at all three follow-up intervals. The return-to-work rates among unemployed patients at baseline increased from 29% (455/1100) at 90 days, 44% (495/608) at 1 year, and 46% (366/426) at 2 years postoperatively. The only two significant factors associated with return-to-work at all three follow-up intervals were Medicaid, as compared with private insurance, and male gender.

CONCLUSION

In patients inquiring about long-term return-to-work after lumbar surgery, insurance status represents the important determinant of employment status.Level of Evidence: 2.

Comparative study on the activities of part-time occupational physicians in Japan between 2008 and 2016: effects of the stress-check program

The Ministry of Health, Labor, and Welfare of Japan recommends that an occupational physician (OP) play an important role in implementing the stress-check program since 2015. This study aimed to compare the activities and encountered difficulties of Japanese part-time OPs in 2008 and 2016, and to investigate the effects of the stress-check program. Questionnaires were sent via mail to 946 part-time OPs in Kyoto prefecture in 2016. Completed questionnaires were returned by 181 OPs who were private practitioners or physicians in hospitals, and served as OPs on a part-time basis. In 2016, OPs utilized long hours for activities related to general health examination and to stress-check. Hours for specific health examination, health and hygiene education, health promotion activity, development of a comfortable workplace, and guidance of workers on sick leave reduced from 2008 to 2016. A total of 62% OPs frequently encountered difficulties in the stress-check-related activities in 2016. Many OPs also reported difficulties in the mental health care and the prevention of health hazard due to overwork both in 2008 and 2016. Enforcement of the stress-check program in 2015 changed the activities of part-time OPs in Japan. OPs should be given opportunities to gain more information in this area.

Correlation of return to work with patient satisfaction after surgery for lumbar spondylolisthesis: an analysis of the Quality Outcomes Database

OBJECTIVE

Return to work (RTW) and satisfaction are important outcome measures after surgery for degenerative spine disease. The authors queried the prospective Quality Outcomes Database (QOD) to determine if RTW correlated with patient satisfaction.

METHODS

The QOD was queried for patients undergoing surgery for degenerative lumbar spondylolisthesis. The primary outcome of interest was correlation between RTW and patient satisfaction, as measured by the North American Spine Society patient satisfaction index (NASS). Secondarily, data on satisfied patients were analyzed to see what patient factors correlated with RTW.

RESULTS

Of 608 total patients in the QOD spondylolisthesis data set, there were 292 patients for whom data were available on both satisfaction and RTW status. Of these, 249 (85.3%) were satisfied with surgery (NASS score 1–2), and 224 (76.7%) did RTW after surgery. Of the 68 patients who did not RTW after surgery, 49 (72.1%) were still satisfied with surgery. Of the 224 patients who did RTW, 24 (10.7%) were unsatisfied with surgery (NASS score 3–4). There were significantly more people who had an NASS score of 1 in the RTW group than in the non-RTW group (71.4% vs 42.6%, p < 0.05). Failure to RTW was associated with lower level of education, worse baseline back pain (measured with a numeric rating scale), and worse baseline disability (measured with the Oswestry Disability Index [ODI]).

CONCLUSIONS

There are a substantial number of patients who are satisfied with surgery even though they did not RTW. Patients who were satisfied with surgery and did not RTW typically had worse preoperative back pain and ODI and typically did not have a college education. While RTW remains an important measure after surgery, physicians should be mindful that patients who do not RTW may still be satisfied with their outcome.

Organizational justice and illness reporting among Japanese employees with chronic diseases

Purpose

This study examined the association between perceived organizational justice (i.e., procedural justice and interactional justice) and reporting of illness to one's company (illness reporting) among Japanese employees with chronic diseases.

Methods

This online cross-sectional survey included 1,134 employees (aged 18–65 years) who required workplace support to combine work with disease treatment. Participants were classified into tertiles of perceived organizational justice (low, moderate, and high). Multiple logistic regression analyses were conducted to examine sex differences in the associations between perceived justice and illness reporting.

Results

Males reporting perceived high levels of procedural and interactional justice had significantly higher odds of illness reporting than those with perceived low levels of procedural (odds ratio [OR] 2.62, 95% confidence interval [CI]: 1.47–4.66) and interactional justice (OR 4.34, 95% CI: 2.28–8.27). Females with perceived high levels of interactional justice had significantly higher odds of illness reporting than those with perceived low levels of interactional justice (OR 1.74, 95% CI: 1.08–2.80). There was no significant association between procedural justice and illness reporting among females.

Conclusion

The findings indicate that high perceived organizational justice is positively associated with illness reporting among Japanese employees who require workplace support to combine work and disease treatment.

Physician decision-making in the management of work related upper extremity injuries

BACKGROUND

Physicians working in a tertiary care injured worker clinic are faced with clinical decision-making that must balance the needs of patients and society in managing complex clinical problems that are complicated by the work-workplace context.

OBJECTIVE

The purpose of this study is to describe and characterize the decision-making process of upper extremity specialized surgeons when managing injured workers within a specialized worker's compensation clinic.

METHOD

Surgeons were interviewed in a semi-structured manner. Following each interview, the surgeon was also observed in a clinic visit during a new patient assessment, allowing observation of the interactional patterns between surgeon and patient, and comparison of the process described in the interview to what actually occurred during clinic visits.

RESULTS

The primary central theme emerging from the surgeon interviews and the clinical observation was the focus on the importance of comprehensive assessment to make the first critical decision: an accurate diagnosis. Two subthemes were also found. The first of these involved the decision whether to proceed to management strategies or to continue with further investigation if the correct diagnosis is uncertain. Once the central theme of diagnosis was achieved, a second subtheme was highlighted; selecting appropriate management options, given the complexities of managing the injured worker, the workplace, and the compensation board.

CONCLUSIONS

This study illustrates that upper extremity surgeons rely on their training and experience with upper extremity conditions to follow a sequential but iterative decision-making process to provide a more definitive diagnosis and treatment plan for workers with injuries that are often complex. The surgeons are challenged by the context which takes them out of their familiar zone of typical clinical practice to deal with the interactions between the injury, worker, work, workplace and insurer.

Working Together and Being Physically Active Are Not Enough to Advise Uniformly and Adequately Low Back Pain Patients: A Cross-Sectional Study

The profession of the health-care providers (HCPs) influences their recommendations to the patients. Conversely, interdisciplinarity seeks to challenge such differences, so that the patient receives one single and consistent therapeutic message. Some studies also suggest associations between HCPs life habits and recommendations. Our hypotheses were (1) that despite interdisciplinary work, the profession remains a predictor of recommendations and (2) that HCPs who are more physically active recommend more activity. Three clinical vignettes were presented to a group of experts of low back pain (LBP) (guidelines), and 20 physicians, 22 physiotherapists, and 23 nurses to assess how they evaluate the symptoms and pathologies of LBP patients and how much work and physical activity they recommend. Physical activity was assessed with accelerometers and questionnaires. Some interprofessional differences remained present within an interdisciplinary team. The nurses were more restrictive and further away from the guidelines. The physicians were the most in line with them. The physiotherapists recommend as much physical activity, but less work activity than the physicians. The level of physical activity of the HCPs is not associated with their recommendations. To ensure a clear and unique message, educational actions may be undertaken to promote the biopsychosocial model and clarify the guidelines.

Application of the Theoretical Domains Framework and the Behaviour Change Wheel to Understand Physicians' Behaviors and Behavior Change in Using Temporary Work Modifications for Return to Work: A Qualitative Study

Purpose Applying the theoretical domains framework (TDF) and the Behaviour Change Wheel (BCW) to understand physicians' behaviors and behavior change in using temporary work modifications (TWMs) for return to work (RTW). Methods Interviews and focus group discussions were conducted with 15 occupational physicians (OPs). Responses were coded using the TDF and the BCW. Results Key behaviors related to applying TWMs were initiating the process with the employee, making recommendations to the workplace, and following up the process. OP behaviors were influenced by several factors related to personal capability and motivation, and opportunities provided by the physical and social environment. Capability comprised relevant knowledge and skills related to applying TWMs, remembering to initiate TWMS and monitor the process, and being accustomed to reflective practice. Opportunity comprised physical resources (e.g., time, predefined procedures, and availability of modified work at companies), and social pressure from stakeholders. Motivation comprised conceptions of a proper OP role, confidence to carry out TWMs, personal RTW-related goals, beliefs about the outcomes of one's actions, feedback received from earlier cases, and feelings related to applying TWMs. OPs' perceived means to target these identified factors were linked to the following BCW intervention functions: education, training, persuasion, environmental restructuring, and enablement. The results suggest that at least these functions should be considered when designing future interventions. Conclusions Our study illustrates how theoretical frameworks TDF and BCW can be utilized in a RTW context to understand which determinants of physicians' behavior need to be targeted, and how, to promote desired behaviors.

Application of the Theoretical Domains Framework and the Behaviour Change Wheel to Understand Physicians' Behaviors and Behavior Change in Using Temporary Work Modifications for Return to Work: A Qualitative Study

Purpose Applying the theoretical domains framework (TDF) and the Behaviour Change Wheel (BCW) to understand physicians' behaviors and behavior change in using temporary work modifications (TWMs) for return to work (RTW). Methods Interviews and focus group discussions were conducted with 15 occupational physicians (OPs). Responses were coded using the TDF and the BCW. Results Key behaviors related to applying TWMs were initiating the process with the employee, making recommendations to the workplace, and following up the process. OP behaviors were influenced by several factors related to personal capability and motivation, and opportunities provided by the physical and social environment. Capability comprised relevant knowledge and skills related to applying TWMs, remembering to initiate TWMS and monitor the process, and being accustomed to reflective practice. Opportunity comprised physical resources (e.g., time, predefined procedures, and availability of modified work at companies), and social pressure from stakeholders. Motivation comprised conceptions of a proper OP role, confidence to carry out TWMs, personal RTW-related goals, beliefs about the outcomes of one's actions, feedback received from earlier cases, and feelings related to applying TWMs. OPs' perceived means to target these identified factors were linked to the following BCW intervention functions: education, training, persuasion, environmental restructuring, and enablement. The results suggest that at least these functions should be considered when designing future interventions. Conclusions Our study illustrates how theoretical frameworks TDF and BCW can be utilized in a RTW context to understand which determinants of physicians' behavior need to be targeted, and how, to promote desired behaviors.