Document 6
Review of the Effectiveness and
Cost Effectiveness of
Interventions, Strategies,
Programmes and Policies to
reduce the number of
employees who take long-term
sickness absence on a
recurring basis
Report
May 2008
Document 6
Review of the Effectiveness and Cost
Effectiveness of Interventions, Strategies,
Programmes and Policies to reduce the
number of employees who take long-term
sickness absence on a recurring basis
Dr Jo Rick
Dr Christopher Carroll
Jim Hillage
Hazel Pilgrim
Nick Jagger
School Of
Health
And
Related
Research
Final Draft Report
Published by: INSTITUTE FOR EMPLOYMENT STUDIES Mantell Building University of Sussex Falmer Brighton BN1 9RF UK Tel. + 44 (0) 1273 686751 Fax + 44 (0) 1273 690430 http://www.employment‐studies.co.uk Copyright © 2008 Institute for Employment Studies No part of this publication may be reproduced or used in any form by any means—
graphic, electronic or mechanical including photocopying, recording, taping or information storage or retrieval systems—without prior permission in writing from the Institute for Employment Studies. The Institute for Employment Studies
The Institute for Employment Studies is an independent, apolitical, international centre of research and consultancy in public employment policy and organisational human resource issues. For over 40 years the Institute has been a focus of knowledge and practical experience in employment and training policy, the operation of labour markets and human resource planning and development. IES is a not‐for‐profit organisation with over 60 multidisciplinary staff plus associates. IES aims to help bring about sustainable improvements in employment policy and human resource management. IES achieves this by increasing the understanding and improving the practice of key decision makers in policy bodies and employing organisations. Institute of Work Psychology, Sheffield University
The Institute of Work Psychology is dedicated to conducting applied research in work settings, in both the public and private sectors. The aims of the Institute are to: ■ advance knowledge about the causes of individual, team and organisational effectiveness at work ■ increase understanding of the well‐being of people at work ■ advance knowledge about innovation and creativity at work ■ disseminate this knowledge in the scientific community, in the workplace and in the wider public domain ■ design, implement and evaluate methods of promoting effectiveness, innovation and well‐being at work. The School of Health and Related Research, Sheffield
University
ScHARR is a large multi‐disciplinary School within the Faculty of Medicine at the University of Sheffield. It employs around 200 staff, primarily behavioural and social scientists, epidemiologists, statisticians, public health specialists and health economists. Its research infrastructure and its multi‐disciplinarily approach offer huge potential for collaboration with leading researchers in other fields, whilst its Information Resources Section is able to provide first class support with systematic literature searches. ScHARR staff have considerable expertise in systematic review methodology and have contributed to the development of the latest techniques for identifying, assessing and synthesising non RCT evidence in systematic review methodology. v
Contents
The Institute for Employment Studies Institute of Work Psychology, Sheffield University The School of Health and Related Research, Sheffield University v
v
v
Contents vi
Executive Summary ix
Initial title and abstract sifting Full paper screening Included papers Intervention Theme 1: Exercise and education programmes to prevent reoccurrence of lower back pain Intervention Theme 2: Pain management through group learning Intervention Theme 3: Clinical interventions to treat lower back pain Conclusions 1
2
1
1.1
1.1
1.2
2
2
3
Background Research objectives Structure of report Methodology 4
Identifying potentially relevant studies Selection of studies for inclusion Data extraction and quality appraisal Synthesis and formulation of evidence statements Effectiveness Findings 3.1
3.2
3.3
xii
xiii
xiii
xiv
Introduction 2.1
2.2
2.3
2.4
3
xi
xi
xi
4
8
24
27
28
Theme 1: Exercise and education programmes to prevent reoccurrence of lower back pain Theme 2: Pain management through group learning Theme 3: Multi‐disciplinary interventions for lower back pain vi
29
39
43
3.4
3.5
4
48
59
Cost Effectiveness Findings 60
4.1
4.2
60
4.3
4.4
4.5
5
Evidence tables for the three themes Applicability of the evidence to the UK populations in the scope Cost–effectiveness results Theme 1: exercise and education programmes to prevent the reoccurrence of lower back pain Theme 2: Multi‐disciplinary interventions to treat lower back pain Applicability of the evidence to the UK populations in the scope Evidence tables for the three studies 62
64
68
68
Discussion 72
5.1
5.2
5.3
72
73
74
Effectiveness studies Cost‐effectiveness studies Emergent themes References 76
Appendix 1: Example Search Strategy used for Research Questions 1 to 3 78
MEDLINE primary study search strategy research Questions 1 to 3 (intervention effectiveness) Methodological filters 78
79
Appendix 2: Sifting Criteria Used 82
NICE Absence Sift Criteria: Effectiveness primary studies Questions 1 to 3 NICE Absence Sift Criteria: Economics (primary studies and reviews) Questions 1 to 3 NICE Absence Sift Criteria: Effectiveness reviews Questions 1 to 3 and Question 4 82
84
86
Appendix 3: Full Paper Screening Checklists 88
Appendix 4: Excluded Primary Studies by Reason for Exclusion 95
Effectiveness studies: Excluded studies by reason Schumacher, H. L. & Baumann, N. 2003, ʺTemporary working disability among younger patients with back pain and its interaction with severity of pain, functional capacity, social factors and personality stylesʺ, Rehabilitation, vol. 42, no. 4, pp. 245‐252. Cost effectiveness: Excluded studies by reason Appendix 5: Studies Pending 156
156
165
Cost–effectiveness primary studies Review studies 166
166
Appendix 6: Example Completed Effectiveness Data Extraction form and Quality Checklist 95
vii
167
Appendix 7: Economic Data Extraction and Quality Assessment Form viii
178
Executive Summary
The National Institute for Health and Clinical Excellence (NICE) has been asked by the Department of Health to develop guidance for primary care services and employers on the management of long‐term sickness and incapacity. The guidance will provide recommendations for good practice that are based on the best available evidence of effectiveness and cost effectiveness. This report is one in a series of reviews of the literature covering primary studies of interventions, strategies, programmes and policies to reduce the number of employees who take long‐term sickness absence on a recurring basis. As such, the report aims to inform the guidance on managing long‐term sickness absence through two linked systematic reviews of the literature on the effectiveness and the cost effectiveness of interventions to prevent the re‐occurrence of long term sickness absence. Specifically, this review addressed the following primary research question: ‘What work or primary care‐based interventions, programmes, policies or strategies are effective and cost‐effective in helping to reduce the number of employees who take long‐term sickness absence on a recurring basis?’ A protocol was developed which specified the population, interventions and outcomes of interest for the effectiveness and cost effectiveness reviews. The protocol provided the detailed inclusion and exclusion criteria that were applied to the literature retrieved via the online searches specified in the protocol. In addition to these database and website searches, experts and the Programme Development Group (PDG) were contacted for addition studies. The citations of and references given in the included papers have also been checked. The process took into account the following included and excluded population groups. ■ Populations covered: □ All adults over age 16 in full or part‐time employment, both paid and unpaid □ All adults over age 16 who have experienced long‐term sickness (which may be defined as ‘long‐term absence’ or ‘sickness absence’ in the research) ix
□ All employers in the public, private and ‘not for profit’ sectors. ■ Locations to be included: □ countries belonging to the Organisation for Economic Co‐operation and Development (OECD) ■ Populations excluded were: □ self‐employed individuals □ pregnant women who have taken sickness absence related to their pregnancy, during the course of their pregnancy □ unemployed individuals ■ The locations excluded were: □ Studies set in developing or non OECD countries ■ The interventions, programmes, policies and strategies included were: □ Any that aim to reduce the number of incidences of re‐occurring long‐term sickness absence. ■ Interventions, programmes, policies and strategies excluded were any that: □ aim to prevent the first occurrence of short or long‐term sickness absence (primary prevention) □ target pregnant women exclusively and/or which focus on illnesses associated with pregnancy, during the course of a pregnancy □ tackle workplace absences which are not reported and/or recorded as sickness absence (for example, maternity leave) □ are delivered outside the workplace or primary care settings (subject to above conditions) □ deal solely with the effectiveness of private health insurance schemes and/or claiming of statutory or occupational sick pay □ deal solely with preventing ill‐health retirement (ie where recipient has no intention of returning to work). Based on the protocol, searches were undertaken of 19 research and specialist economics data bases and six websites by the Centre for Review and Dissemination (CRD) at York University plus five more suggested by the PDG. x
Initial title and abstract sifting
A total of 17,840 articles were identified (covering 15,345 effectiveness and 2,495 cost effectiveness primary studies) in the initial screening processes supplemented by websites searches, references in relevant reviews, suggestions from the PDG and other experts and subsequent reference checking and citation searching of included papers. The titles and abstracts of these articles were all initially sifted against the agreed inclusion and exclusion criteria from the protocol. Papers definitely meeting the criteria were put forward for full paper screening. Those where it was unclear if a study met all the criteria were also ordered and screened. Otherwise papers were excluded from the review. The list of ‘includes’ and get full papers’ was re‐screened prior to the papers being ordered. A total of 813 papers from all sources were ordered for full paper screening for both elements of the review, of which 805 have been screened and eight were not received by the agreed cut off date. Full paper screening
The full paper screening involved a more thorough check of the studies’ suitability for inclusion in the review. This screening was undertaken using full paper screening checklist based on the agreed protocol. Given that the decisions were based on the full papers rather than simply the title and abstract, and in some cases only the title, more definitive decisions could be made. Included papers
Articles passing the full paper screen were then put though a process of data extraction and quality assessment. Data extraction was performed by one reviewer and checked by another. Quality assessment was undertaken by two reviewers independently and ratings of quality were then compared. Any differences were settled through discussion. Seven effectiveness articles including three cost‐
effectiveness articles passed this full paper screen. The seven included papers presented evaluations of the effectiveness and cost‐effectiveness in preventing the re‐
occurrence of long term sickness absence through three broad themes. xi
Intervention Theme 1: Exercise and education programmes
to prevent reoccurrence of lower back pain
Effectiveness evidence statement for Theme 1
Four studies present some, mainly limited, evidence of the positive effects of interventions
involving exercise and physical activity on preventing the reoccurrence of sick leave among
employees who had been previously off sick with low back pain.
One RCT study in Norway (rated ‘+‘) found evidence that workers, aged between 18 and 60, on
long-term sick leave with lower back pain who receive consultations with a physician (specialising
in physical medicine and rehabilitation) and a physiotherapist to improve skills to cope with their
condition may be effective at helping workers return to work up to a year after they start sick
leave than comparable people who receive were treated in primary care. In the consultation,
patients received information, reassurance and encouragement to engage in physical activity as
normal as possible and reports were sent to their primary care physician and local national
insurance office. However, there was no significant difference between the groups in terms of
return to work in the second or third year. Although the study found significant differences in the
average number of sick leave days at the 12-month point between the intervention group and the
control group, there was no significant difference between the groups in the proportions
experiencing further sickness episodes over the three year period. Therefore there is insufficient
evidence from this study to suggest that this intervention was effective in preventing the reoccurrence of sickness absence in the long-term. (Molde Hagen et al, 2003).
There is limited evidence from one Norwegian RCT (rated ‘-‘) to suggest that the delivery of a
physical exercise and education and training programme (involving stretching and relaxation
exercises and information on ergonomic and physical exercises), called the Mensendieck
approach, delivered by specially trained physical therapists to male and female employees with a
history of musculoskeletal symptoms, such as lower back pain, can result in lower reported
recurrence of lower back pain and a reduction in re-occurring long-term sickness absence
(although the results of the study are limited by the exclusion of one outlying case). (Soukup et
al. 1999).
There is limited evidence from a Finnish cohort study (rated ‘-‘) to suggest that an intensive
exercise programme (involving water and gymnasium-based exercises and lectures on practical
physical and relaxation exercises) delivered to a small group of machinists in a military setting by
provided by a physician, physiotherapist, a physical training instructor, a psychologist and a
specialist in ergonomics can result in lower levels of re-occurring sickness absence and reported
re-occurring back pain (Holopainen et al., 2004).
These two studies suggest that the positive impact may be enhanced by increasing the amount of
sustained physical exercise taken by participants (Soukup et al. 1999 and Holopainen et al, 2004).
There is limited evidence from a prospective controlled study (rated ‘-‘) which examined changes
in fitness, health and work ability among male lumberjacks employed by two companies in Finland
xii
who had been off sick with lower back pain for up to a 30 day period but were back at work that a
free of charge (with 80% of salary losses compensated) intensive one-week residential workoriented physical fitness course (involving lectures, fitness tests and exercising - lasting 12 hours
for 5 days), led by a physiotherapist or instructor in physical activity; followed by a reenforcement session 6 months posts the residential course had a positive but not statistically
significant effect on the frequency and average number of days of subsequent sick leave. Selfassessed ‘work ability’ increased after the intervention and was assessed significantly higher than
among the control group at the six-month follow-up. Self-reported leisure time increased in both
groups in the six months after the intervention. (Leino et al. 1994).
Cost effectiveness evidence statement for Theme 1
There is evidence from one Norwegian cost benefit (randomised controlled trial) evaluation (rated
‘++’) that an examination at a primary care spine clinic by physician and physiotherapist and
provision of information and individual instruction, as well as advice on how to stay active, is
likely to be cost effective compared to primary care treatment in preventing the re-occurrence of
long term sickness absence due to low back pain (Molde Hagen et al 2003).
Intervention Theme 2: Pain management through group
learning
Effectiveness evidence statement for Theme 2
There is limited evidence from one Norwegian RCT study (grade ‘-‘) to suggest that a learning
programme (based on phenomenological perspectives and Kelly’s personal construct theory)
delivered by specially trained group counsellors to small groups may help adults aged 20-59
experience less musculoskeletal pain and increase their ability to cope with pain. While there is
some evidence that they are less likely to take up disability benefits and make visits to the
doctor, there is insufficient evidence to indicate that such a programme can positively affect selfreported re-occurring sickness absence from work (Haugli, 2001).
Intervention Theme 3: Clinical interventions to treat lower
back pain
Effectiveness evidence statement for Theme 3
A Dutch RCT study (rated ‘+’), among 196 men and women aged between 18 and 65 who had been
on sick leave for between two and six weeks due to lower back pain, found that a multi-stage
return to work programme (involving a workplace assessment and work modifications based on
participative ergonomics and counselling the employee about return to work) was effective at
getting them back to work sooner than if they had just had usual care. There is also evidence that
the workplace intervention was effective in reducing the total number of days taken as re-
xiii
occurring sick leave among the study population and that the clinical intervention (in combination
with usual care or the workplace intervention) did not have a positive effect, although the clinical
intervention was only adhered to by 65 per cent of cases (Steenstra et al., 2006).
A Norwegian RCT (rated ‘+’) of 210 patients aged between 20 and 65 on long-term sick leave
which compared medical exercise therapy (under continuous supervision by the physiotherapist)
conventional physiotherapy (a combination of methods such as heat or cold massage, stretching,
different forms of electrotherapy, traction, and a few exercises on the treatment table) and self
exercise (patients given information and told to walk for one hour three times a week for 12
weeks) found all three interventions could be effective in reducing total re-occurring sickness
absence. However no significant difference was found in the proportion of patients who returned
to work during the trial period among the three groups (Torstensen et al 1998).
Cost effectiveness evidence statement for Theme 3
There is evidence from one Dutch economic (randomised controlled trial) evaluation (rated ‘+’)
that work modifications based on participative ergonomics and counselling the employee about
return to work are likely to be cost effective in reducing the re-occurrence of absence due to low
back pain when compared against usual care as outlined by Dutch Occupational Physician
guidelines for lower back pain. Within this study patients are randomised to receive a clinical
intervention or usual care at 8 weeks if they have not returned to work and therefore this may
confound the results; although the authors have tried to calculate an adjustment for this. The
cost per return to work day gained is estimated to be £17 and the cost per quality adjusted life
year (QALY) gained is estimated to be dominating (-£1,295) for the workplace intervention in
comparison to usual care. However, based on the analysis, it is unlikely that graded exercise
based on operant behavioural principles provided for those who remain on sickness absence after
8 weeks of receiving either the workplace intervention or usual care in terms of return to work is
cost-effective in comparison to the provision of Dutch usual care for the same indication
(Steenstra et al., 2006).
There is evidence from one Norwegian cost benefit (randomised controlled trial) evaluation (rated
‘+’) that both medical exercise therapy (under continuous supervision by the physiotherapist) and
conventional physiotherapy (a combination of methods such as heat or cold massage, stretching,
different forms of electrotherapy, traction, and a few exercises on the treatment table) are likely
to be cost effective in comparison to self exercise (patients given information and told to walk for
one hour three times a week for 12 weeks) for preventing the re-occurrence of long term sickness
absence in a Norwegian adult population (Torstensen et al 1998).
Conclusions
All of the studies identified for this part of the review are concerned with low back pain. This represents a clear lack of evidence about other forms of intervention or other conditions which may benefit from intervention to reduce or prevent the re‐
occurrence of long term sickness absence. This is particularly the case in relation to xiv
acute medical conditions, mental health and stress which are the other main recognised causes of long‐term sickness absence in the UK. With the exception of two of the effectiveness studies, the studies are sufficiently diverse as to preclude aggregation of data, so there are limits to the conclusions that can be drawn about specific interventions on the basis of this evidence, particularly in relation to a UK population. There are, however a few of emergent themes. Across the effectiveness and cost effectiveness studies, the interventions which are successful in reducing the re‐
occurrence of long term sickness absence share certain characteristics: ■ Most involve early interventions (ie between two and eight weeks from the start of sick leave). This compares to far broader inclusion criteria in the studies which failed to show significant findings (60 days over the past two years; thirty days in the previous year). ■ The interventions tend to involve some direct workplace input, either through design or assessment or workplace adaptation and delivery. Overall this suggests that successful interventions are more likely to incorporate a range of perspectives, have some form of direct contact with the workplace and involve early intervention. This review question is very specific in nature, concerned as it is with prevention of the re‐occurrence of long term sickness absence and many studies were excluded on the basis that they did not have a ‘prevention of re‐occurrence’ outcome. As such, these excluded studies may also be relevant to review question 2 (return to work from long term sickness absence). It is possible that data from review question 2 will also provide greater understanding of promising areas for research into interventions to prevent the re‐occurrence of long term sickness absence. xv
IES, IWP, ScHARR
1
1 Introduction
The National Institute for Health and Clinical Excellence (NICE) has been asked by the Department of Health to develop guidance for primary care services and employers on the management of long‐term sickness and incapacity. The guidance will provide recommendations for good practice that are based on the best available evidence of effectiveness and cost effectiveness. The Institute for Employment Studies and the Institute of Work Psychology and School of Health and Related Research (both at Sheffield University) were contracted to undertake a series of three effectiveness and cost effectiveness reviews of primary randomised controlled or longitudinal studies (covering four research questions) and an economic analysis of the evidence in those studies to support the production of this guidance. This report is the second effectiveness and economic review to be delivered to the Programme Development Group (PDG). The first examined interventions aimed at moving people from Incapacity Benefit to employment (research question 4) and was discussed at the PDG meeting in December 2007. This review covers research question 3 and looks at primary studies of interventions, strategies, programmes and policies to reduce the number of employees who take long‐term sickness absence on a recurring basis and was discussed at the PDG meeting in February 2008. The third review, covering the remaining two research questions (ie 1 and 2), was initially presented to the PDG in April 2008. This review has been revised in the light of the comments received from the PDG and any further evidence received through the search and sifting process since the first draft was completed. An economic analysis, including economic modelling, will be presented at the PDG meeting in May 2008. This will cover a selection of topics identified in the reviews which have been chosen by the PDG and where there are sufficient data to make modelling feasible. 2
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
1.1 Background
In 2006, UK employees were absent for an average 3.5 per cent of the time they were due to spend working. An estimated 40 million working days are lost each year in Britain due to ill health and injury. Sickness absence costs the British economy an estimated £13 billion each year (CBI 2006), although the quality and accuracy of available data on absence and sickness absence is variable (Barham and Leonard 2002; Barham and Begum 2005). One‐fifth of absences are classified as long term (ie four weeks/20 working days or longer) and on average, in 2006, one per cent of the UK workforce was absent from work due to long‐term sickness. It is estimated that 12 per cent of employees on long‐
term leave are covered by the Disability Discrimination Act. Back pain, musculo‐
skeletal injuries, acute medical conditions, mental ill health and stress are the most common causes. In the public sector, mental ill health and stress were identified as the main causes of long‐term sickness absence for non‐manual workers; musculo‐skeletal injuries and back pain most affected manual workers (CIPD 2006). It is against this background that the Department of Health has asked NICE to provide guidance to primary care services and employers on the management of long term sickness absence. The guidance is intended to be used by professionals and managers who have public health as part of their remit working in the NHS, local authorities and the wider public, private, voluntary and community sectors. 1.1 Research objectives
This review addresses the following specific research question which is referred to as ‘research question 3’ throughout the report: ‘What work or primary care‐based interventions, programmes, policies or strategies are effective and cost‐effective in helping to reduce the number of employees who take long‐term sickness absence on a recurring basis?’ The following secondary research questions were developed to interrogate the data further (data permitting): ■ What is the frequency, content, length and duration of an effective intervention, programme, policy or strategy? ■ Which are the most effective, cost effective and acceptable interventions, programmes, policies or strategies for different groups? (eg age, conditions, gender, ethnic groups or social classes) IES, IWP, ScHARR
3
■ Does the effectiveness of an intervention, programme, policy or strategy depend on the person leading it? (What are the significant characteristics of an effective leader: what training and skills are required?) ■ What are the barriers to‐and facilitators of‐effective implementation? ■ Does the intervention, programme, policy or strategy lead to any adverse or unintended (positive and negative) outcomes? ■ Which interventions, programmes, policies or strategies are ineffective and/or are not cost effective? It is important to recognise that any evidence subsequently presented in relation to the secondary research questions is drawn from a limited pool of studies and cannot be considered on the same level as evidence about the primary outcome. 1.2 Structure of report
The structure of this report is as follows: ■ Chapter 2 discusses how the literature search was conducted, the retrieval of papers, the selection of studies for inclusion, data extraction and quality assessment. ■ Chapter 3 presents the effectiveness findings. ■ Chapter 4 provides the cost‐effectiveness findings. ■ Chapter 5 discusses the review findings, highlighting their applicability, limitations and any gaps. Seven appendices present supporting documents. 4
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
2 Methodology
This chapter details the methodology for identifying studies for inclusion in this review. First the effectiveness and cost effectiveness search strategies are given, with details of the data bases and websites searched. The methods for title and abstract screening are described along with the inclusion and exclusion criteria used. The process for contacting experts and members of the PDG is explained. Next the full paper screening process is detailed, including the review level papers, and the additional inclusion and exclusion criteria used at this stage are given. Finally the data extraction and quality assessment is presented and a summary of included papers given. 2.1 Identifying potentially relevant studies
Because three of the research questions covered such similar issues, in consultation with NICE it was decided to develop a joint search strategy covering research questions 1, 2 and 3 which contained three components: 1. effectiveness – primary studies 2. effectiveness – reviews; and 3. cost effectiveness – primary studies and reviews. Nineteen databases and six websites were searched by the Centre for Reviews and Dissemination (CRD) at York University, using a search protocol supplied by the IES/University of Sheffield team. An additional five website searches were undertaken by NICE following suggestions received from the PDG. IES, IWP, ScHARR
5
2.1.1 Effectiveness literature searches
The following key terms and limiters were used in the search. Key search terms were defined as ‘long term sick’, ‘long term absence’, ‘sick leave’, ‘work absence’, ‘sickness absence’, ‘return to work’ or other synonyms. Methodological filters were also applied to the search in order to identify primary studies of Randomised Control Trials (RCTs) and other intervention studies of longitudinal design, as well as reviews. The search strategies for the Medline search can be seen in Appendix 1. The following limits were placed on the search strategy: ■ Published from 1990 onwards ■ Published in English language only ■ Developed/Organisation for Economic Co‐operation and Development (OECD) countries only ■ Intervention studies of RCT or other longitudinal design (ie with at least one measurement after baseline). The following 19 databases and six websites were searched to identify primary studies and review‐level studies for this effectiveness rapid review: 2.1.2 Databases
■ Cochrane Database of Systematic Reviews (CDSR) ■ Database of Abstracts of Reviews of Effectiveness (DARE) ■ Cochrane Central Register of Controlled Trials ■ MEDLINE ■ EMBASE ■ PsycINFO ■ CINAHL (Cumulative Index of Nursing and Allied Health Literature) ■ AMED (Allied and Complementary Medicine) ■ Business Source Premier ■ British Nursing Index ■ NHS HTA (NHS Health Technology Assessment) ■ ASSIA (Applied Social Science Index and Abstracts) ■ Social Science Citation Index 6
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
■ Science Citation Index ■ Sociological Abstracts. Four databases of grey literature were also searched: ■ HMIC (Health Management Information Consortium. Comprises King’s Fund Database and DH‐Data database) ■ SIGLE (International System for grey literature) ■ National Research Register ■ Current Contents. 2.1.3 Websites
A series of websites were also searched to identify any relevant literature: ■ Department for Work & Pensions: http://www.dwp.gov.uk/ ■ Institute for Public Policy & Research: http://www.ippr.org.uk/ ■ Employment Studies Research Unit: http://www.uwe.ac.uk/bbs/research/esru/wps.shtml ■ Centre for Longitudinal Studies: http://www.cls.ioe.ac.uk/ ■ Health and Safety Executive: http://www.hse.gov.uk/index.htm ■ Department for Business, Enterprise and Regulatory Reform: http://www.dti.gov.uk/index.html. The database and website search for research questions 1‐3 resulted in 15,345 primary study titles and abstracts. 1 In addition 308 review‐level references were also identified by this search. 2.1.4 Cost effectiveness literature searches
Specific economic searches were performed on the following specialist economic databases. These searches used the same limiter as the effectiveness searches with the exception that the study design criteria was not applied: 1 This comprises 48 titles and abstracts from the website search and 15,297 titles and abstracts from the database searches. The latter number differs slightly from those presented in previous reports as duplicates have been excluded and search results re‐allocated between the two elements of the review and between research questions 1 to 3 and research question 4. IES, IWP, ScHARR
7
■ Health Economics Evaluation Database (HEED) ■ NHS EED (NHS Economics Evaluation Database) ■ Econlit. The economic search resulted in 2,495 titles and abstracts for research questions 1 to 3. 2.1.5 Suggestions from experts and PDG
The IES/University of Sheffield team put together a list of experts in the area of managing sickness absence and return to work. The list included academics working in the field, policy makers and commentators. This list, together with the titles of articles identified as relevant to research questions 1 to 3 following the first stage of screening (see 2.2.1. for further details), were circulated to PDG members by NICE in October 2007. PDG members were asked to suggest additional experts who should be contacted and for any references they felt relevant to the review, which were not on the list. Experts suggested by IES/University of Sheffield, NICE and the PDG were then all contacted with the titles of articles identified as relevant (following title and abstract screening ) to research questions 1 to 3 and asked to suggest any additional references. This resulted in an additional (to the above database and website searches) 18 effectiveness titles and abstracts. No economic titles and abstracts for research questions 1 to 3 were suggested additional to those already identified. 2.1.6 Additional web-site searches
Following consultation with the PDG a further five website searches were undertaken: ■ Advisory Conciliation and Arbitration Service (ACAS) ■ Institute of Occupational Health ■ Oxford Health Alliance ■ National Audit Office ■ Xpert HR. The above website searches resulted in a further 611 effectiveness titles and abstracts and no additional economic titles/abstracts for research questions 1 to 3 being identified (see section 2.2.4 below). 8
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
2.2 Selection of studies for inclusion
2.2.1 Title and abstract appraisal
The purpose of title and abstract appraisal is to identify studies that ‘help to answer the questions being addressed by the review’ (NHS CRD, 2001). Study selection should be systematic, replicable and free from bias. Sifting is informed by inclusion criteria reflecting the population, intervention, outcome and study design, and by exclusion criteria defined in the scoping document, such as language and date. Only the criteria relevant to the research question 3 review are presented here. The criteria for research questions 1 and 2 are reported in a separate review 1. The inclusion criteria are set out below. Settings included covered:
■ Studies based in developed/ Organisation for Economic Co‐operation and Development (OECD) countries ■ Setting had to be work/employer‐based or primary care‐based. Population included covered:
■ All adults over age 16 in full or part‐time employment, both paid and unpaid ■ All adults over age 16 who have experienced long‐term sickness (which may be defined as ‘long‐term absence’ or ‘sickness absence’ in the research) ■ All employers in the public, private and ‘not for profit’ sectors. Interventions, programmes, policies and strategies included covered:
■ Those aimed at helping to reduce re‐occurrence of long‐term sickness absences. Outcomes included covered:
■ Long‐term sickness absence 1 J Hillage et al. ‘Review of the Effectiveness and Cost Effectiveness on Interventions, Strategies, Programmes and Policies to reduce the number of employees who move from short‐term to long‐
term sickness absence and to help employees on long‐term sickness absence to return to work’. IES, IWP, ScHARR
9
■ Return to work after long term sickness absence ■ Re‐occurrence of long‐term sickness absence ■ Other work related outcomes. Study designs that were included:
■ Primary level study designs: □ randomised controlled trials (RCTs) □ longitudinal intervention studies (ie there is at least one follow‐up measure after baseline). ■ Review level studies: □ Reviews of RCTs or longitudinal studies. The sifting was limited to these study designs in line with the requirements of the research question. The aim of the sifting was to identify studies that demonstrate causality, ie that demonstrate that an intervention does have a significant, direct impact on the outcome of choice (ie return to work or work readiness) rather than simply demonstrating an association. Causality can only be demonstrated by research that uses longitudinal study design (ie studies with at least one follow up measure after baseline). Therefore the inclusion criteria were constructed to limit the retrieved studies to those reporting longitudinal data. The exclusion criteria were as follows: Excluded locations were:
■ Studies set in developing or non OECD countries. Excluded populations were:
■ Self‐employed individuals ■ Pregnant women who have taken sickness absence related to their pregnancy, during the course of their pregnancy ■ Unemployed individuals. 10
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
Excluded Interventions, programmes, policies and strategies were any that:
■ Aim to prevent the first occurrence of short or long‐term sickness absence (primary prevention) ■ Target pregnant women exclusively and/or which focus on illnesses associated with pregnancy, during the course of a pregnancy ■ Tackle workplace absences which are not reported and/or recorded as sickness absence (for example, maternity leave) ■ Are delivered outside the workplace or primary care settings ■ Deal solely with the effectiveness of private health insurance schemes and/or claiming of statutory or occupational sick pay ■ Deal solely with preventing ill‐health retirement (ie where recipient has no intention of returning to work). ■ Involved the clinical diagnosis or treatment (including pharmacological treatment) of conditions associated with short and/or long term sickness or incapacity (for example, low back pain). Excluded study types
■ Studies which describe the relationship between health/ill‐health and short or long‐
term absence (ie correlate studies or non evaluative studies of an intervention, policy, programme or strategy). Descriptive studies of participants’ views and experiences and cross‐sectional studies (ie with only one data collection point) are also excluded. ■ Dissertations/theses. ■ Non‐English language studies. 2.2.2 Development of title and abstract screening checklists
Detailed sifting criteria in the form of title/abstract screening checklists were developed. The inclusion/exclusion criteria outlined in the scope guided the sift process and helped to ensure consistency in screening across the abstract sifting team. In total, the following three abstract screening checklists were developed and used to screen the titles and abstracts retrieved: 1. Effectiveness:‐primary studies: RCTs and longitudinal intervention studies 2. Economics:‐primary studies and reviews literature IES, IWP, ScHARR
11
3. Reviews:‐reviews of the effectiveness literature. The abstract screening checklists are given in Appendix 2. 2.2.3 Title and abstract screening process
For the effectiveness primary studies, a two‐stage screening process was established (Figure 2.1). An initial screening of the 15,297 primary studies from the original database search results and the 48 primary studies from the original website results for research questions 1‐3 took place using the abstract screening checklists in Appendix 2. When a title/abstract appeared to satisfy all of the inclusion criteria it was coded as ‘include’. When it was unclear regarding its possible relevance and inclusion, then it was coded as ‘get full paper’ and many were identified for a second opinion by another member of the review team. Any titles and abstracts meeting any of the exclusion criteria were excluded from the review. This initial process for the effectiveness component of the review identified a total of 1,182 papers as either ‘include’ (493) or ‘get full paper’ (689)1. As these papers were being ordered it became clear that the list contained a number of additional duplicates and many of those designated ‘get full paper’ were still awaiting a second opinion to see whether they were relevant. As a quality check, a second screening by another set of assessors took place, again using the abstract screening checklists in Appendix 2. This excluded a further 509 papers leaving 673 papers as definite ‘includes’ (415) or ‘get full papers’ (258) for further scrutiny for which full papers were ordered for retrieval. Subsequently at the screening stage further duplicates were identified. Excluding these duplicates further reduces the actual number of ‘includes’ from the main search for research questions 1 to 3 to 654 papers. Title and abstract screening of the review‐level search results were also undertaken using the appropriate checklist (see Appendix 2), this resulted in 102 reviews being identified (once book chapters and duplicates had been excluded) as potentially relevant for full paper retrieval (see section 2.2.7 for further details of the process for dealing with review‐level material). For the economic search results to be considered an economic evaluation, a study has to analyse explicitly both the costs and the outcomes of the intervention under investigation in comparison to the costs and outcomes of at least one alternative. Titles and abstracts could also provide potentially relevant background data which 1 The numbers referred to in this and subsequent paragraphs are slightly different from those presented in some previous reports as duplicate papers have been excluded and search results re‐
allocated between the effectiveness and cost‐effectiveness elements of the review and between research questions 1 to 3 and research question 4. 12
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
may assist with the modelling review – any such abstracts were tagged and coded appropriately. The initial search for economics references identified 2,495 papers, from which the title and abstract screening process for the economics references and removal of any duplicates resulted in a total of 96 papers as either ‘include or ‘get full paper’ which were ordered for full paper retrieval (2399 references were rejected). Any titles and abstracts from the search for the research question 4 that appeared relevant to research questions 1‐3 were also tagged as such and then re‐screened using the abstract screening checklist in Appendix 2. This process resulted in no further references being identified. 2.2.4 Additional website searches
The searches results for the additional five websites (see above section 2.1.4) identified 611 potential papers for question 1 to 3 (and 280 for question 4). The Xpert HR website search yielded a high number of hits (580 for research questions 1 to 3 and 267 for research question 4 prior to de‐duplication). However, it was felt that the titles/abstracts identified by these searches may not be particularly relevant and the time required to screen these results would only yield minimal relevant material. In order to determine this a ten per cent random sample of the titles/abstracts were selected and screened using the appropriate forms by the NICE team. Ten per cent of the sample were considered potentially relevant and coded as ‘get full paper’. Given the small percentage it was agreed that the remaining titles/abstracts from these search results would not be screened at this stage. This therefore left 31 search results for review questions 1 to 3 and 13 search results for review question 4 from the remaining four additional websites searched. Seven effectiveness titles/abstracts were identified as potentially relevant following title/abstract screening and full papers were ordered for retrieval. 2.2.5 Number of papers ordered
The result of the title/abstract screening process was a list of references coded as ‘includes’ or ‘get full paper’ from the original effectiveness and cost‐effectiveness literature searches, the additional website searches and the suggestions from experts and the PDG for research questions 1‐3. For some of these categories it was possible to identify if a title/abstract was specifically relevant to research question 3 and the full papers were ordered for retrieval. Where it was not possible to identify in a category which of the titles/abstracts were specifically relevant to research question 3 all of the references (ie those relevant for research questions 1, 2 or 3) were ordered for full paper retrieval for this review. Table 2.1 summarises the numbers of titles and abstracts coded as include or get full paper for each of these categories. IES, IWP, ScHARR
13
Table 2:1: References passing Q3 title and abstract sift by source 4
Source
Q1-3 Effectiveness primary studies search
Number of title and
abstracts screened
Number coded as include or
get full paper for research
questions 1-3
15,345 5
654
2,495
96
309
102
5,471
0
Q4 Economics primary studies and review-level
studies search
353
06
Q4 Effectiveness review-level studies search
716
0
Q1-3 Additional website searches∗
31
7 (effectiveness)
Q4 Additional website searches
13
0
Effectiveness references suggestions provided
by experts and PDG members
18
2
Economics references suggestions provided by
experts and PDG members
0
0
Q1-3 Economics primary studies and reviewlevel studies search
Q1-3 Effectiveness review-level studies search
Q4 Effectiveness primary studies search
∗ Includes four websites suggested by PDG. (It was decided not to fully screen the Xpert-HR website
see section 2.2.4) 2.2.6 Full paper screening
Of the 759 7 primary effectiveness and cost‐effectiveness papers ordered as ‘includes’ or ‘get full papers’ following the abstract screening stage, 753 (99 per cent) have been retrieved 8. That leaves six outstanding papers (all effectiveness) which had not arrived at the agreed cut off date for processing of potentially relevant primary studies. Detailed full paper screening checklists were developed to allow a more accurate assessment of whether each paper met all the inclusion and exclusion criteria (see Appendix 3 for details of the three full paper screening checklists developed). The full 4 These numbers are slightly different from those presented in previous reports (eg the Mapping Report) as some duplicates have been excluded and search results re‐allocated between the two elements of the review and between research questions 1 to 3 and research question 4 5 ie 15,297 papers from the initial database search and 48 from the initial website search. 6 Papers from the searches for the research question 4 review which were tagged as a research questions 1 to 3 paper, then excluded when screened against the research questions 1 to 3 checklist therefore some of the figures presented do not match those in the Mapping Report. 7 ie 654 from the effectiveness search, 96 from the cost‐effectiveness (economics) search , seven from the website search and two from Expert and PDG suggestions. This number excludes the papers ordered through reference and citation checking – see 2.2.8 and 2.2.9 below and includes papers subsequently identified as further duplicates (eg originating from the same initial study). 8 Including 657 effectiveness papers, 96 cost‐effectiveness papers. 14
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
paper screening checklists were based on all the inclusion and exclusion criteria detailed in section 2.2.1. Some of these inclusion and exclusion criteria were expanded to reflect the detail in the scope or parameters discussed and agreed by the PDG. This detail enabled a better categorisation of papers included at the full paper screening stage and ensured that any data relevant for the economic modelling was identified and coded appropriately. The additional criteria are set out below. Interventions, programmes, policies and strategies:
■ Delivered in a primary care setting and/or workplace setting and/or planned, designed, delivered, managed or funded in collaboration with primary care providers and/or employers. These interventions, policies, programmes or strategies can be delivered by a number of providers (such as voluntary, private, statutory sectors) and/or in various settings not just workplace or primary care settings as long as they are fully or co‐planned, designed, delivered, managed and/or funded in collaboration with employers and primary care settings. Primary outcomes
■ Work absence related primary outcomes to be considered (but not limited to): ■ Return to work (paid and unpaid) after re‐occurring long‐term sickness. □ original role with same hours □ original role with reduced hours □ alternative role with same hours □ alternative role with different hours ■ Reduced incidence of recurring (>1 episode) long‐term sickness ■ Shorter periods of recurring sickness absence ■ Reduction in number of sick days taken ■ Improvements in individual and/or population‐level health status which enables remaining in work following sickness absence incidences ■ No effect on return to work after re‐occurring long‐term sickness or no effect on number of sick days taken ■ Cost effectiveness of intervention/policy/strategy or programme. IES, IWP, ScHARR
15
Study design for effectiveness papers:
At the full paper screening stage the study design of all included papers was classified into one of the following categories to allow grouping of papers for data extraction and quality assessment: ■ RCT ■ Controlled before and after ■ Cohort ■ Case control ■ Before and after ■ Interrupted time series ■ Other (please specify). Study design for cost effectiveness papers:
At the full paper screening stage the study design of all included papers was classified into one of the following categories to allow grouping of papers for data extraction and quality assessment: ■ Cost benefit analysis (CBA) ■ Cost effectiveness ■ Cost utility ■ Other (please specify). Mixed studies ■ If the study was a combined population, topic or location can the public health data be disaggregated. Mixed studies are ones that included data on treatment and an intervention, policy, strategy or programme relevant to this rapid review, or covered multiple population groups or mixed locations which met both inclusion and exclusion criteria. Mixed studies would only be included if the data relevant to the specified inclusion criteria could be sufficiently disaggregated. 16
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
Study types excluded
■ Studies which describe the relationship between health/ill‐health and re‐occurring long term sickness absence (ie correlates studies or non evaluative studies of an intervention, policy, programme or strategy). ■ Books and book chapters ■ Studies that deal solely with the provision of clinical diagnosis, treatment (including pharmacological or therapeutic interventions) and management of conditions associated with short and/or long term sickness. 2.2.7 Review-level material
As noted above in Section 2.1, searches were also made for relevant review‐level material, such as effectiveness and cost effectiveness reviews or meta‐analyses of RCT’s and longitudinal studies. All 102 review‐level references assessed (following title/abstract screening) to be potentially relevant to research questions 1 to 3 were ordered for full paper retrieval and retrieved – see table 2.2. A full paper screening checklist was developed and used to screen these reviews (See Appendix 3). Additional details on the screening criteria for review studies were also specified as follows: Population inclusion criteria
■ The review must wholly or partly cover evaluations of an intervention/policy/ strategy/programme which aims to prevent the re‐occurrence of long term sickness absence. Setting inclusion criteria
■ At least one of the studies reported in the review must be concerned with preventing the re‐occurrence of long term sickness absence. Effectiveness study design criteria: ■ The review must include at least one RCT or longitudinal study. IES, IWP, ScHARR
17
Cost effectiveness study design criteria: ■ The study must contain effectiveness studies or economic evaluations with cost effectiveness, cost benefit, cost utility, cost consequences, cost minimization or net monetary (cost) benefit data. If a review met the full paper screening inclusion and exclusion criteria its reference lists were then checked by two reviewers to identify potentially relevant additional primary studies. Any duplicates with primary study references already obtained were removed and titles/abstracts ordered for retrieval. Abstracts of any primary studies thus identified were then screened using the appropriate abstract screening checklist and if accepted/included, they were added to the references requested for full paper retrieval. As Table 2.2 indicates no additional primary level studies were identified for research question 3 from the reference lists of the 43 identified effectiveness reviews none outstanding) and no economics review‐level papers were identified. Table 2:2: Review level studies ordered, pending and included for reference tracking
Effectiveness review-level material for
reference checking:
Economics review-level material for
reference checking:
Review
studies
ordered
Review studies
assessed to be
relevant to
research
questions 1 - 3
Number of primary
studies identified from
reference checking of
relevant reviews
relevant to research
questions 3.
102
43
0
0
0
0
Source: IES/IWP/ScHARR
2.2.8 Reference tracking
Additionally to the reference checking of included review studies, the reference lists for all primary studies that met the inclusion criteria lists were examined to identify any additional relevant references. To simplify the process and avoid duplication the reference checking for papers included in the review of research question 3 and those from the review of research questions 1 and 2 was combined. A list of any additional references thought to be relevant was checked against the Reference Manager databases of literature search results. Abstracts were obtained for any references not identified in the Reference Manager databases (previously identified references would have already been screened) and they were then screened following the same process described above for titles and abstracts generated by the search of electronic databases. One further, additional reference was identified from the cost effectiveness studies, but was excluded at the full paper screening stage. A further 29 additional references were identified from the effectiveness studies and papers ordered for full 18
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
paper screening. One further paper (28 were excluded) has been included in this review as a result of this exercise. 2.2.9 Citation searching
The citations of all included primary studies were also searched for by one reviewer using Web of Science and CINAHL to determine whether any additional primary studies citing these included references had been missed. Citation searching for the cost effectiveness and effectiveness included papers identified 368 potential cost effectiveness and effectiveness references. These have been checked against the original reference manager databases and any new primary study references ordered for full paper retrieval. Sixteen effectiveness and eight cost effectiveness primary studies were ordered and full paper screened (two effectiveness papers had not arrived at the agreed cut off point). No further papers were identified from this process for inclusion in this review. Table 2:3: Primary studies ordered, pending and included in the question 3 review
Primary studies ordered
Primary studies included
654
3 (6 pending)
96
3 (in cost effectiveness
review and also included in
effectiveness review)
Additional website searches-effectiveness
7
0
Additional website searches – cost
effectiveness
0
0
References suggested by PDG and experts –
effectiveness
2
0
Reference suggested by PDG and experts economics
0
0
Reference tracking of included papers
(effectiveness)
29
1
Reference tracking of included papers (cost
effectiveness)
1
0
Citation searching of included papers
(effectiveness)
16
0 (2 pending)
Citation searching of included papers (cost
effectiveness)
8
0
Effectiveness search
Cost-Effectiveness search
Other sources
Source: IES/IWP/ScHARR
IES, IWP, ScHARR
19
2.2.10 Summary of effectiveness studies identified for inclusion
As Table 2.3 outlines, 708 9 effectiveness primary studies were thought to be relevant to this research questions 1‐3 and full papers ordered and all but eight have been received (99 per cent retrieval rate) and screened. One reviewer checked all of the received papers against the inclusion criteria using the full paper screening list checklist given in Appendix 3 and at least one in ten were double checked by a second reviewer. As a result of this process, 696 papers were excluded and four studies identified as relevant to this review covering research question 3. An additional three studies were also identified as relevant to the effectiveness component (as well as cost effectiveness) when screening the cost‐effectiveness studies. For the sources of all possible studies to answer this question, and the points at which studies were excluded, see Figure 2.1. The following four effectiveness papers were identified for inclusion using the above process and went forward for data extraction and quality assessment: ■ Haugli, L., Steen, E., Laerum, E., Nygard, R., and Finset, A. (2001), ‘Learning to have less pain ‐ is it possible? A one‐year follow‐up study of the effects of a personal construct group learning programme on patients with chronic musculoskeletal pain’, Patient Education and Counselling, vol. 45, no. 2, pp. 111‐118. ■ Holopainen K, Nevala N, Kuronen P, and Arokoski JPA (2004). Effects of Vocationally Oriented Medical Rehabilitation for Aircraft Maintenance Personnel – A Preliminary Study of Long‐Term Effects With 5‐Year Follow‐up, Journal of Occupational Rehabilitation Vol.14, No. 4, December 2004 ■ Leino P, Kivekäs J, Hänninen K (1994) ‘Effects of Work‐Oriented Fitness Courses in Lumberjacks with Low Back Pain’ Journal of Occupational Rehabilitation, VO. 4, No. 2. ■ Soukup MG, PT, MSci; Glomsrod B, PT; Lonn JH, PT; Bo K, PT, PE, PhD; Larsen S, MSc, DrSc. (1999) ‘The Effect of a Mensendieck Exercise Program as Secondary Prophylaxis for Recurrent Low Back Pain: A Randomised, Controlled Trial with 12 month follow‐up’. SPINE Vol 24, Number 15, pp 1585 – 1592. In addition the following three cost‐effectiveness papers were also identified as relevant to the effectiveness section: ■ Molde Hagen E; Grasdal A; Eriksen, HR (2003) ‘Does Early Intervention with a Light Mobilisation Program Reduce Long‐term Sick Leave for Low Back Pain: A three‐year follow‐up study’ SPINE Vol 28 No. 20 pp 2309‐2316 9 This includes 654 from the initial database and website search plus seven from the additional website search, two suggested by experts and PDG members, 29 from reference tracking and 16 from citation searching. 20
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
■ Steenstra IA; Anema JR ; van Tulder MW; Bongers PM; de Vet HCW; and van Mechelen W (2006) ‘Economic Evaluation of a Multi‐Stage Return to Work Program for Workers on Sick‐Leave Due to Low Back Pain’ Journal of Occupational Rehabilitation 5 November 2006
■ Torstensen TA; Ljunggre, AE; Meen HD; Odland E; Mowinckel P Geijerstam S (1997) Efficiency and Costs of Medical Exercise Therapy, Conventional Physiotherapy and Self‐exercise in Patients with Chronic Low Back Pain: A pragmatic, randomised, single‐blinded controlled trial with one‐year follow‐up. Appendix 4 provides the reference details of the excluded primary studies following full paper screening. Studies were excluded because they failed to meet at least one of the inclusion criteria. As soon as they failed to meet one of the criteria then were excluded. In the appendix the references are ordered by the criterion by which they were excluded. Most were excluded because they did not cover the right population (eg were not employees and/or had not experienced long‐term sickness absence) (76 per cent), but these may well have failed against other criteria too. Some 12 per cent did not report on interventions, strategies, programmes or policies to prevent the re‐
occurrence of long‐term sickness absence and ten per cent were excluded because they were not RCT or longitudinal studies. Again there may have been other reasons for not including them as well. The remaining two per cent turned out to: not to include relevant sickness outcomes, not be written in English, based in the setting with no primary care or workplace involvement (eg secondary care) or otherwise excluded. The eight outstanding primary studies identified through the search process that have not been retrieved by the agreed cut off time for processing of any potentially relevant studies are presented in Appendix 5. 2.2.11 Summary of cost-effectiveness studies identified for inclusion
As table 2.3 outlines, when sifting the list of titles and abstracts generated by the search of electronic databases, 110 primary studies were originally identified as possible papers that satisfied the inclusion criteria for this review. Fourteen studies were duplicates found by two or more of the searches (Abrams, Aldana, Astrup, Gatchel, Karjalainen, Lindberg, Linz, Loisel, Meijer, Monpere, Pinnington, Rutz, Schweikert, Turk), so the final total number of primary studies ordered for retrieval was 96. Two reviewers then assessed these full papers using the economic full paper screening checklist (see Appendix 3). Of these 96 unique primary studies, 93 were ultimately excluded because none satisfied the inclusion criteria. The principal reasons for exclusion were that the studies were not economic evaluations; the studies’ sample populations were either not actually on long‐term sickness absence or had not experienced long‐term sickness absence; separate data were not given for any numbers in a sample that were actually on or had experienced long‐term sickness IES, IWP, ScHARR
21
absence; or the studies’ outcomes did not include re‐occurrence of long‐term sickness in any form. For details of these excluded studies, and the principal reason for their exclusion, see Appendix 4. Three studies were found to satisfy all of the cost‐
effectiveness inclusion criteria and went forward for quality assessment and data extraction: ■ Molde Hagen E; Grasdal A; Eriksen, HR (2003) ‘Does Early Intervention with a Light Mobilisation Program Reduce Long‐term Sick Leave for Low Back Pain: A three‐year follow‐up study’ SPINE Vol 28 No. 20 pp 2309‐2316 ■ Steenstra IA; Anema JR ; van Tulder MW; Bongers PM; de Vet HCW; and van Mechelen W (2006) ‘Economic Evaluation of a Multi‐Stage Return to Work Program for Workers on Sick‐Leave Due to Low Back Pain’ Journal of Occupational Rehabilitation 5 November 2006
■ Torstensen TA; Ljunggre, AE; Meen HD; Odland E; Mowinckel P Geijerstam S (1997) Efficiency and Costs of Medical Exercise Therapy, Conventional Physiotherapy and Self‐exercise in Patients with Chronic Low Back Pain: A pragmatic, randomised, single‐blinded controlled trial with one‐year follow‐up. Fourteen papers were also identified at this stage which contained potentially relevant data for the modelling stage. Figures 2.1 and 2.2 present a diagrammatic overview of the results of this comprehensive searching and screening process. 22
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
Figure 2.1: Process for identifying effectiveness studies
Q4
Effectiveness
search
Q4
Economics
search
Q1-3
Effectiveness
search
Screening of titles & abstracts using abstracts screening checklist
Tagged as
Q1-3
Effectiveness
Tagged as
Q1-3
Effectiveness
Review
references
Screening of titles & abstracts against Q1-3 Effectiveness inclusion criteria
Possible
papers
Possible
papers
Possible
papers
Expert & PDG
suggestions
Screening of full papers using Q3 Effectiveness full paper screening checklist
Definite
included
studies
Definite
included
studies
Definite
included
studies
Reference
tracking
Source: IES/IWP/ScHARR
Final
included
studies
Citation
searching
Additional
websites
IES, IWP, ScHARR
23
Figure 2.2: Process for identifying cost-effectiveness studies
Q1-3
Effectiveness
search
Q4
Effectiveness
search
Q4
Economics
search
Q1-3
Economics
search
Screening of titles & abstracts using abstracts screening checklist
Tagged as
Economic
Tagged as
Economic
Tagged as
Economic
Screening of titles & abstracts against Q1-3 Economics abstracts screening checklist
Possible
papers
Possible
papers
Possible
papers
Possible
papers
Definite
included
studies
Definite
included
studies
Definite
included
studies
Definite
included
studies
Reference
tracking
Source: IES/IWP/ScHARR
Expert & PDG
suggestions
Screening of full papers against Q1-3 Economics full paper screening checklist
Review
references
Final no of
included
studies
Citation
searching
Additional
websites
24
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
2.3 Data extraction and quality appraisal
2.3.1 Data extraction
The study type of each included effectiveness paper was identified using the following algorithm which was adapted from Methods for development of NICE public health guidance (Figure 2.3). Figure 2.3: Algorithm for classifying primary study designs about effectiveness
Comparison
between
interventions/
exposures
No Non-comparative
study (case series,
case study)1
Yes
Experimental
study
Before &
after study
No
Yes
Did investigator
assign
interventions/
exposure
No
No Before & after
Independent
control group
study or interrupted
included in study?
time series5
Independent
control group
included in study?
Yes
Economic
studies6
Yes
Intervention/
controls randomly
allocated?
Yes
Qualitative
studies7
Observational
study
Representative
(random) samples
of the population
No
Randomised
controlled trial
Non-randomised
controlled trial3
Individuals or
groups (cluster\s)
randomised?
No
Yes
Groups selected
by presentation of
outcome?
Exposure &
outcome assessed
at the same point
in time?
Yes
Cluster
randomised
trial3
Individual
randomised
trial3
Case
control
study4
Sample group is
population level or
individual level?
No
Groups followed
forward in time?
No
Ecological
(population)
study1
Cross
sectional
study1
Perspective
cohort
study2
Retrospective
cohort
study2
Source: IES/IWP/ScHARR
The effectiveness data extraction form contained in the Methods for development of NICE public health guidance was adapted to reflect the parameters of this review – please see Appendix 6 for an example of a completed form. One reviewer extracted data for each full paper using this form. A second independent reviewer checked the IES, IWP, ScHARR
25
data extraction, and any differences were resolved by discussion with a third reviewer. For the cost effectiveness review, the data extraction form contained in the Methods for development of NICE public health guidance was adapted to reflect the parameters of this review and supplemented with questions from the Drummond checklist (Guidelines for authors and peer reviewers of economic submissions to the BMJ, M F Drummond, 1996, on behalf of the BMJ Economic Evaluation Working Party) – please see Appendix 7. One reviewer extracted data for each full paper using this form. A second independent reviewer checked the data extraction, and any differences were resolved by discussion with a third reviewer. Secondary outcomes
If a study is included on the basis that it contains data relevant to the primary research question and outcome, then data on any secondary outcomes will also be reported. The following secondary outcomes are to be considered (but are not limited to): ■ acceptability of the intervention/policy/programme/strategy – content/frequency/ location etc. ■ costs of intervention/policy/strategy or programme ■ identification of any adverse or unintended (positive or negative) outcomes as a result of the intervention, programme policy or strategy. ■ barriers to or facilitators of effective implementation ■ reduction in number and duration of reported and/or recorded sickness absences associated with (but not limited to) the following: □ musculo‐skeletal injuries including back pain □ acute and/or recurring medical conditions □ stress □ mental illness □ alcohol or drug‐related problems □ other long‐term conditions and chronic conditions □ home and family responsibilities ■ increase in number of employers that have introduced policies and procedures to monitor/address sickness absence 26
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
■ increase in number of employers who have made reasonable adjustments in the workplace to enable people to return to work ■ increase in number of employees who are appropriately referred to an occupational health service when they are on long‐term sick leave ■ increase in number of people on long‐term sick leave who liaise with general practitioners and/or physiotherapists or other support staff about their ability to return to work ■ reduction in the number of people who initiate claims under the Disability Discrimination Act 2005 ■ reduction in personal injury claims is about primary prevention and was left out on this basis ■ no effect on any other work related outcome. 2.3.2 Quality assessment for effectiveness primary studies
Quality appraisal was conducted based on the NICE CPHE forms. These forms provide criteria for rating a study based on how robust an example it is of that particular study design. For example, a randomised control trial (RCT) will be rated on how well it meets the defined standards for a robust RCT. Different criteria exist for each type of study design. This means that the quality rating for studies of the same design can be compared with each other (ie an RCT rated ++ is more robust than an RCT rated +). However, quality ratings for different study designs cannot be compared and an RCT rated – is still likely to be provide more robust data than a before and after study rated ++ because an RCT is an inherently stronger study design. It was agreed that the criteria for making the actual quality assessment ratings (++, +, ‐
) should be adapted to reflect study designs found in the social sciences/public health area (eg an RCT would not be downgraded for failure to use complex concealment designs such as double blinding), because such designs are not always possible with intervention studies where the individual delivering the intervention knows what the intervention is. Two independent reviewers assessed the quality of each included study. Any differences in quality assessment were resolved by discussion with a third reviewer or, if agreement could not be reached, details were reported in the review. Appendix 6 gives the quality assessment forms used and a completed checklist is given. The quality assessment checklists contained in the Methods for development of NICE public health guidance were adapted to reflect the parameters of this review – see Appendix 7. IES, IWP, ScHARR
27
2.3.3 Quality assessment for cost effectiveness primary studies
Quality appraisal was conducted using a form based on Drummond (1996). Two independent reviewers assessed the quality of each included study. Any differences in quality assessment were resolved by discussion with a third reviewer or, if agreement could not be reached, details were reported in the review. Appendix 7 gives an example of the data extraction and quality assessment form used 2.4 Synthesis and formulation of evidence statements
2.4.1 Effectiveness studies
The results of the data extraction and quality assessment for each theme identified in the included effectiveness studies were presented in a narrative summary and combined in a summary evidence table. An evidence statement was generated for each theme. Chapter three of the report presents the synthesis of data and evidence statements for the included effectiveness studies. 2.4.2 Cost-effectiveness studies
The results of the data extraction and quality assessment for each theme identified in the included cost‐effectiveness studies were presented in a narrative summary and combined in a summary evidence table. An evidence statement was generated for each theme. Chapter four of the report presents the synthesis of data and evidence statements for the included cost‐effectiveness studies. 28
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
3 Effectiveness Findings
Seven effectiveness studies were identified which met the criteria for inclusion for interventions, programmes and strategies to reduce the re‐occurrence of long term sickness absence. Four of the studies examined interventions based on exercise or physical therapy aimed at reducing absence among sufferers of musculoskeletal disorders (including lower back pain). These are considered under theme 1. One examines the effects of a learning programme on participants’ ability to cope with pain and comprises theme 2. The final two examine multi‐disciplinary programmes (often including physical exercise but supplemented by other measures) (theme 3). Within each category studies are presented in alphabetical order within quality rating (ie with the most positively rated studies first and randomised controlled trials (RCTs) before longitudinal studies). The evidence tables for each of the studies are presented in full alphabetical order (by the first named author) at the end of this chapter. It should be noted that three studies are included in both the effectiveness and cost effectiveness elements of the review. They are all primarily economic evaluations but have findings on the effectiveness of interventions, though not always as comprehensively reported as the preceding three effectiveness studies (although we have found additional papers which further illuminate the findings). The study quality rating attributed to each study may differ between the effectiveness and cost‐
effectiveness element of this review as they are being examined from two different perspectives. The fact that they are included twice should not necessarily imply that any greater weight should attributed to these studies than to any other evidence presented. IES, IWP, ScHARR
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3.1 Theme 1: Exercise and education programmes to
prevent reoccurrence of lower back pain
Four of the effectiveness studies involved interventions which included a physical exercise programme with aim of preventing the recurrence of lower back pain and other musculoskeletal conditions. 3.1.1 Molde Hagen et al. (2003)
This study (rated ‘+’) describes a randomised controlled trial aiming to evaluate the effect and economic benefits of light mobilisation on long‐term sick leave of people with sub‐acute lower back pain in Norway over a period of three years. Patients, aged between 18 and 60, to have been sick‐listed 10 for between eight to 12 weeks for low back pain were drawn from Norwegian National Insurance Offices. Exclusion criteria were pregnancy, recent lower back trauma, cauda equina symptoms, cancer, osteoporosis, rheumatic low back disease, and ongoing treatment for low back pain by another specialist. Patients were randomly allocated to an intervention group and a control group. Five hundred and ten patients were invited to participate in the study, 220 (115 men and 105 women) of the 256 (86 per cent) randomised to the control group agreed to take part and 237 (123 men and 114 women) of the 254 (93 per cent) allocated to the intervention group also agreed. Most (80 per cent) in both groups worked in jobs with heavy physical demands. The mean age of the participants was 40.9 years (40.8 years for the intervention group and 41.1 years for the control group). There were no significant differences (p values not reported) between the two groups in terms of marital status, education, job security, previous sick leave or diagnoses given by primary care physician. Eighty per cent of the participants in both groups were working in occupations with heavy physical demands (undefined). The intervention group were invited to the Spine Clinic within week 12 of their sick leave. They were interviewed and examined by a treatment team consisting of a physician (specialising in physical medicine and rehabilitation) and a physiotherapist. Special attention was give to the description of daily activities and the restrictions caused by LBP in addition to psychosocial conditions at home and at work. Unless symptoms and clinical findings indicated any serious spinal disease, the patients were informed about the good prognosis and the importance of staying active to avoid development of muscle dysfunction. They were encouraged to take daily walks. All patients were advised and instructed individually by the physiotherapist in coping with daily activities at home and at work and how to resume normal activities. The 10 The term ‘sick‐listed’ is used in a number of the studies included in this review and we interpret it to mean off work on sick leave. 30
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
patients were encouraged to contact the spine clinic whenever they wanted. Reports from the examination were sent to the patients’ primary care physician and to the National Insurance Office, with diagnoses, recommendations concerning further diagnostic tests, treatment, job and, if possible, recommendations concerning further sick leave. The control group participants were invited to the local insurance office to complete the same questionnaire as the intervention group, but were treated by a primary health care team, rather than the Spine Clinic. Participants in both groups answered the same standard questionnaires at three, six 12 and 24 months after the sick leave started. Sick leave data were collected from both groups at 3, 6, 12, 24 and 36 months after the initial sick leave. Data were taken from National Insurance Offices and therefore presumably validated. Overall, 13 cases were discontinued at the three‐year follow‐up and a further five cases were deceased at three years – these were treated as missing as their deaths were not related to LBP. These data were used to assess the outcomes of the study. Odds ratios adjusted for gender, age, education and marital status were calculated and ANOVA was used to test the difference between the intervention group and the control group in the number of days of sickness compensation. Primary outcomes
Sickness absence data are reported at the one, two and three year follow‐up stages. Over the three years of observation, the intervention group had significantly fewer days of sick leave (average 125.7 days per person) than the control group (169.6 days per person). 11 The significant differences between the two groups occurred during the first year mainly to a higher level of return to work during the first year (after 12 months 69 per cent of the intervention group were ‘off sick leave’ 12 (although it is not stated if this equates to being back at work) compared with 57 per cent of the controls). There was no significant difference for the second or third year. There was no significant difference between the groups as to their experience of further episodes of sick leave over the three year period: 62 per cent of the intervention group and 61.4 per cent of the control experienced at least one such episodes. 13 11 The 95% confidence interval for the intervention group was 110.8 days to 140.5 days and for the control group was 151.9 days to 187.3 days). 12 The relative risk (RR) of the intervention group being off sick leave (ie at work) compared with the control group was 1.2 (95 per cent confidence limits). 13 No statistical significance data presented. IES, IWP, ScHARR
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The study authors concluded that the intervention is effective in speeding the return to work and has no deleterious effects on long‐term attendance, although there is no long‐term improvement in the proportion of those at work at the three‐year stage. The study authors consider that this may be due to the length of the treatment at the Spine Clinic being too short and implies follow‐up consultations may be important (only 25 per cent of the intervention group participants contacted the Spine Clinic after the initial visit). Secondary outcomes
At the six‐month follow‐up stage, patients in the intervention group were less likely to use bed rest 14 and more likely to use stretching 15 and walking 16 to cope with their back pain compared with the control group. This effect diminished over time. At 12‐
month follow‐up, the only significant difference between the groups was in the use of stretching 17. No data are presented for the two and three year follow‐up points. Limitations of the study
The authors point to the fact that the intervention was relatively short. Participants were invited to re‐contact the spine clinic but only 25 per cent took up this offer. The study does not provide any information about what type(s) of treatment the control group received while in primary care. 3.1.2 Soukup et al., 1999
This study (rated ‘‐’) involved a randomised controlled trial in which an exercise and education and training programme (called the Mensendieck approach) was delivered to a group of employees in Norway and their subsequent medical and employment related outcomes compared with a group of similar employees over a period of a year. A total of 77 study participants were recruited through advertising in local media and referrals from doctors and other clinical practitioners in South Eastern Norway. Of these, 69 took part in the full trial, eight dropped out (five from the Mensendieck 14 RR = 0.66 [95 per cent CI] 15 RR = 1.62 [95 per cent CI] 16 RR = 1.29 [95 per cent CI] 17 RR = 1.39 [95 per cent CI] 32
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
group 18 and three from the control group) 19. The participants were men and women aged 18 to 50 (with an average age of 40 in the intervention group and 39 in the control group) who had experienced one or more episodes of pain to the lumbar region resulting in professional treatment or sick leave from employment (the precise number who had taken sick leave prior to the study is not stated, but the average number of sick leave episodes and days of sick leave are provided). At the time of their enrolment to the trial, participants’ medical treatment had finished and they had returned to work. Various exclusion criteria were applied to eliminate factors that could have confounded results (including previous back surgery, pregnancy, specific rheumatological diseases, spondylolisthesis, spinal tumour, spinal fracture, drug or alcohol abuse and documented mental illness) and ethical permissions obtained. On entry to the trial participants were given a brief medical examination and filled in a questionnaire about their medical history, experience of lower back pain, days of sick leave (in previous three years), demographic details and other health related and well‐being factors. Thirty‐four of the participants took part in the intervention. The aim of the Mensendieck programme was to teach participants ergonomic principles for movements of daily activities and improve their knowledge of how to prevent lower back pain. The training sessions involved a selection of exercises and back management techniques administered in 20 group sessions (consisting of between six to ten participants) of 60 minutes each over a period of 13 weeks, each instructed by a Mensendieck‐educated physical therapist. The exercises included isometric, dynamic, stretching and co‐ordination movements focussing on the pelvis, hip, back and abdomen The educational elements included the anatomic and physiological principles of the spine and ergonomics. In detail the hour involved ten minutes warm‐
up, five minutes of leg, hip and buttock stretching, a 35 minute information session combining ergonomic information and pelvic, hip and abdominal exercises, five minutes stretching for the lower extremities, pelvis and back and a five minute relaxation session. According to a basic principle of the Mensendieck approach, special attention was paid to body awareness and the way to apply the ergonomic knowledge in specific, real‐life situations. The control group (of 35 participants) took part in the same data collection exercises as the intervention group. At the beginning of the study they received some information about the Mensendieck approach but did not attend any of the training sessions. There were no significant differences at the baseline stage between the control and the treatment group other than the former were more likely to participate in regular exercise during their leisure time 18 for reasons of pregnancy (one) changes in work patterns making it difficult to schedule the intervention (3) and none given (1) 19 two were disappointed with being allocated to the control group and one moved out of the area. IES, IWP, ScHARR
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The study found that adherence (assessed by recording individuals’ frequency of participation in the group sessions) to the Mensendieck programme was 86 per cent on average (range 65 per cent to 100 per cent). Primary outcome
The study found that ten out of 34 in intervention group and 11 out of 35 of control group were reported as taking sick leave in the one year follow‐up period, with the Mensendieck group absent for a total of 299 days sick (mean number of days was 30 with a range from 2 to 186) and the control for 416 days (mean number of days was 38 with a range of 2 to 98). One participant in the Mensendieck group was absent for 186 days (no other information about this person was provided). The results are presented with and without this outlier. With the outlier included there was no significant difference (no p value reported) in mean days lost to sick leave between the intervention (29.9 days) and control group (37.8 days). However, once the outlier was excluded, a significant difference (p = <0.01) between the intervention group (12.6 days) compared with the control group (37.8 days) was found. Secondary outcomes
At the 12 month follow‐up point the incidence of reported lower back pain was significantly less (p = <0.05) in the Mensendieck group, compared with the control group. Eleven of the 34 participants in the programme reported recurrent lower back pain episodes, compared with 20 of the 35 in the control group. Furthermore, the number of recurrent episodes of reported lower back pain was lower (no further details provided) and the gap between episodes of lower back pain longer in the Mensendieck compared with the control group (p = <0.05). The study also found a significant increase (at p = <0.05) in self‐reported participation in physical exercise among the Mensendieck group compared with the controls (no further details reported). The study looked at lower back function and general functioning and although it found a reported increase (no further details provided) in the former among the Mensendieck group, the differences between the two groups were not statistically significant 20. Limitations of the study
This study has been quality assessed and rated ’‐‘. 20 ‘p’ value not stated. 34
Interventions, strategies, programmes and policies to reduce the number of employees
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The number of participants is small, although designed to be sufficient for the statistical conclusions drawn. The authors point out that the participants were self‐
selected which may have resulted in a study sample with high motivation for physical training. However, most secondary prevention programs for lower back pain are based on voluntary participation. The self‐reported measures for sick leave and lower back pain episodes may be affected by recall bias, but any bias should be similar for both groups. The results are significantly affected by a single outlier (about whom no further information has been found) Intervention and outcomes are based in a bio‐medical approach, which may be an incomplete consideration of factors (such as personality, motivation and emotional issues) critical to the events studied, especially in light of the fact that pain and reports of pain are more commonly understood now in terms of a bio‐psychosocial model of health. 21 3.1.3 Holopainen et al., 2004
A longitudinal cohort study (rated ‘‐‘) examines the effects of vocationally oriented medical rehabilitation (VOMR) 22 on the physical symptoms (including lower back pain), sick leave and perceived work ability of aircraft maintenance personnel in the Finnish Airforce. In this study, 20 machinists with an average age of 37 (sex not reported) from the Finnish Air Force voluntarily participated in the VOMR course. Each had been working in their role for at least three years, had experienced musculoskeletal symptoms causing them to take at least 60 days sick leave over the past two years and did not have any other symptoms which might inhibit rehabilitation. A range of baseline data was collected from participants with further data collected six months and five years after the intervention. There was no control or comparison group. The intervention was administered in two phases. The first took place over a period of 12 days. Two groups of participants (each comprising ten machinists) were given a physical examination by a physician and a physiotherapist and a rehabilitation plan was established. Each participant then took part in a series of physical training exercises (including water‐based and gymnasium‐based exercises) and lectures (eg 21 A bio‐medical approach is one which is based on a conceptual model of illness that excludes psychological and social factors and includes only biological factors in an attempt to understand a personʹs medical illness or disorder. Where as a bio‐psychosocial adopts a conceptual model that assumes that psychological and social factors must also be included along with the biological in understanding a personʹs medical illness or disorder. 22 An approach which consists mainly of physical exercise and training in ergonomic techniques. IES, IWP, ScHARR
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covering practical physical and relaxation exercises)provided by a physician, physiotherapist, a physical training instructor, a psychologist and a specialist in ergonomics (who provided an evaluation of work techniques and postures and vocational exercises). The second phase (involving similar but shorter interventions) took place over five days, six months after the first sessions. Prior to each session participants completed a questionnaire which collected data on the subjective severity of neck‐shoulder and low‐back pain (measured on a visual analogue scale), visits to physicians, sick‐leave days because of musculoskeletal symptoms. Physical measurements were also taken. The same data was collected five years later (from all 20 participants). Primary outcome
Self‐reported sick leave significantly decreased (p= < 0.05), from a mean of 4.6 days in the previous six months to zero in the six month period prior to the five‐year follow‐
up. The authors suggest that the reduction in sick leave may have been due to the greater physical activation which in turn may be attributed to the rehabilitation regime (although the lack of a control group severely limits the confidence that can be placed in such a conclusion). Secondary outcomes
The self reported severity of low‐back pain was significantly lower (no further details provided) at both the six month and the five year points ((p= < 0.01), although no statistically significant 23 changes (no further details available) occurred in self‐
reported neck pain or reports of the physical and mental strain of work. The physical measurements showed a significant increase (no further details available) of the measured range of motion of the cervical spine 24 ((p= < 0.01), and also in the dynamic strength of the abdominal and back muscles and strength of the upper arms ((p= < 0.01), level). The number of self‐reported exercise breaks at work increased 25 between the first and second intervention and the increase was sustained at the five year point (99 per cent confidence level). 23 ‘p’ values not stated. 24 For example left rotation of the cervical spine improved from a mean of 66.8 degrees rotation to 71.3 degrees after six months. 3 From a mean level of 0.1 times a week to a mean of 2.6 times a week. 36
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
The limitations of the study
The study is rated ‘‐‘. It is based on a small number of cases (20), although all are followed up over a period of five years and the study does not include a control group. The authors argue that setting up a control was practically impossible and may have been unethical (given the time period involved) but accept it is a limiting factor. The setting of the study, ie within a military environment in Finland, and the selection criteria used may limit its generalisability. 3.1.4 Leino et al. (1994)
This prospective (non randomised) controlled study, rated ‘‐‘, examined the changes in fitness, health and work ability among lumberjacks employed by two companies in Finland who had been off sick with low back pain (LBP) but were back at work and had participated in a one‐week work‐oriented physical fitness course. All the lumberjacks working for two large Finnish companies (one based in the north and the other in the east of the country) received a questionnaire on lifestyle, working conditions, health and work ability. There were 1,556 responses (82 per cent of the population). All respondents were male. The lumberjacks were invited to apply for a fitness course through information in company newsletters and from managers and occupational health staff. They were selected (the basis for selection is unclear) using the information in the questionnaire (which formed the baseline for the study). The inclusion criteria described in the paper was that participants had suffered ‘short‐term work disability’ (defined as up to 30 days) because of LBP in the past year. There were no restrictions made as to age or the occurrence of other diseases. No other inclusion or exclusion criteria are reported. Some 87 study participants were allocated to the intervention group and 61 for the control comparison group. The intervention involved a seven‐day residential fitness course at a school of forestry or a school of sports. The course was led by a physiotherapist or an instructor in physical training and lasted 12 hours (sic) each day, apart from the first and last day. Courses were provided free of charge and 80 per cent of salary losses compensated. Eight courses were run with ten to 12 men in each, all from the same company, in each course. Most of the time was spent exercising, but the course also included lectures on spine structure and function and work ergonomics and fitness tests. An individual exercise program was also developed to be followed at home by the participants. The main goal of the courses was get the participants to exercise during their leisure time. The main intervention was followed by a two‐day reinforcement session six months later (no further details about this session are provided). No details were provided about what, if anything, was delivered to the control group. IES, IWP, ScHARR
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Muscle function and oxygen consumption tests were administered at the beginning of the course and repeated after six months during the reinforcement session six months later. A follow‐up questionnaire was sent to the course participants and the control group one year after the course finished. The questionnaire asked about the extent of physical activity perceived fitness and health, and medical symptoms. Baseline and follow‐up questionnaires were received from 90 per cent of course participants and 67 per cent of the controls. Sickness absence data were obtained from company records. Primary outcomes
The average number of spells of sickness absence fell from 0.20 (in the year prior to the intervention) to 0.11 (during the 12 months after the intervention) compared with 0.25 and 0.23 among the control group. However, this was not statistically significant between the groups (p values are not reported). The average number of days off sick fell from 2.7 (in the year before) to 2.2 (in the year after) among the intervention group but rose (from 2.4 to 4.0) among the control group. However the change between groups was not statistically significant at 95 per cent confidence limits, but is at the 90 per cent level (p = <0.10). Secondary outcomes
Self assessed back symptoms among the intervention group and the controls were at a similar level before and remained so six months after the intervention (p values not reported). Work ability 26 (self‐assessed) increased significantly among the intervention group (from 7.0 to 7.5 – on an unspecified scale) (p = <0.05), but remained at similar levels among the controls (6.5 and 6.4) (p values not reported). The difference between the intervention group and the controls at the follow‐up stage was significant (p = <0.05). Self reported leisure time increased in both the intervention group and the control group (p = <0.01). The costs per course were reported as 50,000 Finnish Markka (FIM) and the cost refunding of lost salaries (80,000 FIM) (no other information on costs provided). 26 ‘work ability’ was computed from the answers (based on a scale of 1 to 5) to four questions covering the physical and mental strenuousness of work, subjective ability to work and the need for ‘repose at leisure’. 38
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
Limitations of the study
The study has been quality assessed and rated ‘‐‘. The authors draw attention to the ‘asymmetrical response’ to the follow‐up questionnaire, which negatively affected the control group and meant that they were smaller in number than the intervention group. However, this problem did not affect the collection of sickness data from company records. Both groups reported an increased level of leisure time physical exercise at the follow‐
up questionnaire. There may have been communication between the two groups or the authors suggest that the baseline questionnaire may have had ‘an interventional effect’. The authors felt that the course might have been seen as holiday for the participants and generated the small positive impact. However, they felt it more likely that the increased physical capability following the intervention may have directly influenced their functional capacity. Equally, they felt that the participants may also have had an increased belief in the controllability of back pain especially through exercise. In addition the reviewers identified some gaps in the information provided in the paper, for example the process for selecting participants of the intervention group and the control group is unclear. Evidence statements for Theme 1
Four studies present some, mainly limited, evidence of the positive effects of interventions
involving exercise and physical activity on preventing the reoccurrence of sick leave among
employees who had been previously off sick with low back pain.
One RCT study in Norway (rated ‘+‘) found evidence that workers, aged between 18 and 60, on
long-term sick leave with lower back pain who receive consultations with a physician (specialising
in physical medicine and rehabilitation) and a physiotherapist to improve skills to cope with their
condition may be effective at helping workers return to work up to a year after they start sick
leave than comparable people who receive were treated in primary care. In the consultation,
patients received information, reassurance and encouragement to engage in physical activity as
normal as possible and reports were sent to their primary care physician and local national
insurance office. Although the study found significant differences in the average number of sick
leave days at the 12-month point between the intervention group and the control group, there
was no significant difference between the groups in the proportions experiencing further sickness
episodes over the three year period. Therefore there is insufficient evidence from this study to
suggest that this intervention was effective in preventing the re-occurrence of sickness absence in
the long-term. (Molde Hagen et al, 2003).
There is limited evidence from one Norwegian RCT (rated ‘-‘) to suggest that the delivery of a
physical exercise and education and training programme (involving stretching and relaxation
exercises and information on ergonomic and physical exercises), called the Mensendieck
IES, IWP, ScHARR
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approach, delivered by specially trained physical therapists to male and female employees with a
history of musculoskeletal symptoms, such as lower back pain, can result in lower reported
recurrence of lower back pain and a reduction in re-occurring long-term sickness absence
(although the results of the study are limited by the exclusion of one outlying case). (Soukup et
al. 1999).
There is limited evidence from a Finnish cohort study (rated ‘-‘) to suggest that an intensive
exercise programme (involving water and gymnasium-based exercises and lectures on practical
physical and relaxation exercises) delivered to a small group of machinists in a military setting by
provided by a physician, physiotherapist, a physical training instructor, a psychologist and a
specialist in ergonomics can result in lower levels of re-occurring sickness absence and reported
re-occurring back pain (Holopainen et al., 2004).
These two studies suggest that the positive impact may be enhanced by increasing the amount of
sustained physical exercise taken by participants (Soukup et al. 1999 and Holopainen et al, 2004).
There is limited evidence from a prospective controlled study (rated ‘-‘) which examined changes
in fitness, health and work ability among male lumberjacks employed by two companies in Finland
who had been off sick with lower back pain for up to a 30 day period but were back at work that a
free of charge (with 80% of salary losses compensated) intensive one-week residential workoriented physical fitness course (involving lectures, fitness tests and exercising - lasting 12 hours
for 5 days), led by a physiotherapist or instructor in physical activity; followed by a reenforcement session 6 months posts the residential course had a positive but not statistically
significant effect on the frequency and average number of days of subsequent sick leave. Selfassessed ‘work ability’ increased after the intervention and was assessed significantly higher than
among the control group at the six-month follow-up. Self-reported leisure time increased in both
groups in the six months after the intervention. (Leino et al. 1994).
3.2 Theme 2: Pain management through group learning
3.2.1
Haugli et al. (2001)
A randomised controlled trial (rated ‘‐‘) examined the effects of a group learning programme, based on a phenomenological epistemology and Kelly’s personal construct theory, 27 on participants ‘ experience of pain and sickness absence. One hundred and seventy‐four adults (aged between 20‐59 years), drawn through social insurance offices in Oslo in Norway, volunteered to participate in the study. Inclusion criteria were that participants had to have recurrent episodes of 27 The paper explains that Kelly argues that perception and learning are active processes during which an individual constructs his or her own reality, In Kelly’s view chronic pain should not be understood in terms of isolated sensory events, but rather as an integral part of the person’s construction of reality. 40
Interventions, strategies, programmes and policies to reduce the number of employees
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musculoskeletal symptoms and have been absent from work (for unspecified reasons) for at least four of the previous 52 weeks. Individuals with a history of drug or alcohol abuse or a serious disease were excluded. Each of the initial participants completed a baseline questionnaire before the intervention, which collected data on personal characteristics, experience of pain (eg using self‐reported visual analogue scales (VAS 28)), sickness absence and consumption of health care. Ninety‐two of the volunteers were randomly allocated to the intervention group and 82 to the control group. The control group received standard care (mainly analgesic medication and in some cases physiotherapy), while the intervention group additionally took part in the learning programme. The learning programme participants met in small groups (with six to ten people), each led by two specially trained group counsellors, for four hours every fortnight for a period of eight months. Fourteen participants did not turn up to the first meeting and nine attended fewer than five meetings and were thus recorded as drop‐outs, therefore 69 people were counted as full participants throughout the learning programme. All study participants were given further questionnaires to complete, covering similar ground to the baseline survey, one month and one year after the treatment finished. The first received a 74 per cent response and the latter a 70 per cent response (in each case the response rate from the control group was lower than for the intervention group: 67 per cent compared with 80 per cent and 54 per cent compared with 84 per cent). Thus the final questionnaire was completed by 77 29 people (84 per cent of the initial sample) from the intervention group and 44 (54 per cent) from the control group. The learning programme was based on phenomenological perspectives and Kelly’s personal construct theory and focused on self‐awareness and self‐discovery, sharing and listening to each other. It included experience‐based exercises eg creative drawing, moving to music, guided imagery, use of metaphors, relaxation and awareness exercises. Primary outcome
The study did not find a significant effect on participants’ self‐reported sickness absence from work between the baseline and the year 1 follow‐up. Absence fell by 44 per cent in the intervention group (from a mean level of 93 days to 65 days one month after the intervention and 52 days after one year) and by 30 per cent in control group 28 For instance participants were asked ‘ on a scale of 0 to 100 where 0 is no pain and 100 is unbearable pain, how much pain did you have during the last week?’ 29 This suggests that some of the respondents to the intervention group final questionnaire had not attended the full programme ie had been categorised as drop outs. IES, IWP, ScHARR
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(from 102 days through 84 days to 71 days). The difference in the days absent at the year 1 follow‐up between the intervention and control groups was not significant (p = 0,28). No other statistical data reported. The authors also looked at participants’ self‐reported receipt of disability benefits (given to patients with more than one year of sick leave). The proportion in the intervention group receiving benefits increased from 24.7 per cent (n = 19) (baseline) to 37.7 per cent (n = 29) ((one year follow‐up) 30 and from 20.5 per cent (n = 9) to 59.1 per cent (n = 44) in the control group (p = 0.042). The difference between the intervention and control groups in the prevalence of rehabilitation/disability benefits and pensions one year after the intervention was statistically significant (p = 0.042 chi‐
square). No other statistical data reported. Secondary outcomes
The participants in the learning programme (intervention group) reported a significant (p = 0.03) reduction in pain (scored on a visual analogue scale (VAS)) between the baseline and the one‐year follow‐up, while the scores of the control group were almost identical at both points (no p values reported). (The scores in the intervention group fell from a mean of 53 to 43.9 and were 55.2 and 54.8 in the control group). At the one year follow‐up point, the self reported pain scores were significantly lower in the intervention group than in the control group (p = 0.015). Significant increases in the intervention group’s self‐reported ability to cope with pain (p = 0.04) between baseline and the one year follow‐up were also reported (ie from 59.8 to 66.4 on a visual analogue scale compared with a fall from 61.3 to 58.1 in the control group (no p values reported). The participants in the learning programme significantly (95 per cent confidence) reduced their self‐reported healthcare consumption 31 one month after their programme finished and maintained this a year later. 32 There was a significantly (95 per cent confidence) lower level of healthcare consumption among the intervention group compared with the control group at both follow‐up points after the 30 No data for one‐month follow‐up. 31 As measured by self‐reported number of visits to the doctor. 32 Eg 12 per cent of the intervention group said that they had paid no visits to the doctors in the previous six months at baseline, this increased to 35 per cent at the one month point (although it is unclear whether the same measure scale (ie visits over the previous six months) and 40 per cent after a year. 42
Interventions, strategies, programmes and policies to reduce the number of employees
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programme 33, although there was no significant difference 34 in the number from each group receiving physical therapy. Limitations of the study
The study had a number of limitations and it was graded ‘‐‘. The authors point to the ‘high’ drop‐out rate and particularly that the non‐response rate among the control group at the second follow‐up stage was 46 per cent (but the authors note no differences in baseline data between responders and non‐responders in control group, nor between completers and non‐completers in intervention group). Six dependent variables were used and so the authors advise caution in interpreting the relative effect of the intervention on each separate variable. Given the non‐
significant effect on absenteeism, authors also advise caution in interpreting apparent effect on rehabilitation/disability benefits. The reviewers additionally identified that significantly more control group participants were on sick leave at baseline than intervention group participants. The study only had complete data for 77 participants in the intervention group and 44 in the controls. The recruitment and randomisation procedure was open to bias: the paper had a poor description of the randomisation, and selection effects of the opt‐in for participating social security centres (through which individuals were recruited) may limit the generalisability of results. Evidence statement for Theme 2
There is limited evidence from one Norwegian RCT study (grade ‘-‘) to suggest that a learning
programme (based on phenomenological perspectives and Kelly’s personal construct theory)
delivered by specially trained group counsellors to small groups may help adults aged 20-59
experience less musculoskeletal pain and increase their ability to cope with pain. While there is
some evidence that they are less likely to take up disability benefits and make visits to the
doctor, there is insufficient evidence to indicate that such a programme can positively affect selfreported re-occurring sickness absence from work (Haugli, 2001).
33 In comparison to the intervention group, the proportion of the control group who had no visits to the doctors changed from seven per cent, to 16 per cent a month after the intervention finished (see previous footnote) to 24 per cent after a year. 34 No p values available. IES, IWP, ScHARR
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3.3 Theme 3: Multi-disciplinary interventions for lower back
pain
These last two studies examine the effectiveness of multi‐disciplinary interventions for lower back pain. 3.3.1
Steenstra et al.(2006)
This is a randomised controlled study (rated ‘+’) set in Holland which compares the effectiveness of a workplace intervention with a clinical intervention and usual care provided by an occupational physician. It attempts to replicate the evaluation of the ‘Sherbrooke intervention model’ conducted by Loisel et al. (2003) 35. Participants in the study had to be aged between 18 and 65 and on sick leave for between two and six weeks due to lower back pain. Participants were recruited by occupational physicians and 196 (84 men and 112 women) were included. Some (unspecified) causes of lower back pain were excluded as were pregnant women, people with serious psychiatric disorders, people in legal conflict at work and those who had been sick listed due to lower back pain less than one month prior to the current episode. The study effectively took place in two phases. Participants were initially randomly allocated to either a workplace intervention (WI) (described in detail below) group (n=96) or a usual care (UC) group (as outlined by Dutch Occupational Physician guidelines for lower back pain 36.) (n=100). Initial intervention commenced ’right after inclusion and at least 8 weeks after start of sick leave’. Ten dropped out from the work intervention group (eg by returning to work before the intervention could start). In the second phase, almost half (55) of the 112 people who were still off work eight weeks into the study were then randomly allocated to receive either a clinical intervention (comprising a graded activity) and the other half (57) were allocated to receive usual care. Nineteen of the 55 members of the clinical intervention group could not follow the regime (for a variety of reasons eg contraindications, interference from another practitioner, change in job function), and thus dropped out of the study altogether or received usual care. The workplace intervention was a modified version of the Sherbrooke intervention model (Loisel, 2003) tested in Quebec, Canada and consisted of usual care plus a workplace assessment and work modifications based on participative ergonomics which involved all relevant stakeholders. Additionally communication took place between the occupational physician and the patient’s general practitioner to reach a 35 Reported in the review of research questions 1 and 2. 36 Which emphasise the resumption of daily activities and work within two weeks. 44
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
consensus on counselling the employee about a return to work. The clinical intervention consisted of a graded activity programme based on operant behavioural principles designed to meet the patient’s specific needs and circumstances. The programme consisted of 26 one‐hour sessions and ended as soon as the employee returned to work. Thus the study involved a number of different groups (see flow chart below): ■ Those who had work intervention (WI) only and who returned to work (RTW) within eight weeks of the programme starting (n = 44)). ■ Those who had a work intervention (WI) and were still off work after eight weeks and were given a clinical intervention (CI) (n = 27). ■ Those who had a work intervention (WI) and were still off work after eight weeks and did not receive a clinical intervention (CI), ie received usual care (UC) (n = 25). ■ Those who had usual care (UC) only and who returned to work (RTW) within eight weeks of the programme starting (n = 40). ■ Those who had usual care (UC) and were still off work after eight weeks and were given a clinical intervention (CI) (n = 28). ■ Those who had usual care (UC) and were still off work after eight weeks and did not receive a clinical intervention (CI) ie continued to receive usual care (UC) (n = 32). Allocation of groups to particular interventions in Steenstra et al. (2006)
Total participants
(n = 196)
WI
(n = 96)
UC
(n – 100)
RTW
(n = 44*)
RTW
(n = 40)
CI
(n = 27)
UC
(n = 25)
UC
(n = 32)
CI
(n = 28)
* Includes 10 who returned to work before W I started.
Data were collected from participants at baseline (two to six weeks after sick leave began) and at eight, 12, 26 and 52 weeks after the start of sick leave, mainly through questionnaires, although sick leave data were validated by additional information from social security records. IES, IWP, ScHARR
45
Primary outcomes
After the first randomisation stage the work intervention group returned to work on average 30 days earlier than the usual care group (95 per cent confidence intervals (CI): 3.1 to 51.3). Of those that had not returned to work within 8 weeks of commencing the study, workers in the work intervention/usual care group returned 51 days earlier than the work intervention/ clinical intervention group (95 per cent CI =89.4 to 2.7)). Those in the usual care/clinical intervention group returned to work 21 days later than those who just had usual care (95 per cent CI = ‐74.1 to 29.2). The workplace intervention group as a whole (ie n = 96) also had a lower total number of days re‐occurring sick leave during the year of the study than usual care group (ie n = 100). Workers who had the clinical intervention (with or without WI) had the highest level of re‐occurring sick leave 37 and the authors state that their study found ‘no positive effect for the clinical intervention’. Secondary outcomes
No significant differences in secondary outcomes between work intervention and usual care groups were found or between any of the smaller sub‐groups. Limitations of the study
This study has been quality assessed and rated as ‘+’. It is not clear exactly when baseline data were collected and in particular how far in advance of the intervention. It was a study aimed at measuring the cost effectiveness of the various interventions. The effectiveness results are sometimes difficult to identify (eg in some cases relevant statistical information not presented). It is possible that the study was insufficiently powered to detect significant differences in return to work outcomes between the six distinct intervention groups. In a separate paper (Steenstra et al., 2006) point out that only 65 per cent of the CI group complied with the procedure and that there may have been delays referring patients to the CI intervention which may have reduced its effectiveness. 3.3.2 Torstensen T et al. (1998)
This study (graded ‘+’) is based on a randomised control trial set in Oslo in Norway which aimed to evaluate the relative effects of medical exercise therapy (MET) 37 No statistical significance data provided. 46
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
conventional physiotherapy (CP) and self‐exercise on patients with chronic lower back pain (LBP). A total of 210 patients from 22 social security offices in Oslo were recruited to take part in the trial. There were 105 men and 105 women and their average age was 41.6. To be included patients had to be aged between 20 and 65, had lower back pain, in employment but on sick leave for at least eight weeks 38. Exclusion criteria included physical disorders (such as spondylolisthesis, hip arthrosis or previous back surgery) which would difficult to follow the treatment programme. Patients with psychological disorders such as depression were also excluded. Patients were given a standardised assessment by a physician and 208 were included and randomly allocated to one of three groups: ■ Medical exercise therapy (MET) group – who received specially designed exercises for mobilising hypomobile areas and stabilising other parts as required by the individual case. Patients are given seven to nine different exercises which they repeat 20 or 30 times each graded to their particular condition and involving the use of specialised equipment. The sessions (involving groups of up to five at a time) were delivered by specialist physiotherapists. Patients received three one‐
hour treatments a week for 12 weeks. ■ Conventional physiotherapy (CP) group – received standard physiotherapy (eg application of heat and cold, massage, electrotherapy, stretching exercises etc. at the discretion and based on the judgement of the physiotherapist delivering the session. Again treatments (involving one patient at a time) lasted an hour and were delivered three times a week for 12 weeks. ■ Self‐exercise (SE) group – these patients were asked to take an hour‐long walk three times a week for 12 weeks at a time and in a manner of their choosing (though preferably at least one day apart). They were phoned by the project leader every two weeks to try to ensure they kept up their regime. Thirty‐three patients dropped out during the interventions (12 from the MET group, eight from the CP group and 13 from the SE group). Follow‐up assessments took place at the end of the intervention and one year later (ie three months and 15 months after the start of the study). Measurements were taken at each point for pain intensity (using a visual analogue score (VAS), functional capacity 39, reported satisfaction with their treatment (on a four point scale) and sickness absence (using data collected from social security offices). No‐one dropped during the one‐year follow‐up period. 38 Under the terms of the Norwegian National Insurance Act all people on sick leave for eight weeks or more must be issued with a Special Sickness Certificate II to be eligible for further sickness benefit, 39 Using the Oswestry Low Back Pain Disability Questionnaire. IES, IWP, ScHARR
47
Primary outcomes
There was no significant difference between the three groups in the proportion who returned to work, 41 (57.7 per cent) of the medical exercise therapy group, 42 (62.7 per cent) of conventional physiotherapy group and 40 (57.1 per cent) of self‐exercise group had returned to work by one year follow up point. 40 However, the total number of days on sick leave among the self‐exercise group (from inclusion in the study to the final follow‐up stage ie 15 months) was 13,567 days. This compares with 11,757 days among the medical exercise group and 9,967 days among the conventional physiotherapy group. 41 Secondary outcomes
The study found a positive difference in functional capability after treatment in favour of the medical exercise therapy and physiotherapy groups compared with self‐
exercise group (p=0.01), but no significant differences between the two therapy groups (p values not reported). The results were similar but stronger (p = 0.005) at the end of the year follow‐up period. The study also found a lower level of pain intensity in lower back and buttock (p=0.01) and lower extremities (p=0.003) after treatment among the medical exercise therapy and physiotherapy groups compared with self‐exercise group. Again there were no statistically significant differences between the two therapy groups and the results were maintained at the one year follow‐up. Limitations of the study
This study has been quality assessed and rated ‘+’. The study has been criticised (see Eriksen et al. SPINE Vol. 25, No. 1) because the control group were required to engage in walking exercise and over 40 per cent dropped out and were therefore not in receipt of ‘no intervention’ as argued by the authors. Evidence statement for Theme 3
A Dutch RCT study (rated ‘+’), among 196 men and women aged between 18 and 65 who had been
on sick leave for between two and six weeks due to lower back pain, found that a multi-stage
return to work programme (involving a workplace assessment and work modifications based on
participative ergonomics and counselling the employee about return to work) was effective at
getting them back to work sooner than if they had just had usual care. There is also evidence that
the workplace intervention was effective in reducing the total number of days taken as re-
40 No p values or any other statistical significance tests reported. 41 No p values or any other statistical significance tests reported. 48
Interventions, strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
occurring sick leave among the study population and that the clinical intervention (in combination
with usual care or the workplace intervention) did not have a positive effect, although the clinical
intervention was only adhered to by 65 per cent of cases (Steenstra et al., 2006).
A Norwegian RCT (rated ‘+’) of 210 patients aged between 20 and 65 on long-term sick leave
which compared medical exercise therapy (under continuous supervision by the physiotherapist)
conventional physiotherapy (a combination of methods such as heat or cold massage, stretching,
different forms of electrotherapy, traction, and a few exercises on the treatment table) and self
exercise (patients given information and told to walk for one hour three times a week for 12
weeks) found all three interventions could be effective in reducing total re-occurring sickness
absence. However no significant difference was found in the proportion of patients who returned
to work during the trial period among the three groups (Torstensen et al 1998).
3.4 Evidence tables for the three themes
Table 3.1 presents a summary of the evidence from the seven included papers. IES, IWP, ScHARR
49
Table 3.1: Haugli et al. (1994)
Study details
Title and source:
Haugli, L., Steen, E.,
Laerum, E., Nygard, R.,
and Finset, A. (2001),
‘Learning to have less
pain – is it possible? A
one-year follow-up
study of the effects of a
personal construct
group learning
programme on patients
with chronic
musculoskeletal pain’,
Patient Education and
Counselling, vol. 45, no.
2, pp. 111-118.
Study design:
Randomised controlled
trial
Grade: -
Intervention, policy,
strategy or programme
description
To explore the effects of
a group learning
programme on
experienced pain, pain
coping strategies,
absenteeism, disability
pension and health care
consumption in patients
with chronic
musculoskeletal pain and
high absenteeism.
The programme was
based on
phenomenological
perspectives and Kelly’s
personal construct theory
and focused on selfawareness and selfdiscovery, sharing and
listening to each other. It
included experiencebased exercises eg
creative drawing, moving
to music, guided
imagery, use of
metaphors, relaxation
and awareness exercises.
Comparison:
Control group received
treatment as usual
(analgesic medication
with occasional
physiotherapy.
At commencement of
study (T0), intervention
& control groups were
balanced on age, gender,
Sample and setting
Sample:
Intervention group:
n=92. Control group:
n=82. At final followup: treatment n=77,
control n=44.
Participants invited via
social security offices.
Duration of study and
follow-up period/s
Primary and
secondary outcomes
Results
Confounders and
limitations
12 group meetings over
8 months; follow-up at
1 month (T1) and 1
year (T 2)
Primary Outcome
Primary outcomes
Identified by author:
Self reported
reduction in number
of sick days. Self
reported receipt of
disability benefit (for
long-term absence
from work)
Self-reported sickness
absence fell by 44%in the
intervention group (from
a mean level of 93 days
to 65 days (T1) and 52
days (T2) and by 30%in
control group (from 102
days to 84 days (T1) 71
days (T2)). (P =0.283).
The proportion in the
intervention group selfreporting that they
received disability
benefits increased from
24.7%(T0) to 37.7%(T2)
(T1 data not provided)
and from 20.5% (T0)to
59.1% (T2) in the control
group (P = 0.042).
High drop out rate (but
authors note no
differences in baseline
data between
responders and nonresponders in control
group, nor between
completers and noncompleters in
intervention group).
Included:
Secondary outcome
Patients with
musculoskeletal pain
for 2 or more days a
week for more than 6
months; 4 or more
weeks absent from
work in last 12
months; age 20-59;
able/willing to actively
participate in
programme for 6
months.
Pain and pain coping;
coping with life
demands; healthcare
consumption;
psychological
distress; evaluation
of programme
Excluded:
Those with inadequate
knowledge of
Norwegian; drug and
alcohol abuse affecting
ability to participate;
malignant/serious
disease.
Setting:
Oslo, Norway: precise
setting not reported
Secondary outcomes
Pain: intervention group
showed significant
reduction (17% of visual
analogue scale (VAS)
score) from baseline (T1)
to one-year follow-up
(T3) (p=0.03); control
group almost identical at
T1 and T3. At T3, pain
scores significantly lower
in intervention group
than in control group
(p=0.015).
Psychological distress
contributed to the
variance in pain (F=12.6,
Six dependent variables
used, so authors advise
caution in interpreting
the relative effect of
the intervention on
each separate variable.
Given non-significant
effect on absenteeism,
authors also advise
caution in interpreting
apparent effect on
rehabilitation/disability
benefits.
Identified by reviewers:
Significantly more
control group
participants were on
sick leave at baseline
than intervention group
participants.
High dropout (54%)
from control group at
final follow-up
(although there were
50 Interventions, strategies, programmes and policies to reduce the number of employees
recurring basis
Study details
Intervention, policy,
strategy or programme
description
education, marital
status, pain duration,
absence days, pain, pain
coping and coping with
life demands. However
significantly more control
participants were on sick
leave (83.7%) than
intervention participants
(56.3%). (P< 0.05)
Sample and setting
Duration of study and
follow-up period/s
who take long term sickness absence on a
Primary and
secondary outcomes
Results
p=0.001).
Pain coping: At T3,
intervention group
showed significantly
increased pain coping
abilities (11% on VAS)
(p=0.04) and significantly
greater pain coping
abilities than control
group (p= 0.010).
Coping with life
demands: At one month
follow-up (T2),
intervention group
showed significantly
increased coping abilities
(19% on VAS) (p=0.02)
and significantly greater
coping abilities than
control group at both T2
and T3 (p=0.017).
Healthcare consumption:
Intervention group
showed reduced
healthcare consumption
at T2 and maintained this
to T3. Difference in
healthcare consumption
between intervention and
control group was
significant at both T2
(p=0.22) and T3 (p=0.02).
Number of people
receiving physical
therapy fell by 23% in
intervention group and
12% in control group (non
significant).
Confounders and
limitations
no differences in
baseline data between
completers and noncompleters).
Recruitment and
randomisation
procedure open to bias:
poor description of
randomisation, and
selection effect of optin for participating
social security centres
(through which
individuals were
recruited) may limit
the generalisability of
results.
IES, IWP, ScHARR
51
Table 3.2 Holopainen et al. (2004)
Study details
Title and source:
Kaj Holopainen, Nina Nevala,
Pentti Kuronen, and Jari P.A.
Arokoski. Effects of
Vocationally Oriented
Medical Rehabilitation for
Aircraft Maintenance
Personnel – A Preliminary
Study of Long-Term Effects
With 5-Year Follow-up,
Journal of Occupational
Rehabilitation Vol.14, No. 4,
December 2004
Study design:
Cohort
Grade: -
Intervention, policy,
strategy or programme
description
To verify the effects of
Vocationally Oriented
Medical Rehabilitation
(VOMR) courses on
machinists’ physical
activity, musculoskeletal
symptoms and perceived
work ability within a
follow-up period of 6
months and 5 years.
Rehabilitation course
consisting mainly of
physical exercises and
training in ergonomic
work techniques.
Sample
Duration of study and
follow-up period/s
Primary and
secondary outcomes
Results
Sample:
Duration:
Primary Outcomes
Primary outcomes
20 Finnish Air Force
Machinists (mean age
36.9 yrs, no data on
whether male or
female)who a) had at
least 3 years’
experience as a
machinist in the same
workplace and
intention to continue
in this job, b) had
experienced
musculoskeletal
symptoms causing sick
leave of 60 days at
most during the past 2
years, c) had no other
diseases preventing
rehabilitation, d) were
motivated to work and
e) voluntary
participation in the
course. Final selection
by the Finnish Social
Insurance Institution
(SII).
Groups of 10 per
course, each course
realised over two
phases. First phase
lasted 12 days, the
second (held six
months after the first)
lasted 5 days.
Number of days sick
leave, self-reported.
Self-reported sick leave
significantly decreased
(p<0.05), from mean of 4.6
days in the previous six
months to zero in the six
month period prior to the
five-year follow-up
Setting:
Siilinjarvi
Rehabilitation Centre,
Finland
Follow-up:
At six months, and
five years.
Secondary outcomes
Changes in working
postures measured by
Ovako Working posture
Analysing System
(OWAS):.
Physical capacity,
measured by
respiratory gas
analyzer during
maximal exercise test
on a bicycle
ergometer,
electrocardiograph
(for heart rate), and
other objective
physical tests.
Physical and mental
strain at work,
Physiotherapeutic
treatments, Changes in
leisure-time physical
activity: all measured
by questionnaire
and/or self-reported.
Secondary outcomes
Amount of exercise breaks
at work was significantly
greater during the followup (p<0.01), up from 0.1
dys p wk to 2.4 after 6
months and 2.6 after 5 yrs
Severity of LBP decreases
during the follow-up
(p<0.01), but no statistical
changes occurred in
subjective neck pain.
Physical and mental strain
of the work did not
decrease during the 5-year
follow-up period.
No significant changes
noted in physiotherapeutic
treatments, or changes in
leisure-time physical
activity.
Confounders
and limitations
Identified by
author:
Lack of a control
group and small
number of cases.
Identified by
reviewers:
Selection
criteria and
setting limit the
generalisability
of the study
results to a
wider
population.
52 Interventions, strategies, programmes and policies to reduce the number of employees
recurring basis
who take long term sickness absence on a
Table 3.3: Leino et al. (1994)
Study details
Leino P, Kivekäs J,
Hänninen K (1994)
‘Effects of WorkOriented Fitness
Courses in
Lumberjacks with
Low Back Pain’
Journal of
Occupational
Rehabilitation, VO.
4, No. 2.
Study design:
Prospective (nonrandomised)control
led study
Grade: -
Intervention, policy strategy
or programme description
Aim: To examine the changes
in fitness health and work
ability after a work-oriented
physical fitness course
arranged for lumberjacks
who had been off sick with
LBP and still had LBP but
were back at work
Intervention: Seven day
residential fitness course at a
school of forestry or a school
of sports. Course led by
physiotherapist or an
instructor in physical
training. Course lasted 12
hours each day, apart from
the first and last day.
Courses provided free of
charge and 80% of salary
losses compensated. Most of
the time was spent
exercising, but the course
also included lectures on
spine structure and function
and work ergonomics and
fitness tests. An individual
exercise program was also
developed to be followed at
home by the participants.
The main intervention was
followed by a two day
Sample and setting
Setting: Finland
Sample: Participants
were male professional
lumberjacks employed
by two large Finnish
forestry companies
(one in the north and
one in the east of
Finland).
Intervention group (n =
87) and comparator
group, (n = 61), were
selected non-randomly
by occupational health
personnel from 1556
respondents to a
baseline questionnaire
(82% response rate).
Both groups had
suffered short-term
work disability of up to
30 days in the previous
year due to LBP.
No other inclusion or
exclusion criteria were
reported.
Although not randomly
assigned the
Duration of study and
follow-up periods
Primary and secondary
outcomes
Results
Confounders and
limitations
Duration: Course lasted
seven days followed by a
two day reinforcement
session six months later.
Primary outcome:
Primary outcome:
Identified by author:
Sickness absence data
obtained from company
files for one year
before and after the
intervention.
Among the
intervention group,
the average number
of spells of sickness
absence fell from .20
(during the 12
months before) to
.11 (in the year
after)the
intervention
compared with .25
and .23 among the
control group.
However, this was
not statistically
significant (P value
data not available).
The authors draw
attention to the
asymmetrical response to
the follow-up
questionnaire, which
negatively affected the
control group and meant
that they were much
smaller in number than
the intervention group.
However this problem
did not affect the
collection of sickness
data from company
records.
Follow-up: Questionnaire
follow-up occurred at the
six month session. Nonresponse (16%) was higher
among the controls than
among the intervention
group (3%).
Sickness absence data
obtained for the full year
following the intervention
Secondary outcomes
Additional self assessed
data covering age,
physical activity,
fitness, perceived
health, back symptoms,
distress symptoms,
ergonomic strain and
work ability collected
before and six months
after the intervention.
Average days off sick
fell from 2.7 to 2.2
in the intervention
group from before to
after the
intervention but rose
(from 2.4 to 4.0).
Again not significant
(p<.10) among the
control group.
Secondary outcomes
Both groups reported an
increased level of leisure
time physical exercise at
the follow-up
questionnaire. There
may have been
communication between
the two groups or the
authors suggest that the
baseline questionnaire
may have had ‘an
interventional effect’
The authors felt that the
course might have been
seen as holiday for the
42 ‘work ability’ was computed from the answers (based on a scale of 1 to 5) to four questions covering the physical and mental strenuousness of work, subjective ability to work and the need for ‘repose at leisure’. IES, IWP, ScHARR
reinforcement session six
months later.
No details were provided on
what, if anything, was
delivered to the control
group.
intervention and
comparator group had
similar patterns of
fitness and absence at
baseline
Back symptoms
among the
intervention group
and the controls
were at a similar
level before and
remained so six
months after the
intervention. (p
value data not
available).
Work ability 42 (selfassessed) increased
significantly among
the intervention
group (from 7.0 to 7.5
– on an unspecified
scale) (p = <0.05), but
remained at similar
levels among the
controls (6.5 and 6.4)
(p values not
reported). The
difference between
the intervention
group and the
controls at the
follow-up stage was
significant (p =
<0.05).
Self reported leisure
time increased in
both the intervention
group and the
control group (p =
<.01).
The costs per course
were 50,000 FIM and
the cost refunding of
lost salaries (80,000
FIM)
53
participants and
generated the small
positive impact.
However, they felt it
more likely that the
increased physical
capability following the
intervention may have
directly influenced their
functional capacity.
Equally, they felt that
the participants may also
have had an increased
belief in the
controllability of back
pain especially through
exercise.
Identified by reviewers.
The process for selecting
participants of the
intervention group and
the control group is
unclear.
54 Interventions, strategies, programmes and policies to reduce the number of employees
recurring basis
who take long term sickness absence on a
Table 3.4: Molde Hagen et al. (2003)
Study details
Title and source
Molde Hagen E,
Grasdal A, Eriksen H
R.
Does early
intervention with a
light mobilisation
program reduce longterm sick leave for
low back pain: a 3year follow-up study.
SPINE (2003) 28:20
2309-2316.
Study design:
RCT
Grade: +
Intervention, policy, strategy
or programme description
Sample and setting
Aim: Evaluate the effects on
sickness absence of an simple
early intervention on sicklisted employees suffering
form lower back pain (LBP),
following up a randomised
controlled trial.
237 lower back pain
employees, sicklisted for 8-12
weeks.
Intervention:
Included
A single interview and
assessment (by physician and
physiotherapist) at spine
clinic within week 12 of sick
leave. Information about
positive prognosis and
importance of staying active
to avoid development of
muscle dysfunction. Physio
provided individual advice
and training: how to stretch
at home & practical advice on
how to cope with and resume
daily activities at home and
work. Encouraged to contact
the Spine Clinic whenever
wanted (25% did). Reports
from the examination were
sent to the patients’ primary
care physician and to the
National Insurance Office,
with diagnoses,
recommendations concerning
further diagnostic tests,
treatment, job and, if
possible, recommendations
concerning further sick leave.
With or without
radiating pain.
Duration of study and
follow-up period/s
Intervention group:
18-60 years old.
Excluded
Pregnancy, recent
lower back trauma,
cauda equine
symptoms, cancer,
osteoporosis,
rheumatic low back
disease, ongoing
intervention for LBP
by another
specialist.
Setting
Spine Clinic,
Norway.
Duration:
Intervention in 1995.
Follow-up:
Reports on follow up
at 2 and 3 years, and
results form original
study (3, 6 12 month
post intervention)
Primary and
secondary
outcomes
Results
Primary outcomes
Primary outcomes
Speed of return to
work, frequency of
sick leave, total
length of sick leave
Work status at
specific points in
time.
Nos in receipt of
sickness benefit
Secondary
outcomes
Cost benefit
analysis.
Experience and use
of strategies to
cope with LBP
Confounders and
limitations
st
Significant differences in 1 12
months: at 3 month 52% of
intervention group returned to
work vs. 36% control. At 12 months,
68% intervention group vs. 56% in
control.
At 2 & 3 years no sig. difference
between intervention and control
groups in work status or in numbers
receiving insurance benefits.
Differences in average number
sickness days (after first
consultation) at 12 months echoed
at 3 years: Intervention group 126
days, Control 170 days (p<0.001).
Secondary outcomes
Net benefit of intervention
calculated as 25,526 Norwegian
Krone per patient.
At 6-month follow-up, patients in
the intervention group were less
likely to use bed rest and more
likely to use stretching and walking
to cope with their back pain
compared with the control group.
This effect diminished. At 12month follow-up, the only
significant difference between the
groups was in the use of stretching. Identified by
author:
None re study
design. Propose
developing
intervention (add
follow-up visits) to
increase longer
term benefits.
Identified by
reviewers:
Consent sought
after
randomisation.
Implies every
consenting
participant had
intervention, but
not explicit.
IES, IWP, ScHARR
55
Comparison:
220 control group participants
Invited to local insurance
office to complete same
questionnaires as intervention
group. Treated (‘as usual’
inferred but not stated) by
primary health care team (as
opposed to spine clinic).
Table 3.5 Soukup et al. (1999)
Study details
Intervention, policy,
strategy or programme
description
Sample and setting
Duration of study and
follow-up period/s
Primary and
secondary outcomes
Results
Confounders and
limitations
Title and source:
To evaluate the effect of
a Mensendieck Program
on the incidence of
recurrent episodes of
low back pain (LBP) in
patients with a history of
LBP who currently are
working.
Intervention group:
n=39; Control: n=38. At
final follow-up:
Intervention: n=34;
Control: n=35
Duration: A five month
study period
Primary outcome
Primary outcomes
Identified by author:
Participants’
incidence of sick
leave, receipt of
disability benefits
among participants.
10 out of 34 in
intervention group with
sick leave in follow-up
period and 11 out of 35
of control group
representing no
significant difference
(no p value reported) in
mean days lost between
intervention (29.9 days)
and control group (37.8
days). However, once a
single outlier was
excluded a significant
positive (p<0.01) impact
of the intervention
(12.6 days) compared
with control (37.8 days)
was found.
Self-selected
participants may have
resulted in a study
sample with high
motivation for physical
training. However,
most secondary
prevention programs
for LBP are based on
voluntary
participation. Selfreported measures for
sick leave and LBP
episodes may be
affected by recall bias,
but bias should be
similar for both groups.
Secondary outcomes
Intervention and
outcomes are based in
a bio-medical
approach, which may
be an incomplete
consideration of
factors (such as
personality, motivation
Soukup MG, PT, MSci;
Glomsrod B, PT; Lonn
JH, PT; Bo K, PT, PE,
PhD; Larsen S, MSc,
DrSc. (1999) ‘The Effect
of a Mensendieck
Exercise Program as
Secondary Prophylaxis
for Recurrent Low Back
Pain: A Randomised,
Controlled Trial with 12
month follow-up’.
SPINE Vol 24, Number
15, pp 1585 – 1592.
Study design:
A Randomised,
Controlled Trial
Grade: +
Mensendieck Program
involved
10 min warm-up
exercises; 5 min
stretching for legs, hips,
buttocks; 35 min
information session
combining ergonomic
info and pelvic, hip,
back and abdominal
exercises; 5 min
stretching for lower
extremities, pelvis and
back, and; 5 min
relaxation exercises.
Comparison:
Intervention groups
were balanced at
Included were 18-50
years old, who had
experienced one or more
episodes of LBP (pain
localised to the lumbar
region, with or without
pain radiating to the
lower extremities).
Episode further defined
as LBP resulting in
professional treatment or
use of sick leave. At the
time of their to the study
enrolment, patients
required to have finished
treatment for their LBP
episode and had returned
to work. Also needed to
have time and
opportunity to
participate in
Mensendieck exercise
groups for 13 weeks, and
Follow-up: a 12-month
follow-up.
Secondary outcome
Self-reported
recurrence of LBP
(observed in days from
inclusion until the day
of event, during the
12-month follow-up
period).
Measures:
1) Back pain in
general in preceding
month
2) Back pain related
to 12 daily activities
3) Self assessment of
back function using
100mm visual
analogue scale
4) General functional
At 12 months, incidence
of self reported LBP reoccurring significantly
less for intervention
group (11 of 34) than in
the control group (20 of
Identified by editors
56 Interventions, strategies, programmes and policies to reduce the number of employees
recurring basis
baseline on most
variables (demographic,
LBP history). There was
no significant
differences between
groups except with
regard to baseline
participation in physical
training during leisure
time
who take long term sickness absence on a
status measured by
COOP/ WONCA charts
(note these are a
validated measure of
functional status,
however this was not
referenced in the
paper).
agreed to randomisation
procedure.
Setting:
General physical therapy
practice in South-Eastern
Norway.
35); (p<0.05).
The study also found a
significant increase
(P<0.05) in selfreported participation
in physical exercise
among the intervention
group compared with
the controls.
and emotional issues)
critical to the events
studied, especially in
light of the fact that
pain and reports of
pain are more
commonly understood
now in terms of a biopsychosocial model of
health.
Table 3.6: Steenstra et al. (2006)
Study details
Title and source
Steenstra, IA. Anema,
JR. van Tulder, MW.
Bongers, PM. de Vet,
HCW. and van
Mechelen, W. (2006)
Economic Evaluation
of a Multi-stage
Return to Work
Program for Workers
on Sick-leave Due to
Low Back Pain,
Journal of
Occupational
Rehabilitation, Vol.
16, pp. 557-578
See also: Steenstra I,
Anema J, Bongers P,
d Vet, H, Kurd D and
Van Mechan W
(2006), ‘The
effectiveness of
graded activity for
low back pain in
occupational
healthcare’,
Intervention, policy,
strategy or programme
description
Based on two
randomisation
procedures. The first
was performed by
Occupational Physicians
(OPs) (who had been
stratified by economic
sector) and assigned
participants to either a
Workplace Intervention
(WI) or Usual Care (UC).
The second
randomisation
procedure, conducted
by researchers, then
allocates those that
were still on sickness
absence after 8 weeks
to Clinical Intervention
(CI) or usual care.
Clinical intervention
involved graded activity
protocol developed by
Staal et al, 2004
Sample and setting
Intervention groups:
Workplace Intervention (WI)
(n=96) followed by Clinical
Intervention (CI) (n=27) or only
WI (n=25) for those still on sick
leave after 8 wks
Usual Care (UC) (n=100) followed
by CI (n=28) or UC only (n=32)
Included: Aged 18 to 65, on sick
leave from regular work for 2 to 6
weeks due to Lower Back Pain
(LBP) and able to understand
Dutch to give informed consent
and complete questionnaires.
Excluded: Specific causes of LBP,
pregnancy, serious psychiatric
disorders, in cases of legal
conflict at work or if been sick
listed due to LBP less than one
month prior to current episode.
Setting:
Undertaken by Occupational
Physicians (OPs) in the
Netherlands. WI consists of usual
care plus a workplace assessment
Duration of study
and follow-up
period/s
Primary and secondary
outcomes
Results
Confounders and
limitations
Follow-up:
Baseline
measurement 2
to 6 weeks after
sick leave begins.
Initial
intervention at 6
to 8 weeks after
start of sick
leave.
Measurements at
8, 12, 26 and 52
weeks after start
of sick leave. If
selected for
Clinical
Primary Outcome
Primary outcomes
Identified by author:
Return to Work based
on Social Security
records. Lasting return
to work defined as the
duration of work
absenteeism due to LBP
in calendar days from
the first day of sick
leave to full return to
own or other work with
equal earnings for at
least four weeks
without partial or full
drop out.
The WI group
returned to work
30.0 days earlier
(p=0.014) than the
UC group.
Published in a separate
paper: Steenstra et al 2006
Occupational and
Environmental Medicine.
This includes: only 65% of
workers randomised to CI
complied with the protocol.
There may have been delays
in referring patients to CI
which may have reduced its
effectiveness
Duration:
Intervention this
occurs between 8
and 12 weeks
after start.
Secondary outcomes
Functional status:
measured using the self
report and validated
Roland Disability
Questionnaire.
Pain severity:
measured using self
reported 10 point
numerical rating scale.
The WI*CI group
returned 50.9 days
later (p=0.001)
than the WI*UC
group. The UC*CI
group returned
21.3 days later
(p=0.07) than the
UC*UC group.
Overall, the WI
was effective but
the CI was not
Secondary
outcomes
No significant
differences in
secondary
outcomes between
WI and UC groups.
Identified by reviewers:
This was mainly written up
as a cost effectiveness study
and it is difficult to
distinguish the effectiveness
from the costs effectiveness
as presented.
The effects of the clinical
intervention (CI), which
involved graded activity,
compared with usual care
were examined in greater
detail in Steenstra, Anema,
IES, IWP, ScHARR
Occupational and
Environmental
Medicine 2006; 63,
718-725
Study design:
RCT with factorial
design
Grade: +
and work modifications based on
participative ergonomics which
involved all important
stakeholders. Additionally
communication between OP and
GP to reach consensus on
counselling the work in terms of
Return to Work (RTW).
Quality of life:
measured using self
report and Dutch
version of the EuroQol.
General health:
measured using self
report and visual
analogue scale of
100mm.
The differences
between the WI*CI
and WI*UC as well
as the differences
between the UC*CI
and UC*UC groups
also had no
significant
differences.
57
Bongers et al. (2006) which
emphasised the finding that
none of the results ‘showed
that graded activity
improved return to work for
either functional status or
for pain in the first 26 weeks
after the first day of sick
leave’
58 Interventions, strategies, programmes and policies to reduce the number of employees
recurring basis
who take long term sickness absence on a
Table 3.7: Torstensen et al. (1998)
Study details
Title and source
Torstensen, T. A.,
Ljungggren, A. E.,
Meen, H. D., Odland,
E., Mowinckel, P., &
Geijerstam, S. 1998
‘Efficiency and costs
of medical exercise
therapy, conventional
physiotherapy, and
self-exercise in
patients with chronic
low back pain: A
pragmatic,
randomized, singleblinded, controlled
trial with 1-year
follow- up’, Spine,
vol. 23, no. 23, pp.
2616-2624.
Intervention, policy,
strategy or programme
description
Three randomly allocated
single blinded intervention
groups.
Medical Exercise Therapy
(MET) group, given 36, 1 hour
graduated three a week
exercise sessions over 12
weeks.
Conventional Physiotherapy
(CP) group offered standard
therapy at therapist
discretion at the same
intervals. The third group
given Self Exercise (SE) and
urged to undertake a hours
walking exercise three times
a week for 12 weeks.
Sample
208 total sample. MET:
34 men 37 women 71 in
total. CP: 35 men 32
women 67 in total. SE:
34 men 36 women and
70 in total.
To be included patients
had to be aged between
20 and 65, had lower
back pain, in
employment but on sick
leave for at least eight
weeks. Exclusion
criteria included
physical disorders (such
as spondylolisthesis, hip
arthrosis or previous
back surgery) which
would difficult to follow
the intervention
programme.
Study design:
Setting:
Individual RCT
Private physiotherapy
clinics in city of Oslo in
Norway
QA Grade: +
Duration of study
and follow-up
period/s
Duration: Three
month intervention
with a follow up after
one year.
Follow-up: Three
way comparison
between groups. As
well as before
intervention, after
intervention and one
year follow up
comparisons
Primary and
secondary outcomes
Results
Confounders and
limitations
Primary outcomes:
Primary outcomes:
Secondary outcomes:
Return to work, based
on social security
records
Return to work, 41
(57.7%) of the MET
group, 42 (62.7%) of
CP and 40 (57.1%) of
SE had returned to
work at time of oneyear follow up (no p
values reported).
‘In the current study,
the outcome most
relevant to society,
return to work, showed
no difference between
any of the three
groups.’ ... ‘it [return to
work] is also an outcome
measure that seems to
live its own life, being
influenced by factors
outside the domain of
any medical or
therapeutic
intervention.’
Secondary outcomes:
Pain: self reported
using 100 mm visual
analogue scales.
Function: functional
capability self
reported on basis of
Oswestry Low Back
Pain Disability
Questionnaire.
Satisfaction:
satisfaction with
intervention following
intervention using four
point scale 1 =
completely satisfied
and 4 dissatisfied.
Secondary outcomes:
Functional capability –
difference in function
after intervention in
favour of MET and CP
groups compared with
SE (p=0.01).
Pain – difference in
pain intensity in lower
back and buttock
(p=0.01) and lower
extremities (p=0.003)
after intervention in
favour of MET and CP
groups compared with
SE.
Patient satisfaction –
26 (34.2%) of MET
group, 19 (32.2%) of
CP group, and 6
(9.5%) of SE group
completely satisfied
(no p value reported).
The study has been
criticised (see Eriksen et
al. SPINE Vol 25 No. 1)
because of the control
group were required to
engage in walking
exercise and over 40%
dropped out and not in
receipt of ‘no
intervention’ as argued
by the authors.
IES, IWP, ScHARR
59
3.5 Applicability of the evidence to the UK populations in
the scope
Seven studies have been included in the effectiveness review all of which compare different interventions for lower back pain. Four describe the use of (different) exercise regimes (supplemented with education) to relieve lower back pain, all in a Scandinavian setting. A fifth examines a learning programme to help participants cope with pain and was again based in a Scandinavian setting. The final two compare the effect of multi‐disciplinary intervention, including work‐based interventions for musculoskeletal disorders (again mainly lower back pain). One was based in Scandinavia and the other was set in Holland. In attempting to generalise from these findings to the UK some caution needs to be applied and consideration given to: ■ The different contexts in which sickness absence takes place, most notably different sickness benefit regimes which may affect employees’ absence behaviour in different ways to the system in the UK (and therefore alter the results of the studies if they were conducted in the UK). ■ The different standards of clinical treatment in the countries in question and the UK (ie what would count as ‘usual care’, the non‐intervention case, in the UK). ■ The ability to make interventions similar to those in the studies (eg to apply some of the clinical regimes or workplace interventions) in the UK. 60
Interventions, strategies, programmes and policies to reduce the number of
employees who take long term sickness absence on a recurring basis
4 Cost Effectiveness Findings
4.1 Cost–effectiveness results
Three papers were identified which satisfy the inclusion criteria for this cost‐
effectiveness review. All three of the economic evaluations were carried out from a societal perspective and consider a population of workers on long‐term sick leave with lower back pain. However, it is not viable to meaningfully compare the results of the three studies due to several key differences: ■ There is a mixture of cost‐effectiveness and cost‐benefit analyses (one cost‐
effectiveness evaluation and two cost‐benefit studies). The cost‐effectiveness analysis provides a cost per return to work day gained by the intervention whereas the cost‐benefit analysis calculates a monetary value saved by the intervention in terms of the outcome ‘return to work’ and adds this to the additional cost of the intervention. The results could therefore not be compared whilst remaining in their current format. ■ The studies are based in different countries (two Norwegian, one Dutch). The costs associated with long term sickness absence including direct costs such as hospitalisation and indirect costs such as wages may vary considerably between countries. Similarly outcomes such as general health and quality of life may vary between countries. ■ The interventions and comparators considered in the economic evaluations are different, as shown in Table 4.1. This may, in part, be due to the fact that the studies have been carried out in different countries leading to variability in the standard care of lower back pain, and hence in the comparator within the economic evaluations. Both Norwegian studies are cost‐benefit analyses. However, because the comparator is different between the studies, it is difficult to draw conclusions about the comparative cost‐effectiveness. IES, IWP, ScHARR
61
The quality assessment grade given to each of the studies is based on the criteria shown in Table 4.1. Table 4.1: Criteria used in the quality assessment of cost effectiveness studies
Rating
Criteria
-
An economic evaluation is not carried out, or
Scope is irrelevant
Modelling approach is insufficient
+
Scope of evaluation is relevant
Modelling approach is reasonable
Results and conclusions satisfy objective of evaluation
++
Model assumptions are reasonable
A sensitivity analysis is conducted
Is reasonably generalisable to the UK setting
+++
Modelling approach is robust
A full probabilistic sensitivity analysis is carried out which
tests key model assumptions
Reasonable model validation is carried out
Source: IES/IWP/ScHARR
All of the interventions and comparators considered within the included economic evaluations are shown in Table 4.2 below. Table 4.2: Interventions and comparators considered within the economic evaluations
Study
Country
Molde Hagen et al
(2003)
Norway
Steenstra et al
(2006)
Netherlands
Intervention
Examination at a spine clinic
Treatment in primary care
Work modifications and clinical
intervention
Usual care as outlined by
Dutch Occupational Physician
guidelines for lower back pain
Physiotherapy based on operant
behavioural principles
Torstensen et al
(1998)
Norway
Comparator
Medical exercise therapy
Self-exercise
Conventional physiotherapy
Source: IES/IWP/ScHARR
Because of the heterogeneity between the studies, the results of the economic evaluations have been outlined separately, but using two themes which correspond to the themes outlined in the effectiveness review (see Chapter 3): ■ exercise and education programmes to prevent the reoccurrence of lower back pain ■ multi disciplinary interventions to treat lower back pain 62
Interventions, strategies, programmes and policies to reduce the number of
employees who take long term sickness absence on a recurring basis
The studies are outlined in greater detail in Chapter 3. 4.2 Theme 1: exercise and education programmes to
prevent the reoccurrence of lower back pain
4.2.1 Molde Hagen et al (2003)
The cost‐benefit analysis 43 by Molde Hagen et al (2003) ‘Does early intervention with a light mobilization program reduce long‐term sick leave for low back pain: A three year follow‐up study’ is based on a Norwegian population of workers between 18 and 60 years placed on a sick‐list for eight to 12 weeks for low back pain. For more details of the intervention please see the description for the effectiveness (3.1.1) and the evidence tables at the end of chapter 3. Primary outcome:
The economic evaluation compares the cost‐benefit of return to work of individuals examined at a spine clinic by a physician and physiotherapist and given information and individual instruction, as well as advice on how to stay active, with those treated within primary care. The analysis is based on one RCT of 457 male and female workers (237 intervention, 220 control) and is carried out from a societal perspective over a time horizon of three years. The calculation of the benefits of the intervention expressed in monetary terms is based on gross wage payments, the reduction in public transfers, social value of loss of leisure and the cost of funding public transfers 44. The cost of care is based on personnel costs (physician, physiotherapist, secretary), follow‐up visits to the physiotherapist and operational expenses (buildings, equipment, cleaning, etc.). The costs of the operating expenses are assumed to be equal to personnel costs. Within the analysis, it is assumed that there is a constant labour supply elasticity of 0.4. 45 The quality of life of the individuals has not been taken into account within the cost‐benefit analysis and hence the benefits may be underestimated. 43 A cost‐benefit analysis is a form of economic evaluation where all costs and consequences of a programme are expressed in the same unit, usually money. 44 It should be noted that from a societal perspective, transfer costs should not have been included within the analysis. 45 An elasticity of labour supply of 0.4 means that every 10% increase in wage rates would lead to a corresponding 4% increase in labour supply. IES, IWP, ScHARR
63
However, quality of life estimates would be related to the social value of loss of leisure, limiting the impact of this exclusion within the model upon the results since including both would lead to a certain amount of double counting. Results of the analysis are shown in Table 4.3. This suggests that the intervention is cost saving; however no analysis of uncertainty was undertaken. The ratio of benefits to costs is 12.5 to 1. Table 4.3: Results of cost-benefit analysis
Definition of cost/benefit
NOK (1995)
£ (2007)
Total benefits of care at spine clinic due to fewer sick days
27,740
4,072
Total cost of care at spine clinic
2,214
325
Total cost savings of intervention in comparison to control
25,526
3,747
Limitations of the study:
■ The analysis is based on data from only one RCT ■ No analysis of uncertainty has been undertaken ■ No validation of the model results has been carried out ■ The study is not UK‐based. ■ Follow‐up period of three years possibly underestimates benefits Two reviewers independently assessed the quality of this study; both gave a quality assessment rating of ‘++’. Evidence statement for Theme 1
There is evidence from one Norwegian cost benefit (randomised controlled trial) evaluation
(rated ‘++’) that an examination at a primary care spine clinic by physician and
physiotherapist and provision of information and individual instruction, as well as advice on
how to stay active, is likely to be cost effective compared to primary care treatment in
preventing the re-occurrence of long term sickness absence due to low back pain (Molde
Hagen et al 2003).
64
Interventions, strategies, programmes and policies to reduce the number of
employees who take long term sickness absence on a recurring basis
4.3 Theme 2: Multi-disciplinary interventions to treat
lower back pain
4.3.1 Steenstra et al (2006)
The ‘Economic evaluation of a multi‐stage return to work program for workers on sick‐leave due to low back pain’ by Steenstra et al. (2006) is a cost‐effectiveness analysis 46 comparing work modifications with usual care as outlined by Dutch Occupational Physician guidelines for lower back pain. Those patients in either group who had not returned to work after eight weeks were randomised to receive either graded activity based on operant behavioural principles or usual care. The population considered is 196 male and female workers aged 18 to 65 years sick‐listed for a period of two to six weeks due to low back pain in the Netherlands. For more details of the intervention please see the effectiveness description for this study (3.3.1) and the evidence tables at the end of chapter 3. Primary outcome
The outcomes evaluated within the analysis are: ■ Cost per Lasting Return to Work (RTW) day (duration of work absenteeism in calendar days from the first day of sick leave to full return to own or other work with equal earnings, for at least four weeks without drop‐out.). ■ Cost per Point‐increase in pain severity score avoided (ten‐point numerical self‐rating scale). ■ Cost per Point‐increase in functional status score avoided (Roland disability questionnaire). ■ Cost per QALY gained (Dutch version of EuroQol); and Cost per Point‐
increase in general health score avoided (VAS 0‐100mm). The analysis is based on one RCT (although comprising two separate randomisation steps) and is carried out from a societal perspective over a time period of one year. 46 A cost‐effectiveness analysis is an economic evaluation where the costs and consequences of alternative interventions can be expressed in terms of cost per unit of health outcome. IES, IWP, ScHARR
65
Costs measured are direct health care costs (cost of intervention plus additional visits to a health care provider, prescription medication, professional home care and hospitalisation), direct non‐health care costs (out‐of‐pocket expenses, costs of paid and unpaid help) and indirect costs (loss of production due to lower back pain related absence from paid and unpaid work). Partial return to work was measured by the occupational physician and means that if a person is back at work with a productivity of 50 per cent this is assumed to be equivalent to half a day’s work. The authors report that the interaction between workplace intervention and graded activity was statistically not significant. Therefore, one model was used to describe the effectiveness of the workplace intervention and graded activity, separately, by adjusting for the effect of the other intervention and confounding factors. The patient’s quality of life is based on the Dutch version of the EuroQol. Prices have been uplifted from those stated within the paper by assuming that the analysis was carried out in 2003 since the trial upon which the analysis is based was completed in 2003. For the analysis comparing workplace intervention to usual care, the cost per RTW for one day less sick leave is €19 in 2003 prices which equates to approximately £17 in 2007 prices. Thus, the workplace intervention costs £17 more than usual care for one day less sick leave. The workplace intervention dominates (i.e. is more effective and less costly than the comparator) for all other outcomes (see Table 4.4). Results from the analysis comparing clinical intervention versus usual care following eight weeks of workplace intervention or following eight weeks of usual care suggest that using clinical intervention is dominated by usual care (i.e. is less effective and more costly than usual care) independent of whether the patients had previously received the workplace intervention or usual care. Table 4.4: Results of cost-effectiveness analysis in 2007 British Pounds for usual care versus
the workplace intervention
Outcome measure (defined above)
UC against WI
Lasting RTW
£17
Functional status
Dominating
(-£113)
Pain severity
Dominating
(-£712)
Quality of life
Dominating
(-£1,294)
General health
Dominating
(-£7)
Note: WI = Workplace intervention; UC = Usual care
66
Interventions, strategies, programmes and policies to reduce the number of
employees who take long term sickness absence on a recurring basis
A probabilistic sensitivity analysis using the bootstrapping approach was carried out 47, presented as expected values and cost‐effectiveness planes. This shows that there is limited uncertainty associated with the results. Limitations of the study
■ The analysis is based on data from only one RCT and there is likely to be some confounding in interventions received by the participants (see section 3.1 for further details). ■ The time period of the analysis is limited ■ The year to which prices refer is unclear ■ The study is not UK‐based. ■ Follow‐up period of three years possibly underestimates benefits Two reviewers independently assessed the quality of this study, both gave a quality assessment rating of ‘+’. 4.3.2 Torstensen et al (1998)
The cost‐benefit analysis by Torstensen et al (1998). ‘Efficiency and costs of medical exercise therapy, conventional physiotherapy, and self‐exercise in patients with chronic low back pain: A pragmatic, randomized, single‐blinded, controlled trial with one‐year follow‐up’ is based on a Norwegian population of workers aged 20 to 65 with chronic low back pain or radicular pain sick‐listed for more than eight weeks and less than 52 weeks. For more details of the intervention please see the description for the effectiveness (3.3.2) and the evidence tables at the end of chapter 3. Primary outcome:
This analysis compares the cost‐benefit of return to work of medical exercise therapy (MET) (under continuous supervision by the physiotherapist, patients perform 7‐9 different, specific exercises relating to symptoms, clinical diagnosis, needs and expectations) and conventional physiotherapy (a combination of methods such as heat or cold massage, stretching, different forms of electrotherapy, traction, and a few exercises on the treatment table) with self‐
47 Bootstrapping is a method of resampling using a large number of samples of size n, with replacement, from the original data in order to capture uncertainty within the parameters. IES, IWP, ScHARR
67
exercise (patients given information and told to walk for one hour three times a week for 12 weeks). The analysis is based on one RCT of 208 male and female patients (71 MET, 67 conventional physiotherapy, 70 self‐exercise) and is carried out from a societal perspective over a time horizon of 15 months. The assumptions employed within the economic evaluation are not outlined. The analysis does not include any estimates of quality of life and hence may underestimate the benefits of the interventions. Results of the analysis are shown in Table 4.5 below. This suggests that both the medical exercise therapy and the conventional physiotherapy are cost saving compared with self‐exercise. No analysis of uncertainty was undertaken. Table 4.5: Results of cost-benefit analysis
Definition of cost/benefit
NOK
(1996)
£
(2007)
Total cost savings of MET in comparison to self-exercise
11,453
1,616
Total cost savings of conventional physiotherapy in comparison to self-exercise
22,883
3,229
Limitations of the study:
■ The analysis is based on data from only one RCT ■ No analysis of uncertainty has been undertaken ■ No validation of the model results has been carried out ■ The study is not UK‐based. ■ Follow‐up period of 15 months probably underestimates long‐term benefits Two reviewers independently assessed the quality of this study, both gave a quality assessment rating of ‘+’ Evidence statement for Theme 2:
There is evidence from one Dutch economic (randomised controlled trial) evaluation (rated
‘+’) that work modifications based on participative ergonomics and counselling the employee
about return to work are likely to be cost effective in reducing the re-occurrence of absence
due to low back pain when compared against usual care as outlined by Dutch Occupational
Physician guidelines for lower back pain. Within this study patients are randomised to receive
a clinical intervention or usual care at 8 weeks if they have not returned to work and therefore
this may confound the results; although the authors have tried to calculate an adjustment for
this. The cost per return to work day gained is estimated to be £17 and the cost per quality
adjusted life year (QALY) gained is estimated to be dominating (-£1,295) for the workplace
intervention in comparison to usual care. However, based on the analysis, it is unlikely that
68
Interventions, strategies, programmes and policies to reduce the number of
employees who take long term sickness absence on a recurring basis
graded exercise based on operant behavioural principles provided for those who remain on
sickness absence after 8 weeks of receiving either the workplace intervention or usual care in
terms of return to work is cost-effective in comparison to the provision of Dutch usual care for
the same indication (Steenstra et al., 2006).
There is evidence from one Norwegian cost benefit (randomised controlled trial) evaluation
(rated ‘+’) that both medical exercise therapy (under continuous supervision by the
physiotherapist) and conventional physiotherapy (a combination of methods such as heat or
cold massage, stretching, different forms of electrotherapy, traction, and a few exercises on
the treatment table) are likely to be cost effective in comparison to self exercise (patients
given information and told to walk for one hour three times a week for 12 weeks) for
preventing the re-occurrence of long term sickness absence in a Norwegian adult population
(Torstensen et al 1998).
4.4 Applicability of the evidence to the UK populations in
the scope
The costs associated with long term sickness absence including direct costs such as hospitalisation and indirect costs such as wages per day may vary considerably between countries. Similarly outcomes such as general health and quality of life may vary between countries. Therefore, generalisability of the results of the economic evaluations within the UK setting should be considered with caution. Further, ‘usual care’ of low back pain within the UK may be different to the comparators used within the studies. 4.5 Evidence tables for the three studies
Table 4.6 presents a summary of the evidence from the three included papers. 48 48 Additional information on these studies is presented in the effectiveness evidence tables in Chapter 3. IES, IWP, ScHARR
69
Table 4.6: Summary of evidence from three included papers
Study
details
Interventions and
comparator
Study
population
Time period
of analysis
Perspective
of analysis
Outcomes of
interest
Main results
Authors’ conclusions
Molde
Hagen E,
2003,
Norway
Intervention:
examined in a
spine clinic &
given information
and advice to stay
active
457 workers
between 18
and 60 years
placed on a
sick-list for 8
-12 weeks for
low back
pain.
3 years
Societal
Return to
work; number
of sickness
days
Net benefit of
intervention is
estimated to be
£3,747 [2007]
Care at the spine
clinic has a significant
short-term effect in
reducing sick leave
for patients with low
back pain and has
economic gains for
society.
Year of
analysis:
1998
Study
design:
Costbenefit
analysis
Grade: ++ Comparator:
Treated within
primary health
care
The initial effect on
coping strategies
diminish at 12 months
follow up.
Limitations of
analysis
The analysis is based
on data from only one
RCT
No analysis of
uncertainty has been
undertaken
No validation of the
model results has
been carried out
The study is not UKbased.
70 Interventions, strategies, programmes and policies to reduce the number of employees
recurring basis
who take long term sickness absence on a
Study
details
Interventions and
comparator
Study
population
Time period
of analysis
Perspective
of analysis
Outcomes of
interest
Main results
Steenstra I,
2006,
Netherlands
Intervention:
Workplace
assessment and
work modifications
based on
participative
ergonomics
implemented
between 2 to 8
weeks of sickleave;
196 workers
between 18
and 65 sicklisted for a
period of 2-6
weeks due to
low back pain
12 months
Societal
Return to work
(RTW) (days),
pain intensity,
functional
status, quality
of life, general
health
Cost of work
intervention vs
usual care per
lasting RTW for 1
day’s less sick leave
= €19 [2003] = £17
[2007]
Year of
analysis:
Unknown
Study
design:
Costeffectivenes
s and costutility
Grade: + Graded activity
program based on
operant
behavioural
therapy principles
after 8 weeks of
sick-leave with
usual care/
workplace
intervention
(see Table 3.6 in
the effectiveness
section for more
details of the
intervention
Comparator: Usual
care
Authors’
conclusions
Limitations of
analysis
The workplace
intervention was
more effective and
slightly more costly
than usual care in
terms of the
primary outcome
(RTW) and more
effective and less
costly in improving
most secondary
outcomes.
The analysis is
based on data
from only one RCT
The clinical
intervention was
less effective on all
outcomes and
more costly.
The time period
of the analysis is
limited
The year to which
prices refer is
unclear
The study is not
UK-based.
Usual care is not further described. IES, IWP, ScHARR
71
Study
details
Interventions and
comparator
Study
population
Torstensen,
T, 1998,
Norway
Intervention:
Medical exercise
therapy and
conventional
physiotherapy
208 patients
aged 20 to 65
with chronic low
back pain or
radicular pain
sick-listed for
more than 8
weeks and less
than 52 weeks.
Study
design:
Cost-benefit
analysis
Grade: +
Comparator: Selfexercise by
walking for 1 hour
3 times a week
for 12 weeks
Time
period of
analysis
Perspective
of analysis
Outcomes of
interest
15 months
Societal
Number of
working days
on sick leave
Main results
Authors’
conclusions
Limitations of
analysis
Medical exercise
therapy saved
£1,616 [2007] and
conventional
physiotherapy
saved £3,229 [2007]
per person
compared with the
self-exercise group.
Both the medical
exercise therapy
and the
conventional
physiotherapy are
equally effective
and are significantly
better than the selfexercise.
The analysis is
based on data from
only one RCT
Not treating
patients with
chronic low back
pain poses a risk of
worsening the
disability resulting
in longer periods of
sick leave.
The study is not UKbased.
No analysis of
uncertainty has
been undertaken
No validation of the
model results has
been carried out
72
Interventions strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
5 Discussion
The effectiveness and cost effectiveness reviews identified seven studies in total which met the inclusion criteria for interventions, programmes and strategies to reduce the re‐occurrence of long‐term sickness absence. All seven studies were identified for the effectiveness component of this review and three for the cost effectiveness component. 5.1 Effectiveness studies
The seven included effectiveness studies were of low to medium quality. Four (Molde Hagen et al, 2003; Soukup et al, 1999; Holopainen et al, 2004; and Leino et al, 1994) considered exercise programmes for the prevention of re‐occurrence of low back pain. The Molde Hagen study also appears in the cost effectiveness section. These studies show mixed results. The most robust study (Molde Hagen et al, 2003)) found evidence to suggest that a combination of physical exercise and educational interventions resulted in faster return to work and lower numbers of sick days taken in employees with lower back pain at 12 months and three years (however, there was no difference in the re‐occurrence of an episode of sick leave between the two groups over the three year period). Two further studies (Soukup et al., 1999 and Holopainen et al, 2004)) found evidence that a combination of physical exercise and educational interventions led to reductions in subsequent levels of sickness absence, and that this positive effect can be enhanced by increasing the amount of sustained physical exercise undertaken by participants. The final study (Leino, 1994) in this group found no significant differences between control and intervention groups in average number of re‐occurring spells of sickness absence or average number of days off sick following intervention. The evidence base for this theme is insufficient to draw conclusions about these specific interventions, although all four studies have common features and report on interventions that are comprehensive (in terms of range of inputs) and appropriate to participants. IES, IWP, ScHARR
73
One effectiveness study (Haugli et al, 2001) was of low methodological quality (‘‐‘) and examined pain management through group learning. The study indicates that the approach had no effect in reducing the re‐occurrence of long term sickness absence, although those in the intervention group were significantly less likely than those in the control group to be claiming disability benefits one year post intervention. This study provides limited evidence for the impact of the intervention on musculoskeletal pain, but not re‐occurrence of long term sick leave. The evidence base for this theme is insufficient to draw conclusions about the effectiveness of this intervention on the re‐occurrence of long term sickness absence. Under the third and final theme, two further studies (Steenstra et al., 2006 and Torstensen et al, 1998) looked at multi‐disciplinary interventions for low back pain. Both these papers also appear in the cost effectiveness section as they are primarily cost effectiveness or cost benefit evaluations. Both the studies provide evidence for the effectiveness of the interventions they evaluated. The first (Torstensen et al. 1998), a Norwegian study (graded ‘+’) found that both medical exercise therapy and conventional physiotherapy are effective when compared to self‐exercise in reducing total sickness absence. However, no significant difference was found between the control and intervention groups in terms of the numbers of patients returning to work during the study. The second study (Steenstra et al., 2006) in this theme (also graded ‘+’) evaluated a multi‐stage return to work programme. This was found to be more effective than usual care in reducing the number of sick days taken following return to work. It was also effective in increasing the rate of return to work amongst the intervention group. In general, this reflects a lack of evidence about the effects of interventions to prevent the re‐occurrence of long term sickness absence (rather than evidence of no effect). In particular, the seven studies included here deal with low back pain and no evidence was found in relation to other conditions or types of interventions which could equally reduce or prevent the re‐occurrence of long term sickness absence, in particular interventions related to other causes of long‐term absence (eg acute medical conditions, mental health and stress). 5.2 Cost-effectiveness studies
The cost‐effectiveness review identified three studies which (as for the effectiveness review) all evaluated interventions to address low back pain and prevent the re‐
occurrence of long term sickness absence. One of these papers was of high methodological quality (ie ‘++’) (Molde Hagen et al, 2003) and two were graded as medium methodological quality (ie ‘+)’ (Steenstra et al. 2006 and Torstensen et al, 74
Interventions strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
1998) 49. Due to differences in intervention and methodology, the three papers were considered separately. The first of these papers (Molde Hagen et al., 2003) compared examination at a spine clinic and information and advice on how to stay active with a control group made up of those treated in the Norwegian primary care system. Their findings indicate that this approach might be cost beneficial in preventing the re‐occurrence of long term sickness absence as opposed to primary care. The second paper (Steenstra et al., 2006) compared two forms of intervention (a workplace assessment and modifications on the one hand and clinical intervention on the other) with usual care (existing Dutch Occupational Physician guidance on management of lower back pain). The study found that compared to usual care for lower back pain, the workplace intervention was both more effective and less costly, while the clinical intervention was opposite (ie less effective and more costly) than usual care. The third paper (Torstensen et al., 1998) examines two different forms of exercise therapy against self‐exercise. The study found evidence for the cost benefit of both medical exercise therapy and conventional physiotherapy over self exercise. All three papers offer some evidence for the cost‐effectiveness or cost benefit of different exercise interventions against self exercise or treatment from existing guidance. There are too many dissimilarities between the studies for these effects to be compared with each other or for to be conclusions to be drawn about which form of intervention is most effective. 5.3 Emergent themes
All of the studies identified for this review are concerned with low back pain. This represents a clear lack of evidence about other forms of intervention or other conditions which may benefit from intervention to reduce or prevent the re‐
occurrence of long term sickness absence, specifically acute medical conditions, mental health and stress. With the exception of the first group of effectiveness studies (Molde Hagen et al (2003); Soukup et al (1999); Leino et al (1994) and Holopainen (2004)), the studies are sufficiently diverse as to preclude aggregation of data, so there are limits to the conclusions that can be drawn about specific interventions on the basis of this evidence, particularly in relation to a UK population. 49 Please note papers are graded separately, using different criteria, for the effectiveness and cost effectiveness reviews and therefore can have different ratings. IES, IWP, ScHARR
75
There are, however a number of emergent themes. Across the effectiveness and cost effectiveness studies, the interventions which are successful in reducing the re‐
occurrence of long term sickness absence share certain characteristics: ■ Most involve early intervention (in the Molde Hagen study participants were identified at eight to 12 weeks sick listing; Steenstra, two to six weeks sick leave; and Torstensen, a minimum of eight weeks sick leave). This compares to far broader inclusion criteria in the studies which failed to show significant findings (60 days over the past two years; thirty days in the previous year; four weeks in the previous 52). The only exception is Soukup et al study in which the precise number of participants who had taken sick leave prior to the study is not stated. ■ The interventions tend to involve some direct workplace input, either through design or assessment or workplace adaptation and delivery. Overall this suggests that successful interventions are more likely to incorporate a range of perspectives, have some form of direct contact with the workplace and involve early intervention. This review question is very specific in nature, concerned as it is with prevention of the re‐occurrence of long term sickness absence and many studies were excluded on the basis that they did not have a ‘prevention of re‐occurrence’ outcome. As such, these excluded studies may also be relevant to research question 2 (return to work from long term sickness absence). It is possible that data from research question 2 will also provide greater understanding of promising areas for research into interventions to prevent the re‐occurrence of long term sickness absence. 76
Interventions strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
References
Barham C, Begum N (2005) ‘Sickness absence from work in the UK’. Labour market trends. London: Office for National Statistics. Barham C, Leonard J (2002) ‘Trends and sources of data on sickness absence’. Labour market trends. London: Office for National Statistics. Chartered Institute of Personnel and Development (2006) Annual survey report 2006: absence management. London: Chartered Institute of Personnel and Development. CBI (2006) Absence minded: absence and labour turnover 2006, London: Confederation of British Industry Curtis L, Netten A. Unit costs of Health and Social Care 2004, Personal Social Services Research Unit, University of Kent. Drummond MF, Jefferson TD. Guidelines for authors and peer reviewers of economic submissions to the BMJ. British Medical Journal 1996;313:275‐83. Haugli, L., Steen, E., Laerum, E., Nygard, R., and Finset, A. (2001), ‘Learning to have less pain – is it possible? A one‐year follow‐up study of the effects of a personal construct group learning programme on patients with chronic musculoskeletal pain’, Patient Education and Counselling, vol. 45, no. 2, pp. 111‐118. Holopainen K, Nevala N, Kuronen P, and Arokoski JPA (2004). Effects of Vocationally Oriented Medical Rehabilitation for Aircraft Maintenance Personnel – A Preliminary Study of Long‐Term Effects With 5‐Year Follow‐up, Journal of Occupational Rehabilitation Vol.14, No. 4, December 2004 Leino P, Kivekäs J, Hänninen K (1994) ‘Effects of Work‐Oriented Fitness Courses in Lumberjacks with Low Back Pain’ Journal of Occupational Rehabilitation, VO. 4, No. 2. Loisel, P., Durand, P., Abenhaim, L., Gosselin, L., Simard, R., Turcotte, J., & Esdaile, J. M. 1994, ʺManagement of occupational back pain: The Sherbrooke model. IES, IWP, ScHARR
77
Results of a pilot and feasibility studyʺ, Occupational & Environmental Medicine, vol. 51, no. 9, pp. 597‐602. Molde Hagen E Grasdal A; Eriksen, HR (2003) ‘Does Early Intervention with a Light Mobilisation Program Reduce Long‐term Sick Leave for Low Back Pain: A three‐
year follow‐up study’ SPINE Vol 28 No. 20 pp 2309‐2316 Soukup MG, PT, MSci; Glomsrod B, PT; Lonn JH, PT; Bo K, PT, PE, PhD; Larsen S, MSc, DrSc. (1999) ‘The Effect of a Mensendieck Exercise Program as Secondary Prophylaxis for Recurrent Low Back Pain: A Randomised, Controlled Trial with 12 month follow‐up’. SPINE Vol 24, Number 15, pp 1585 – 1592 Steenstra, I. A., Anema, J. R., van, T. M. W., Bongers, P. M., de, V. H. C., & van, M. W. 2006, ‘Economic evaluation of a multi‐stage return to work program for workers on sick‐leave due to low back pain’, Journal of Occupational Rehabilitation, vol. 16, no. 4, pp. 557‐578. Torstensen, T. A., Ljungggren, A. E., Meen, H. D., Odland, E., Mowinckel, P., & Geijerstam, S. 1998, ‘Efficiency and costs of medical exercise therapy, conventional physiotherapy, and self‐exercise in patients with chronic low back pain: A pragmatic, randomized, single‐blinded, controlled trial with 1‐year follow‐ up’, Spine, vol. 23, no. 23, pp. 2616‐2624. 78
Interventions strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
Appendix 1: Example Search Strategy
used for Research Questions 1 to 3
MEDLINE primary study search strategy research Questions 1
to 3 (intervention effectiveness)
1. long term absen$.ti,ab. 2. long term sick$.ti,ab. 3. exp sick leave/ 4. (sick$ adj3 leave).ti,ab. 5. (sick$ adj3 absen$).ti,ab. 6. (work adj3 absen$).ti,ab. 7. (return$ adj3 work$).ti,ab. 8. work readiness.ti,ab. 9. sick$ benefit$.ti,ab. 10. disability leave.ti,ab. 11. (injur$ adj3 claim$).ti,ab. 12. (stay$ adj3 work$).ti,ab. 13. (participat$ adj3 work$).ti,ab. 14. (participat$ adj3 employ$).ti,ab. 15. (attend$ adj3 work$).ti,ab. IES, IWP, ScHARR
16. (attend$ adj3 employ$).ti,ab. 17. absenteeism/ 18. ((sick$ or work$ or illness$ or employee$) adj3 absenteeism).ti,ab. 19. (welfare adj3 work$).ti,ab. 20. (sicklist$ or sick list$).ti,ab. 21. or/1‐20 Methodological filters
Randomized controlled trials:
MEDLINE
1. RANDOMIZED CONTROLLED TRIAL.pt. 2. CONTROLLED CLINICAL TRIAL.pt. 3. RANDOMIZED CONTROLLED TRIALS/ 4. CONTROLLED CLINICAL TRIALS/ 5. RANDOM ALLOCATION/ 6. DOUBLE BLIND METHOD/ 7. SINGLE BLIND METHOD/ 8. CLINICAL TRIAL.pt. 9. exp CLINICAL TRIALS/ 10. (clin$ adj25 trial$).ti,ab. 11. ((singl$ or doubl$ or trebl$ or tripl$) adj25 (blind$ or mask$)).ti,ab. 12. PLACEBOS/ 13. placebo$.ti,ab. 14. random$.ti,ab. 15. RESEARCH DESIGN.sh. 16. or/1‐15 79
80
Interventions strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
Longitudinal/Intervention studies:
MEDLINE
1. exp longitudinal studies/ 2. longitudinal$.tw. 3. exp retrospective studies/ 4. retrospective study.tw. 5. exp prospective studies/ 6. prospective study.tw. 7. quasi‐experimental.tw. 8. (follow‐up$ or follow$ up).tw. 9. repeat$ measure$.tw. 10. (post‐test or posttest or (pre adj5 post)).tw. 11. (t1 or t2 or t3).tw. 12. baseline.tw. 13. (over time or time period).tw. 14. interrupted time series.tw. 15. predict$ design$.tw. 16. case control$.tw. 17. cohort.tw. 18. exp cohort studies/ 19. exp case‐control studies/ 20. (intervention$ or program$ or strateg$ or initiative$ or policy or policies).ti,ab. 21. or/1‐20 IES, IWP, ScHARR
Reviews:
MEDLINE
1. COCHRANE DATABASE OF SYSTEMATIC REVIEWS.jn. 2. meta‐analysis.pt. 3. medline.tw. 4. systematic review.tw. 5. search.tw. 6. or/1‐5 81
Interventions strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
82
Appendix 2: Sifting Criteria Used
The NICE Absence Sift Criteria for Research Questions 1 to 3 are set out below. NICE Absence Sift Criteria: Effectiveness primary studies
Questions 1 to 3
The ultimate aim of this review is to provide guidance on the most
effective actions to manage sickness absence and support return to work.
For all titles and abstracts answer ALL questions unless coded as rev or econ
at Q1 or excluded at any stage
QUESTION
Q1
ANS
QUALIFIER
ACTION
Is this an evaluation of an No
intervention, policy,
strategy or programme?
Review/Systematic Review or Meta Code as
Analysis
Rev
Economic data
Code as
Econ
ie a piece of empirical
research evaluating an
intervention, policy,
strategy or programme
Other
Exclude
Population – if focuses solely on
children (under 16)
Exclude
Delivered in non workplace or non
primary care setting
Exclude
Absence not due to sickness (ie
maternity leave)
Exclude
Doc type – dissertation
Exclude
Yes
IES, IWP, ScHARR
QUESTION
ANS
QUALIFIER
83
ACTION
Intervention – if focuses solely on
provision of pharmacological
treatment
Exclude
Intervention, policy etc – other
Go to
Q2
Intervention, policy etc., population, Go to
setting, absence or document type - Q2
unclear
Q2
Does the study measure
work related outcomes?
No
Yes
ie any measure of how the
intervention, policy,
strategy or programme
impacts on work
behaviour or attendance
Exclude
Reduce the numbers of employees
moving from short to long term
sickness absence?
Aid the return to work of employees code as
after long term sickness absence? Review
2 (R2)
Reduce the re-occurrence of an
employees long term sickness
absence?
code as
Review
3 (R3)
Assist incapacity benefit recipients
in returning to work
Go to
Q2a
Other work-related outcome
Code
Other
Code
Unclear
Unclear
Q2a If benefits related, is the
population UK only?
Q3
Is the study longitudinal?
(ie at least one follow up
measure after baseline)
code as
Review
1 (R1)
No
If not relevant to R1, R2, R3
Exclude
Yes
Code as
Review
4 (R4)
Unclear
Code
unclear
No
Tag
Yes
Include
Unclear
Code
Unclear
84
Interventions strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
QUESTION
ANS
QUALIFIER
ACTION
Enter decision in final column – if any ‘unclear’ code as GFP
Q4
Book chapter?
Yes
Tag
NICE Absence Sift Criteria: Economics (primary studies and
reviews) Questions 1 to 3
The ultimate aim of the economics reviews is to provide guidance on the
most cost effective actions to manage sickness absence and support
return to work or to help those in receipt of incapacity benefit to return
to full or part time work
For all titles and abstracts answer ALL questions UNLESS coded as exclude at
any stage
QUESTION
Q1
Is the study a
comparative economic
evaluation of an
intervention, policy,
strategy or programme
related to sickness
absence?
ie study type is ‘costeffectiveness’, ‘cost
consequences’, ‘cost
benefit’, ‘cost-utility’,
‘cost-minimisation’ or
reports outcomes cost
per x gained or cost per x
avoided or net monetary
benefit (cost benefit
only). Code as unclear
anything with costs and
consequences reported
separately but doesn't
call it any of the above.
ANS
Yes
QUALIFIER
ACTION
Population – if focuses solely
on children (16 & under)
Exclude
Setting - delivered in non
workplace or non primary
care setting or delivered
solely in a developing country
Exclude
Absence - not due to sickness
(eg maternity leave)
Exclude
Topic – if focuses solely on
pharmacological treatment
Exclude
Topic – if focus is prevention
of 1st instance of sickness
absence
Exclude
Topic – if focuses solely on
effectiveness of IB system,
private health insurance
schemes or statutory sick pay
Exclude
Abstracts describes
comparative economic
evaluation of an intervention,
Go to Q2
IES, IWP, ScHARR
QUESTION
ANS
Unclear
Does the study contain
work related outcome
measures?
Is the study based in UK
Abstracts unclear if
comparative economic
evaluation of an intervention,
policy etc
Code
U/C & go
to Q2
Abstracts includes work
related costs & consequences
but not comparative economic
evaluation of intervention,
policy etc
Code Modelling
No
Exclude
No
Exclude
Yes
Q3
Reduce the numbers of
employees moving from short
to long term sickness
absence?
code R1
Aid the return to work of
employees after long term
sickness absence?
code R2
Reduce the re-occurrence of
an employees long term
sickness absence?
code R3
Assist UK incapacity benefit
recipients in returning to work
Go to Q3
Other work-related outcome
Code Oth
Unclear
Code
U/C
No
Exclude
Yes
Include in Q4 economics
review
Unclear
Enter decision in final column – if any ‘unclear’ code as GFP
Tag if book chapter & tag if benefits recipients
ACTION
policy etc
ie. not costs of an illness
Q2
QUALIFIER
85
Code as
Review 4
Code
U/C
86
Interventions strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
NICE Absence Sift Criteria: Effectiveness reviews Questions 1
to 3 and Question 4
The ultimate aim of the review is to provide guidance on the most
effective actions to manage sickness absence and support return to work
or to help those in receipt of incapacity benefit to return to full or part
time work
For all titles and abstracts answer ALL questions UNLESS coded as exclude at
any stage
QUESTION
Q1
Is the article a
review of
interventions,
policies, strategies
or programmes
aimed at reducing
sickness absence or
aiding return to
work?
ANS
Yes
Unclear
Q2
Is it a review of
QUALIFIER
ACTION
Population – if focuses solely on
children (16 & under)
Exclude
Setting – if related to reducing
sickness absence and delivered in
non workplace or non primary care
setting (check IB relevant)
Exclude
Setting - delivered solely in a
developing country
Exclude
Absence - not due to sickness (eg
maternity leave)
Exclude
Intervention – if solely health
promotion or prevention of 1st
instance
Exclude
Intervention – if focuses solely on
pharmacological treatment
Exclude
Intervention – deals solely with
effectiveness of IB system, private
health insurance schemes or statutory
sick pay
Exclude
Intervention, policy etc – other
Go to Q2
Intervention, policy etc – unclear
unclear
& go to
Q2
No
Exclude
Yes
Go to Q3
IES, IWP, ScHARR
QUESTION
ANS
QUALIFIER
87
ACTION
longitudinal studies?
Q3
Q4
Does the review
report on work
related outcome
measures?
Does the review
contain data from
(a) UK based
study/ies
TAG
No
Exclude
Unclear
unclear
& go to
Q3
No
Exclude
Yes
Reduce the numbers of employees
moving from short to long term
sickness absence?
code
Review 1
Aid the return to work of employees
after long term sickness absence?
code
Review 2
Reduce the re-occurrence of an
employees long term sickness
absence?
code
Review 3
Assist UK incapacity benefit recipients
in returning to work
Go to Q4
Other work-related outcome
Code
Other
Unclear
Code
unclear
No
Exclude
Yes
Include
Unclear
Code
unclear
Book chapter
Tag
Economics data
Tag
Primary study
Tag
Enter decision in final column – if any ‘unclear’ code as GFP
88 Interventions strategies, programmes and policies to reduce the number of employees
recurring basis
who take long term sickness absence on a
Appendix 3: Full Paper Screening Checklists
Table 2
Full paper screening TRIAGE Form: Q3 Effectiveness (primary study)
Paper checked by:
Date of check:
1. Population: Does the study population include adults over age 16 in full or part-time employment, both paid and unpaid who have
experienced long-term sickness (which may be defined as ‘long-term absence’ or ‘sickness absence’ in the research)?
2. Intervention: Does the intervention/policy/strategy/programme being delivered aim to reduce the re-occurrence or the number of
incidences or re-occurrence of long-term sickness absence?
3. Setting: Is the setting…
•
based in a developed/OECD country/ies
•
a primary care setting and/or workplace setting and/or planned, designed, delivered, managed or funded in collaboration with
primary care providers and/or employers. (These interventions, policies, programmes or strategies can be delivered by a number
of providers (such as voluntary, private, statutory sectors) and/or in various settings not just workplace or primary care settings as
long as they are fully or co-planned, designed, delivered, managed and/or funded in collaboration with primary care providers
and/or employers? ). Interventions can include mixed component studies - eg treatment and public health )
4. Outcome: Is one of the following work absence related outcomes being measured:
•
return to work (paid and un-paid) after re-occurring long-term sickness. (This could be a return to work in: original role with
same hours, original role with reduced hours, alternative role with same hours, or alternative role with different hours).
•
reduced incidence of recurring (>1 episode) long-term sickness
•
shorter periods of recurring sickness absence
•
reduction in number of sick days
•
improvements in individual and/or population-level health status which enables remaining in work following sickness absence
incidences
•
no effect on return to work after re-occurring long-term sickness or no effect on number of sick days taken
•
cost effectiveness of intervention/policy/strategy or programme
•
other work absence related outcome (please specify)
Ref Man ID No:
Yes
No
unclear
Yes
No
unclear
Yes
No
unclear
Yes
No
unclear
IES, IWP, ScHARR
5.
Study Design: Is the study longitudinal in design (ie at least one measurement after baseline)
If yes what is the study design?(circle): RCT
Controlled before and after
Cohort
Case control
Before and after
Interrupted Time Series
Other (please specify as reported)………………………………………..
IF ANY 1-5 = ‘NO’, CHECK Q8 THEN EXCLUDE
6. If 1-5 all Yes, does the study meet any of the following exclusion criteria:
•
Study – pre 1990
•
Study not English language
•
Deals solely with preventing ill-health retirement (ie where recipient has no intention of returning to work)
•
Deals solely with self-employed individuals
•
Deals solely with unemployed individuals
•
Deals solely with pregnant women who have taken sickness absence related to their pregnancy, during the course of their
pregnancy
•
Deals solely with workplace absences which are not reported and/or recorded as sickness absence (eg maternity leave)
•
Solely aims to prevent the first occurrence of short or long sickness absence (primary prevention)
•
Deal solely with the provision of clinical diagnosis, treatment (including pharmacological or therapeutic interventions) and
management of conditions associated with short and/or long-term sickness
•
Solely target pregnant women exclusively and/or which focus on illnesses associated with pregnancy, during the course of
pregnancy
•
Deal solely with the effectiveness of private health insurance schemes and/or claiming of statutory or occupational sick pay
• Dissertation or thesis
IF ANY Q6 = ‘YES’, CHECK Q8 THEN EXCLUDE
7.
8.
If the study is a combined population, topic or location, can the public health data be disaggregated?
Does the study contain economic/cost data or effectiveness data relevant to the other research questions* OR data relevant for the
economic modelling for this research question (which does not have to be UK)
I Q7 = ‘NO’, TAG AS MIXED, THEN EXCLUDE: IF ANY Q1-7 = ‘UNCLEAR’, REFER FOR SECOND OPINION
Modelling
Put forward for QUALITY ASSSESSMENT and DATA EXTRACTION (studies to be grouped by study design type) Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
unclear
unclear
unclear
unclear
unclear
unclear
unclear
unclear
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
unclear
unclear
unclear
unclear
unclear
unclear
Yes
No
unclear
Yes
Yes
No
No
unclear
unclear
Yes
No
unclear
Yes
No
unclear
Yes
No
unclear
Yes
Yes
No
No
unclear
unclear
Yes
No
unclear
Q1
Q2
Q4
89
90 Interventions strategies, programmes and policies to reduce the number of employees
recurring basis
who take long term sickness absence on a
IES, IWP, ScHARR
Full paper screening TRIAGE Form: Q3 Reviews
Ref Man ID No:
Paper checked by:
Date of check:
1. Population: Does the review partly or wholly cover studies where the population is adults over age 16 in full or part-time employment, both
Yes No
unclear
paid and unpaid who have experienced long-term sickness (which may be defined as ‘long-term absence’ or ‘sickness absence’ in the
Yes No
unclear
research)?
2. Intervention: Does the review partly or wholly cover studies where the intervention/policy/strategy/programme being delivered aim to
reduce the re-occurrence or the number of incidences of re-occurrence of long-term sickness absence?
3. Setting: Does the review partly or wholly cover studies where the setting is…
Yes No
unclear
•
based in a developed/OECD country/ies
Yes No
unclear
•
a primary care setting and/or workplace setting and/or planned, designed, delivered, managed or funded in collaboration with primary
care providers and/or employers. (These interventions, policies, programmes or strategies can be delivered by a number of providers
(such as voluntary, private, statutory sectors) and/or in various settings not just workplace or primary care settings as long as they are
fully or co-planned, designed, delivered, managed and/or funded in collaboration with primary care providers and/or employers? ).
Interventions can include mixed component studies - eg treatment and public health )
Yes No
unclear
4. Outcome: Does the review cover studies where one of the following work absence related outcomes are being measured:
•
return to work (paid and un-paid) after re-occurring long-term sickness. (This could be a return to work in: original role with same hours,
original role with reduced hours, alternative role with same hours, or alternative role with different hours).
•
reduced incidence of recurring (>1 episode) long-term sickness
•
shorter periods of recurring sickness absence
•
reduction in number of sick days taken
•
improvements in individual and/or population-level health status which enables remaining in work following sickness absence
incidences
•
no effect on return to work after re-occurring long-term sickness or no effect on number of sick days taken
•
cost effectiveness of intervention/strategy/policy or programme
Yes No
unclear
•
other work absence related outcome (please specify)
5. Study Design: Does the review include studies that are longitudinal in design (ie at least one measurement after baseline)
If yes what are the study designs?(circle as appropriate):
RCT
Controlled before and after
Cohort
Case control
Before and after
Interrupted Time Series
Other (please specify as reported)………………………………………..
IF ANY 1-5 = ‘NO’, CHECK Q8 THEN EXCLUDE
6. If 1-5 all Yes, does the review meet any of the following exclusion criteria:
Yes No
unclear
•
Review – pre 1990
Yes No
unclear
•
Review not English language
Yes No
unclear
•
Deals solely with preventing ill-health retirement (ie where recipient has no intention of returning to work)
Yes No
unclear
91
92 Interventions strategies, programmes and policies to reduce the number of employees
recurring basis
•
•
•
7.
8.
who take long term sickness absence on a
Deals solely with self-employed individuals
Deals solely with unemployed individuals
Deals solely with pregnant women who have taken sickness absence related to their pregnancy, during the course of their
pregnancy
•
Deals solely with workplace absences which are nor reported and/or recorded as sickness absence (eg maternity leave)
•
Solely aims to prevent the first occurrence of short or long term sickness absence (primary prevention)
•
Deals solely with the provision of clinical diagnosis, treatment (including pharmacological or therapeutic interventions) and
management of conditions associated with short and/or long-term sickness
•
Solely targets pregnant women exclusively and/or which focuses in illnesses associated with pregnancy, during the course of
pregnancy
•
Deals solely with the effectiveness of private health insurance schemes and/or claiming of statutory or occupational sick pay
•
Dissertation or thesis
IF ANY Q6 = ‘YES’, CHECK Q7 THEN EXCLUDE
*Does the review contain economic/cost data or effectiveness data relevant to the other research questions OR data which may be useful
for the economic modelling (specify)……………………………………………………………………………………….
If any Q1-7 =‘UNCLEAR’, REFER FOR SECOND OPINION
Put forward for reference checking
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
unclear
unclear
unclear
unclear
unclear
Yes
No
unclear
Yes
Yes
No
No
unclear
unclear
Yes
No
unclear
* Q1 – Preventing/reduce employees moving from short to long term sickness (including re-occurrence of short term sickness); Q2 Help employees return to work from
LTSA; Q3 prevent the re-occurrence of LTSA
IES, IWP, ScHARR
93
Full paper screening TRIAGE Form: Q3 Economics (primary study)
Paper checked by:
Date of check:
1. Population: Does the study population include adults over age 16 in full or part-time employment, both paid and unpaid who have
experienced long-term sickness (which may be defined as ‘long-term absence’ or ‘sickness absence’ in the research)?
2. Intervention: Does the intervention/policy/strategy/programme being delivered aim to reduce the re-occurrence or the number of
incidences of re-occurrence of long-term sickness absence?
3. Setting: Is the setting…
•
based in a developed/OECD country/ies
•
a primary care setting and/or workplace setting and/or planned, designed, delivered, managed or funded in collaboration with primary
care providers and/or employers. (These interventions, policies, programmes or strategies can be delivered by a number of providers
(such as voluntary, private, statutory sectors) and/or in various settings not just workplace or primary care settings as long as they are
fully or co-planned, designed, delivered, managed and/or funded in collaboration with primary care providers and/or employers? ).
Interventions can include mixed component studies - eg treatment and public health )
4. Outcome: Is one of the following work absence related outcomes being measured:
•
return to work (paid and un-paid) after re-occurring long-term sickness. (This could be a return to work in: original role with same
hours, original role with reduced hours, alternative role with same hours, or alternative role with different hours).
•
reduced incidence of recurring (>1 episode) long-term sickness
•
shorter periods of recurring sickness absence
•
reduction in number of sick days taken
•
improvements in individual and/or population-level health status which enables remaining in work following sickness absence
incidences
•
no effect on return to work after re-occurring long-term sickness or no effect on number of sick days taken
•
cost effectiveness of intervention/policy/strategy/programme
•
other work absence related outcome (please specify)
5. Study design: Is the study an economic evaluation (ie an RCT or longitudinal study with at least one follow up measure after baseline) with
cost effectiveness, cost consequence, cost benefit, cost utility, cost minimization or net monetary (cost) benefit data?
If yes to Q5, What is the study design?(circle)
Cost benefit (CBA)
Cost effectiveness
Cost utility
Other (please specify as reported)
IF ANY 1-5 = ‘NO’, CHECK Q8 THEN EXCLUDE
6. If 1-5 all Yes, does the study meet any of the following exclusion criteria:
•
Study – pre 1990
•
Study not English language
•
Deals solely with preventing ill-health retirement (ie where recipient has no intention of returning to work)
•
Deals solely with self-employed individuals
•
Deals solely with unemployed individuals
Reference Manager ID
No:
Yes
No
unclear
Yes
No
unclear
Yes
No
unclear
Yes
No
unclear
Yes
No
unclear
Yes
No
Unclear
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
unclear
unclear
unclear
unclear
unclear
unclear
94 Interventions strategies, programmes and policies to reduce the number of employees
recurring basis
•
•
•
•
•
•
•
7.
8.
who take long term sickness absence on a
Deals solely with pregnant women who have taken sickness absence related to their pregnancy, during the course of their
pregnancy
Deals solely with workplace absences which are not reported and/or recorded as sickness absence (eg maternity leave)
Solely aims to prevent the first occurrence of short or long term sickness absence (primary prevention)
Deal solely with the provision of clinical diagnosis, treatment (including pharmacological or therapeutic interventions) and
management of conditions associated with short and/or long-term sickness
Solely targets pregnant women exclusively and/or which focus on illnesses associated with pregnancy, during course of
pregnancy
Deal solely with the effectiveness of private health insurance schemes and/or claiming of statutory or occupational sick pay
Dissertation or thesis
IF ANY Q6 = ‘YES’, CHECK Q8 THEN EXCLUDE
If the study is a combined population, topic or location, can the public health data be disaggregated?
Does the study contain economic/cost data or effectiveness data relevant to the other research questions* OR data relevant for the
economic modelling for this research question (which does not have to be UK)
IF Q7 = ‘NO’, TAG AS MIXED, THEN EXCLUDE;IF ANY Q1-7 = ‘UNCLEAR’, REFER FOR SECOND OPINION
Yes
Yes
Yes
No
No
No
unclear
unclear
unclear
Yes
Yes
Yes
No
No
No
unclear
unclear
unclear
Yes No
Q1
Q2
Q3
Modelling
Unclear
9. Put forward for QUALITY ASSSESSMENT and DATA EXTRACTION (studies to be grouped by study design type)
(*Q1 Preventing/reduce employees moving from short to long term sickness (including re‐occurrence of short term sickness); Q2 Help employees return to work from LTSA; Q4 return to work for IB recipients) IES, IWP, ScHARR
95
Appendix 4: Excluded Primary Studies by
Reason for Exclusion
Effectiveness studies: Excluded studies by reason 50
Population
(eg the study did not include employees or people with experience of long‐term sickness absence who were back at work and therefore at risk of a re‐occurrence of long‐term sickness absence) Abbass, A. 2002, ʺIntensive short‐term dynamic psychotherapy in a private psychiatric office: Clinical and cost effectivenessʺ, American Journal of Psychotherapy, vol. 56, no. 2, pp. 225‐232. Abenhaim, L., Rossignol, M., Valat, J. P., Nordin, M., Avouac, B., Blotman, F., Charlot, J., Dreiser, R. L., Legrand, E., Rozenberg, S., & Vautravers, P. 2000, ʺThe role of activity in the therapeutic management of back pain ‐ Report of the International Paris Task Force on Back Painʺ, Spine, vol. 25, no. 4, pp. 1S‐33S. Abrams, D., Barker, L. T., Haffey, W., & Nelson, H. 1993, ʺThe economics of return to work for survivors of traumatic brain injury: Vocational services are worth the investmentʺ, Journal of Head Trauma Rehabilitation, vol. 8, no. 4, pp. 59‐76. Adams, J. H. & Williams, A. C. D. 2003, ʺWhat affects return to work for graduates of a pain management program with chronic upper limb pain?ʺ, Journal of Occupational Rehabilitation, vol. 13, no. 2, pp. 91‐106. 50 Once a study falls against one criterion it is not checked against the others. Studies may not pass a number of criteria for inclusion but are listed here under the first reason for which they are excluded. 96
Interventions strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
Adams, R. J., Boath, K., Homan, S., Campbell, D. A., & Ruffin, R. E. 2001, ʺA randomized trial of peak‐flow and symptom‐based action plans in adults with moderate‐to‐severe asthmaʺ, Respirology, vol. 6, no. 4, pp. 297‐304. Ahlgren, Ã., Bergroth, A., Ekholm, J., & Schüldt, K. 2007, ʺWork resumption after vocational rehabilitation: A follow‐up two years after completed rehabilitationʺ, Work, vol. 28, no. 4, pp. 343‐354. Alaranta, H., Rytokoski, U., Rissanen, A., Talo, S., Ronnemaa, T., Puukka, P., Karppi, S. L., Videman, T., Kallio, V., & Slatis, P. 1994, ʺIntensive physical and psychosocial training program for patients with chronic low back pain. A controlled clinical trialʺ, Spine, vol. 19, no. 12, pp. 1339‐1349. Aldana, S. G., Merrill, R. M., Price, K., Hardy, A., & Hager, R. 2005, ʺFinancial impact of a comprehensive multisite workplace health promotion programʺ, Preventive Medicine, vol. 40, no. 2, pp. 131‐137. Almog, G., Lamond, P. J., & Gosselin, G. 2004, ʺEffects of chiropractic care on spinal symptomatology among professional drivers: a pilot studyʺ, Clinical Chiropractic, vol. 7, no. 3, pp. 114‐119. Altchiler, L. & Motta, R. 1994, ʺEffects of aerobic and nonaerobic exercise on anxiety, absenteeism, and job satisfactionʺ, Journal of Clinical Psychology, vol. 50, no. 6, pp. 829‐840. Ambrosuis, F. M., Kremer, A. M., Bartz, S. R., & Herkner, P. B. 1994, ʺA preliminary comparison of isokinetic data among back‐injured surgical and nonsurgical patients, and the effect of a functional restoration program on their ability to return to workʺ, Isokinetics and Exercise Science, vol. 4, no. 1, pp. 34‐40. Anderson, J. & Dusenbury, L. 1999, ʺWorksite cholesterol and nutrition: An intervention project in Coloradoʺ, AAOHN Journal, vol. 47, no. 3, pp. 99‐106. Anema, J. R., Steenstra, I. A., Urlings, I. J. M., Bongers, P. M., de Vroome, E. M. M., & van Mechelen, W. 2003, ʺParticipatory ergonomics as a return‐to‐work intervention: A future challenge?ʺ, American Journal of Industrial Medicine, vol. 44, no. 3, pp. 273‐281. Arnetz, B. B., Sjogren, B., Rydehn, B., & Meisel, R. 2003, ʺEarly workplace intervention for employees with musculoskeletal‐related absenteeism: A prospective controlled intervention studyʺ, Journal of Occupational & Environmental Medicine, vol. 45, no. 5, pp. 499‐506. Arnetz, J. & Arnetz, B. 2000, ʺImplementation and evaluation of a practical intervention programme for dealing with violence towards health care workersʺ, J Advanced Nursing, vol. 31, no. 3, pp. 668‐680. IES, IWP, ScHARR
97
Arrelov, B., Borgquist, L., Ljungberg, D., & Svardsudd, K. 2003, ʺThe influence of change of legislation concerning sickness absence on physiciansʹ performance as certifiers ‐ A population‐based studyʺ, Health Policy, vol. 63, no. 3, pp. 259‐268. Ashburner, C., Meyer, J., Cotter, A., Young, G., & Ansell, R. 2004, ʺSeeing things differently: evaluating psychodynamically informed group clinical supervision for general hospital nurses... including commentary by Bishop Vʺ, NT Research, vol. 9, no. 1, pp. 38‐49. Astrup, S. J., McGovern, P. M., & Kochevar, L. K. 1992, ʺThe relationship between wellness participation and health care benefit utilizationʺ, Benefits Quarterly, vol. 8, no. 2, pp. 41‐54. Atlas, S. J., Singer, D. E., Keller, R. B., Patrick, D. L., & Deyo, R. A. 1996, ʺApplication of outcomes research in occupational low back pain: The Maine Lumbar Spine study Adding a vocational focus to mental health rehabilitationʺ, American Journal of Industrial Medicine, vol. 29, no. 6, pp. 584‐589. Azrin, N. H., McMahon, P. T., Donohue, B., Besalel, V. A., Lapinski, K. J., Kogan, E. S., Acierno, R. E., & Galloway, E. 1994, ʺBehavior therapy for drug abuse: a controlled treatment outcome studyʺ, Behaviour research and therapy, vol. 32, no. 8, pp. 857‐866. Badii, M., Keen, D., Yu, S., & Yassi, A. 2006, ʺEvaluation of a comprehensive integrated workplace‐based program to reduce occupational musculoskeletal injury and its associated morbidity in a large hospitalʺ, Journal of Occupational and Environmental Medicine, vol. 48, no. 11, pp. 1159‐1165. Bailey, E. L., Ricketts, S. K., Becker, D. R., Xie, H., & Drake, R. E. 1998, ʺDo long‐term day treatment clients benefit from supported employment?ʺ, Psychiatric Rehabilitation Journal, vol. 22, no. 1, pp. 24‐29. Bailyn, L., Collins, R., & Song, Y. 2007, ʺSelf‐scheduling for hospital nurses: an attempt and its difficultiesʺ, Journal of Nursing Management, vol. 15, no. 1, pp. 72‐77. Bambra, C., Whitehead, M., & Hamilton, V. 2005, ʺDoes ʹwelfare‐to‐workʹ work? A systematic review of the effectiveness of the UKʹs welfare‐to‐work programmes for people with a disability or chronic illnessʺ, Social Science and Medicine, vol. 60, no. 9, pp. 1905‐1918. Bartleson, J. D. 2000, ʺTriptans to the rescue: effective therapy for migraine headaches in the workplace.[comment]ʺ, Mayo Clinic Proceedings, vol. 75, no. 8, pp. 780‐781. Bates, R. A. 2001, ʺPublic sector training participation: An empirical investigationʺ, International Journal of Training and Development, vol. 5, no. 2, pp. 136‐152. 98
Interventions strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
Battie, M. C., Fulton Kehoe, D., & Franklin, G. 2002, ʺThe effects of a medical care utilization review program on back and neck injury claimsʺ, Journal of Occupational and Environmental Medicine, vol. 44, no. 4, pp. 365‐371. Batt‐Rawden, K. B. & Tellnes, G. 2005, ʺNature‐culture‐health activities as a method of rehabilitation: An evaluation of participantsʹ health, quality of life and functionʺ, International Journal of Rehabilitation Research, vol. 28, no. 2, pp. 175‐180. Bell, M. D., Lysaker, P. H., & Milstein, R. M. 1996, ʺClinical benefits of paid work activity in schizophreniaʺ, Schizophrenia bulletin, vol. 22, no. 1, pp. 51‐67. Ben‐Ari, E., Rothbaum, D. A., Linnemeier, T. A., Landin, R., Tavel, M., Steinmetz, E. F., Hillis, J. S., Hallam, C. C., Noble, R. J., See, M. R., Ball, M., & Martin, P. 1992, ʺReturn to work after successful coronary angioplasty: Comparison between a comprehensive rehabilitation program and patients receiving usual careʺ, Journal of Cardiopulmonary Rehabilitation, vol. 12, no. 1, pp. 20‐24. Bendix, A. F., Bendix, T., & Haestrup, C. 1998, ʺCan it be predicted which patients with chronic low back pain should be offered tertiary rehabilitation in a functional restoration program? A search for demographic, socioeconomic, and physical predictors... including commentary by Mayer TGʺ, Spine, vol. 23, no. 16, pp. 1775‐1784. Bendix, A. F., Bendix, T., Haestrup, C., & Busch, E. 1998, ʺA prospective, randomized 5‐year follow‐up study of functional restoration in chronic low back pain patientsʺ, European Spine Journal, vol. 7, no. 2, pp. 111‐119. Bendix, A. F., Bendix, T., Kirkbak, S., & Ostenfeld, S. 1997, ʺComparison of three intensive programs for chronic low back pain patients: A prospective, randomized, observer‐blinded study with one‐year follow‐upʺ, Scandinavian Journal of Rehabilitation Medicine, vol. 29, no. 2, pp. 81‐89. Bendix, A. F., Bendix, T., Labriola, M., & Boekgaard, P. 1998, ʺFunctional restoration for chronic low back painʺ, Spine, vol. 23, no. 6, pp. 717‐725. Bendix, A. F., Bendix, T., Ostenfeld, S., Bush, E., & Andersen 1995, ʺActive treatment programs for patients with chronic low back pain: a prospective, randomized, observer‐blinded studyʺ, European Spine Journal, vol. 4, no. 3, pp. 148‐152. Bendix, A. F., Bendix, T., Vaegter, K., Lund, C., Frolund, L., & Holm, L. 1996, ʺMultidisciplinary intensive treatment for chronic low back pain: a randomized, prospective studyʺ, Cleveland Clinic Journal of Medicine, vol. 63, no. 1, pp. 62‐69. BenEliyahu, D. J. 1996, ʺMagnetic resonance imaging and clinical follow‐up: Study of 27 patients receiving chiropractic care for cervical and lumbar disc herniationsʺ, Journal of Manipulative & Physiological Therapeutics, vol. 19, no. 9, pp. 597‐606. IES, IWP, ScHARR
99
Berger, M. L., Howell, R., Nicholson, S., & Sharda, C. 2003, ʺInvesting in healthy human capitalʺ, Journal of Occupational and Environmental Medicine, vol. 45, no. 12, pp. 1213‐1225. Bernaards, C. M., Jans, M. P., van den Heuvel, S. G., Hendriksen, I. J., Houtman, I. L., & Bongers, P. M. 2006, ʺCan strenuous leisure time physical activity prevent psychological complaints in a working population?ʺ, Occupational and Environmental Medicine, vol. 63, no. 1, pp. 10‐16. Bernacki, E. J., Guidera, J. A., Schaefer, J. A., & Tsai, S. 2000, ʺA facilitated early return to work program at a large urban medical centerʺ, Journal of Occupational and Environmental Medicine, vol. 42, no. 12, pp. 1172‐1177. Bertera, R. L. 1990, ʺThe effects of workplace health promotion on absenteeism and employment costs in a large industrial populationʺ, American Journal of Public Health, vol. 80, no. 9, pp. 1101‐1105. Beutel, M. E., Rasting, M., Stuhr, U., Ruger, B., & Leuzinger Bohleber, M. 2004, ʺAssessing the impact of psychoanalyses and long‐term psychoanalytic therapies on health care utilization and costs Adding a vocational focus to mental health rehabilitationʺ, Psychotherapy Research, vol. 14, no. 2, pp. 146‐160. Biswas, S., Clark, A., & Shields, D. A. 2007, ʺRandomised clinical trial of the duration of compression therapy after varicose vein surgeryʺ, European Journal of Vascular and Endovascular Surgery, vol. 33, no. 5, pp. 631‐637. Bjorklund, C., Grahn, A., Jensen, I., & Bergstrom, G. 2007, ʺDoes survey feedback enhance the psychosocial work environment and decrease sick leave?ʺ, European Journal of Work and Organizational Psychology, vol. 16, no. 1, pp. 76‐93. Blankertz, L. & Robinson, S. 1996, ʺAdding a vocational focus to mental health rehabilitationʺ, Psychiatric Services, vol. 47, no. 11, pp. 1216‐1222. Blomberg, S., Svardsudd, K., & Mildenberger, F. 1992, ʺA controlled, multicentre trial of manual therapy in low‐back painʺ, Scandinavian Journal of Primary Health Care, vol. 10, no. 3, pp. 170‐178. Blonk, R. W., Brenninkmeijer, V., Lagerveld, S. E., & Houtman, I. L. 2006, ʺReturn to work: A comparison of two cognitive behavioural interventions in cases of work‐related psychological complaints among the self‐employedʺ, Work & Stress, vol. 20, no. 2, pp. 129‐144. Boden, S. D. 2003, ʺBed rest and normal daily activity were equivalent for acute low‐
back painʺ, Journal of Bone & Joint Surgery ‐ American Volume, vol. 85, no. 5, p. 975. Bohr, P. C. 2000, ʺEfficacy of office ergonomics educationʺ, Journal of Occupational Rehabilitation, vol. 10, no. 4, pp. 243‐255. 100
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effectiveness of a graded exercise therapy program for patients with chronic shoulder complaints. International Journal of Technology Assessment in Health Care 22(1):76‐83. Gournay K, Brooking J. (1995) The community psychiatric nurse in primary care: an economic analysis. Journal of Advanced Nursing 22(4):769‐778. Green‐McKenzie J, Rainer S, Behrman A, Emmett E. (2002) The effect of a health care management initiative on reducing workersʹ compensation costs. Journal of Occupational & Environmental Medicine 44(12):1100‐1105. Hall JP, Wiseman VL, King MT, Ross DL, Kovoor P, Zecchin RP et al. (2002) Economic evaluation of a randomised trial of early return to normal activities versus cardiac rehabilitation after acute myocardial infarction. Heart, Lung and Circulation 11(1):10‐18. Hiller W, Fichter MM, Rief W. (2003) A controlled treatment study of somatoform disorders including analysis of healthcare utilization and cost‐effectiveness. Journal of Psychosomatic Research 54:369‐380. Jarvis KB, Phillips RB, Morris EK. (1993) Cost per case comparison of back injury claims: chiropractic versus medical management for conditions with identical diagnostic codes. Journal of Chiropractic 30:40‐46. Jay TC, Jones SL, Coe N, Breen AC. (1998) A chiropractic service arrangement for musculoskeletal complaints in industry: a pilot study. Occupational Medicine 48(6):389‐395. Kauppinen R, Vilkka V, Sintonen H, Klaukka T, Tukiainen H. (2001) Long‐term economic evaluation of intensive patient education during the first treatment year in newly diagnosed adult asthma. Respiratory Medicine 95:56‐63. Korthals‐de Bos IBC, Hoving JL, van Tulder MW, Rutten‐van Molken MPMH, Ader HJ, de Vet HCW et al. (2003) Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. BMJ 326(7395):911. Kovacs FM, Llobera J, Abraira V, Lazaro P, Pozo F, Kleinbaum D et al. (2002) Effectiveness and cost‐effectiveness analysis of neuroreflexotherapy for subacute and chronic low back pain in routine general practice: a cluster randomized, controlled trial. Spine 27(11):1149‐1159. Ladabaum U, Fendrick AM, Glidden D, Scheiman JM. (2002) Helicobacter pylori test‐
and‐treat intervention compared to usual care in primary care patients with suspected peptic ulcer disease in the United States. American Journal of Gastroenterology 97(12):3007‐3014. 160
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Lahdensuo A, Haahtela T, Herrala J, Kava T, Kiviranta K, Kuusisto P et al. (1998) Randomised comparison of cost effectiveness of guided self management and traditional treatment of asthma in Finland. British Medical Journal 316:1138‐1139. Lahiri S, Gold J, Levenstein C. (2005) Estimation of net‐costs for prevention of occupational low back pain: Three case studies from the US. Am J Ind Med 48(6):530‐541. Lindberg M, Ahlner J, Ekstrom T, Jonsson D, Moller M. (2002) Asthma nurse practice improves outcomes and reduces costs in primary health care. Scandinavian Journal of Caring Sciences 16(1):73‐78. Lindqvist K, Lindholm L. (2001) A cost‐benefit analysis of the community‐based injury prevention programme in Motala, Sweden‐a WHO safe community. Public Health 115:317‐322. Linz DH, Shepherd CD, Ford LF, Ringley LL, Klekamp J, Duncan JM. (2002) Effectiveness of occupational medicine center‐based physical therapy. Journal of Occupational and Environmental Medicine 44(1):48‐53. Levin LA, Perk J, Hedback B. (1991) Cardiac rehabilitation ‐ A cost analysis. Journal of Internal Medicine 230(5):427‐434. McCrone P, Knapp M, Proudfoot J, Ryden C, Cavanagh K, Shapiro DA et al. (2004) Cost‐effectiveness of computerised cognitive‐behavioural therapy for anxiety and depression in primary care: randomised controlled trial. British Journal of Psychiatry 185:55‐62. McGrail MP, Jr., Lohman W, Gorman R. (2001) Disability prevention principles in the primary care office. American Family Physician 63(4):679‐684. Miller, P., Kendrick, D., Bentley, E., & Fielding, K., (2002), ‘Cost‐effectiveness of lumbar spine radiography in primary care patients with low back pain’, Spine 22 (20): 2291‐2297 Morris JA, Smith PS. (2001) Demonstrating the cost effectiveness of an expert occupational and environmental health nurse: application of AAOHNʹs success tools. AAOHN Journal 49(12):547‐556. Nordstrom DC, Konttinen YT, Solovieva S, Friman C, Santavirta S. (1996) In‐ and out‐
patient rehabilitation in rheumatoid arthritis: a controlled open, longitudinal, cost‐effectiveness study. Scandinavian Journal of Rheumatology 25(4):200‐206. Pinnington, M. A., Miller, J., Stanley, I. (2004), ‘An evaluation of prompt access to physiotherapy in the management of low back pain in primary care’, Family Practice 21 (4): 372‐380. IES, IWP, ScHARR
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Proper K, de Bruyne M, Hildebrandt V, van der Beek A, Meerding W, Mechelen W (2004) Costs, benefits and effectiveness of worksite physical activity counselling from the employer’s perspective, Scandinavian Journal of Work, Environment and Health 30(1): 36‐46. Ross RH, Callas PW, Sargent JQ, Amick BC, Rooney T. (2006) Incorporating injured employee outcomes into physical and occupational therapistsʹ practice: a controlled trial of the Worker‐Based Outcomes Assessment System. Journal of Occupational Rehabilitation 16(4):607‐629. Rutz W, Carlsson P, von KL, Walinder J. (1992) Cost benefit analysis of an educational program for general practitioners by the Swedish Committee for the Prevention and Treatment of Depression. Acta Psychiatrica Scandinavica 85:457‐464. Schoenbaum M, Unutzer J, Sherbourne C, Duan N, Rubenstein LV, Miranda J et al. (2001) Cost‐effectiveness of practice‐initiated quality improvement for depression: results of a randomized controlled trial. Journal of the American Medical Association 286(11):1325‐1330. Schweikert B, Jacobi E, Seitz R, Cziske R, Ehlert A, Knab J et al. (2006) Effectiveness and cost‐effectiveness of adding a cognitive behavioral treatment to the rehabilitation of chronic low back pain. Journal of Rheumatology 33(12):2519‐2526. Seferlis T, Lindholm L, Nemeth G. (2000) Cost‐minimisation analysis of three conservative treatment programmes in 180 patients sick‐listed for acute low‐
back pain. Scand J Prim Health Care 18(1):53‐57. Serxner S, Gold D. (2001) How health promotion outweighed STD costs. Business & Health 19(6):25‐28. Smit F, Willemse G, Koopmanschap M, Onrust S, Cuijpers P, Beekman A. (2006) Cost‐
effectiveness of preventing depression in primary care patients: randomised trial. British Journal of Psychiatry 188(4):330‐336. Wehman P, Kregel J, Keyser Marcus L, Targett P, Campbell L, West M et al. (2003) Supported employment for persons with traumatic brain injury: A preliminary investigation of long‐term follow‐up costs and program efficiency. Archives of Physical Medicine and Rehabilitation 84(2):192‐196. Westley CR, Spiecher B, Starr L, Simons P, Sanders B, Marsh W et al. (1997) Cost effectiveness of an allergy consultation in the management of asthma. Allergy and Asthma Proceedings 18(1):15‐18. Witt CM, Jena S, Selim D, Brinkhaus B, Reinhold T, Wruck K et al. (2006) Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. American Journal of Epidemiology 164(5):487‐496 162
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Potential LTSA population data not disaggregated
(eg. population includes some of sample potentially on LTS, but actual numbers or % of sample on LTSA unclear and outcomes related to this population also unclear) Grahn BE, Borgquist LA, Ekdahl CS. (2000) Motivated patients are more cost‐
effectively rehabilitated: a two‐year prospective controlled study of patients with prolonged musculoskeletal disorders diagnosed in primary care. International Journal of Technology Assessment in Health Care 16(3):849‐863. Grahn BEM, Borgquist LA, Ekdahl CS. (2004) Rehabilitation benefits highly motivated patients: a six year prospective cost‐effectiveness study. International Journal of Technology Assessment in Health Care 20(2):214‐221. Hakkaart‐van Roijen L, van Straten A, Al M, Rutten F, Donker M. (2006) Cost‐utility of brief psychological treatment for depression and anxiety. British Journal of Psychiatry 188:323‐329. Hazard RG, Bendix A, Fenwick JW. (1991) Disability exaggeration as a predictor of functional restoration outcomes for patients with chronic low‐back pain. Spine 16(9):1062‐1067. Hamre HJ, Witt CM, Glockmann A, Ziegler R, Willich SN, Kiene H. (2006) Health costs in anthroposophic therapy users: a two‐year prospective cohort study BMC Health Services Research 6: 65. Hochanadel CD, Conrad DE. (1993) Evolution of an on‐site industrial physical therapy program. Journal of Occupational Medicine 35(10):1011‐1016. Ijzelenberg H, Meerding Willem J, Burdorf A. (2007) Effectiveness of a back pain prevention program ‐ A cluster randomized controlled trial in an occupational setting. Spine 32(7):711‐719. Jensen IB, Bergstrom G, Ljungquist T, Bodin L. (2005) A 3‐year follow‐up of a multidisciplinary rehabilitation programme for back and neck pain. Pain 115(3):273‐283. Jensen I, Harms‐Ringdahl K. (2007) Strategies for prevention and management of musculoskeletal conditions. Neck pain. Best Practice & Research in Clinical Rheumatology 21(1):93‐108. Karjalainen K, Malmivaara A, Mutanen P, Roine R, Hurri H, Pohjolainen T. (2004) Mini‐intervention for subacute low back pain: two‐year follow‐up and modifiers of effectiveness. Spine 29(10):1069‐1076. Karjalainen K, Malmivaara A, Pohjolainen T, Hurri H, Mutanen P, Rissanen P et al. (2003) Mini‐intervention for subacute low back pain: a randomized controlled trial. Spine 28(6):533‐540. IES, IWP, ScHARR
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Linton SJ, Boersma K, Jansson M, Svard L, Botvalde M. (2005) The Effects of Cognitive‐Behavioral and Physical Therapy Preventive Interventions on Pain‐
Related Sick Leave A Randomized Controlled Trial. Clin J Pain 21(2):109‐119. Linton SJ, Nordin E. (2006) A 5‐year follow‐up evaluation of the health and economic consequences of an early cognitive behavioral intervention for back pain: a randomized, controlled trial. Spine 31(8):853‐858. Malmivaara A, Hakkinen U, Aro T, Heinrichs ML, Koskenniemi L, Kuosma E et al. (1995) The treatment of acute low back pain: bed rest, exercises, or ordinary activity? New England Journal of Medicine 332(6):351‐355. Niemisto L, Rissanen P, Sarna S, Suopanki T, Lindgren KA, Hurri H. (2005) Cost‐
effectiveness of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain: A prospective randomized trial with 2‐year follow‐up. Spine 30(10):1109‐
1115. Not a recurrence of long-term sickness absence outcome
Dardennes R, Lafuma A, Fagnani F, Pribil C, Bisserbe J, Berdeaux G. (2000) Economic assessment of a maintenance treatment strategy in prevention of recurrent depressive disorder. Value in Health 3(1):40‐47. Frolich M, Heshmati A, Lechner M. (2004) A microeconometric evaluation of rehabilitation of long‐term sickness in Sweden. Journal of Applied Econometrics 19(3):375‐396. Haldorsen EMH, Grasdal AL, Skouen JS, Risa AE, Kronholm K, Ursin H. (2002) Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long‐term sick‐listed employees with musculoskeletal pain. Pain 95(1‐2):49‐63. Loisel P, Lemaire J, Poitras S, Durand MJ, Champagne F, Stock S et al. (2002) Cost‐
benefit and cost‐effectiveness analysis of a disability prevention model for back pain management: a six year follow up study. Occupational and Environmental Medicine 59(12):807‐815. Meijer EM, Sluiter JK, Heyma A, Sadiraj K, Frings‐Dresen MH. (2006) Cost‐
effectiveness of multidisciplinary treatment in sick‐listed patients with upper extremity musculoskeletal disorders: a randomized, controlled trial with one‐
year follow‐up. International Archives of Occupational and Environmental Health 79(8):654‐664. 164
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who take long term sickness absence on a recurring basis
Inappropriate study design
Greenberg SN, Bello RP. (1996) The work hardening program and subsequent return to work of a client with low back pain. Journal of Orthopaedic and Sports Physical Therapy 24(1):37‐45. Karrholm J, Ekholm K, Jakobsson B, Ekholm J, Bergroth A, Schuldt K. (2006) Effects on work resumption of a co‐operation project in vocational rehabilitation. Systematic, multi‐professional, client‐centred and solution‐oriented co‐
operation. Disability and Rehabilitation: An International Multidisciplinary Journal 28(7):457‐467. Kemmlert K. (1996) Economic impact of ergonomic intervention ‐ Four case studies. Journal of Occupational Rehabilitation 6(1):17‐32. Not English language
Monpere C, Rajoelina A, Vernochet P, Mirguet C, Thebaud N. (2000) Return to work after cardiovascular rehabilitation in 128 coronary patients followed up for 7 years: results and medico‐economic analysis. Archives des Maladies du Coeur et des Vaisseaux 93(7):797‐806. Montero JMM, de PZC, Duran MDM, Ramirez RA. (1996) Cardiac rehabilitation: cost‐
effectiveness analysis. Revista Espanola de Cardiologia 49:753‐758. IES, IWP, ScHARR
Appendix 5: Studies Pending
165
51
Dettori, J. R., Pearson, B. D., Basmania, C. J., & Lednar, W. M. 1994, ʺEarly ankle mobilization, Part I: The immediate effect on acute, lateral ankle sprains (a randomized clinical trial)ʺ, Military medicine, vol. 159, no. 1, pp. 15‐20. Ekto‐Andersen J, Ingvarsson E, Kullendorf M, Orbaek P. 2008 “High cost‐benefit of early team‐based biomedical and cognitive behaviour intervention for long‐term pain‐related sickness absence” Journal of Rehabilitation Medicine; 40(1):1‐8 Haug, H. J. 2001, ʺLong‐term rehab. Implementing ingenuityʺ, Rehab Management: The Interdisciplinary Journal of Rehabilitation, vol. 14, no. 3, p. 46. Lofvander, M. B. 2002, ʺCognitive‐behavioural treatment of chronic pain in primary care: A three‐year follow‐upʺ, European Journal of General Practice, vol. 8, no. 4, pp. 151‐158. Lofvander, M., Engstrom, A., Theander, H., & Furhoff, A. K. 1997, ʺRehabilitation of young immigrants in primary careʺ, Scandinavian Journal of Primary Health Care, vol. 15, no. 3, pp. 123‐128. Mawhinney, T. C. 1999, ʺCumulatively large benefits of incrementally small intervention effects: Costingʺ, Journal of Organizational Behavior Management, vol. 18, no. 4, p. 83. Norrefalk JR, Ekholm K, Linder J, Borg K, Ekholm J. 2008 “Evaluation of a multi‐
professional rehabilitation programme for persistent musculo‐skeletal‐related pain: Economic benefits of return to work”. Journal of Rehabilitation Medicine; 40(1):15‐22 Watson, D. P. A randomised controlled trial of vocationally orientated pain management versus best practice advice in managing return to work in chronic 51 and not received by the agreed cut off date of 3 April 2008. 166
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pain. Department of Work and Pensions Complete. Ref Type: Electronic Citation Cost–effectiveness primary studies
There are no pending papers for this element of the review. Review studies
There are no pending papers for this element of the review. IES, IWP, ScHARR
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Appendix 6: Example Completed
Effectiveness Data Extraction form and
Quality Checklist
Ref ID RCT 835:
Data Extraction Form Authors/Title/Source Margreth G Soukup, PT, MSci; Bredo Glomsrod, PT; Jan H. Lonn, PT; Kari Bo, PT, PE, PhD; Stig Larsen, MSc, DrSc. The Effect of a Mensendieck Exercise Program as Secondary Prophylaxis for Recurrent Low Back Pain: A Randomised, Controlled Trial with 12 month follow‐up. SPINE Vol 24, Number 15, pp 1585 – 1592, 1999 Project: Question 3 Data extracted by: Darcy Hill Date of extraction: 18/12/07 Describe the study: Systematic review (including at least one RCT) … Systematic review of experimental studies … Systematic review of observational studies … Randomised controlled trial: Individual ; Randomised controlled trial: Cluster … Controlled non‐randomised trial … Controlled before‐and‐after … Interrupted time series … Before and after study … Economic analysis (use economic data extraction and quality assessment forms) … Case study … Other (please state) … 168
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What was the research question? To evaluate the effect of a Mensendieck Program on the incidence of recurrent episodes of low back pain in patients with a history of the condition who currently are working. Other study parameters: Setting: Geographical (City/country): South‐eastern Norway Social (school/workplace etc): setting General physical therapy practice Date of study (to/from): Paper acknowledged 30 April 1998 Who funded the study? Norwegian Fund for Post Graduate Training in Physiotherapy, the Royal Norwegian Ministry of Health and Social Affairs Participants: Number of participants/organisations etc enrolled: Treatment group: n=39; Control: n=38. At final follow‐up: treatment: n=34; Control: n=35 Details on age, gender, and other characteristics (specifically disability, ethnicity, sexual orientation, religion or belief and socio‐economic status) if presented: See tables 1 and 2 for full details (photocopy attached) Were intervention groups balanced at baseline?: Yes, on most variables (demographic, LBP history) there was no significant differences between groups except with regard to baseline participation in physical training during leisure time. Potential bias is likely to have a negative effect on results, reducing observed differences between groups. Comments: Unit of allocation/recruitment: Individual Sex Group Age (range or mean) IES, IWP, ScHARR
169
Organisation/Institution Community/Environment Policy/socio‐political Method of recruitment/enrolment and response rate: Sought by advertising in local media, and by referral from doctors, physical therapists and chiropractors in general practice in South‐eastern Norway. Method of allocation to intervention: Was allocation concealed? clear … Yes ; No … Not Selection criteria: Inclusion: 18‐50 years old, who had experienced one or more episodes of LBP (pain localised to the lumbar region, with or without pain radiating to the lower extremities). Episode further defined as LBP resulting in professional treatment or use of sick leave. At the time of enrolment, patients required to have finished treatment for their LBP episode and had returned to work. Also needed to have time and opportunity to participate in Mensendieck exercise groups for 13 weeks, and agreed to randomisation procedure. Exclusion: Previous back surgery, pregnancy, specific rheumatologic diseases, spondylolisthesis, spinal tumour, spinal fracture, drug or alcohol abuse and documented mental illness. Intervention: Description of the Intervention: Exercises and biomechanical/ergonomic education in 20 group sessions of 60 minutes each, for 13 weeks (two session per week for 7 weeks, and one session per week for 6 weeks). Detailed breakdown of session content also described. Description of the comparator(s): Received written and oral information about the Mensendieck approach (no 170
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who take long term sickness absence on a recurring basis
attendance to practical training sessions). Method/mode of delivery(for example, peer education): Group training sessions Providers/deliverers of the intervention(including organisations involved): Mensendieck – educated physical therapists Length, duration and intensity of the intervention: (see above) 10 min warm‐up exercises; 5 min stretching for legs, hips, buttocks; 35 min information session combining ergonomic info and pelvic, hip, back and abdominal exercises; 5 min stretching for lower extremities, pelvis and back; 5 min relaxation exercises. Time to follow‐up (average/median): 5 months, 12 months How many (n, %) participants completed the intervention? 90% completed (87% of treatment group, 92% of control group) Details on age, gender, and other characteristics (specifically disability, ethnicity, sexual orientation, religion or belief and socio‐economic status) if presented: See attached tables 1 and 2 For non‐completers, were the reasons for non‐completion described? Yes. Pregnancy (1); scheduling difficulties due to unforeseen changes to working situation (3); failure to return after randomisation with no reason given (1); disappointment with allocation to control group (2); moved to another city (1). IES, IWP, ScHARR
171
Outcomes 1: Primary outcomes: Sustained return to work (paid and un‐paid) after long‐term sickness. Primary outcome: recurrence of LBP (observed in days from inclusion until the day of event, during the 12‐month follow‐up period). reduced incidence of recurring (>1 episode) long‐term sickness shorter periods of recurring sickness absence improvements in individual and/or population‐level health status which enables remaining in work following sickness absence incidences no effect on return to work after long‐term sickness Describe outcome measures: •
•
type and number of health care contacts number of sick leave days Were baseline measurements of outcomes assessed? Yes ; No … Were the outcome measure(s) validated? Yes … No ; Not clear … If yes, how? outcome measures are self‐reported and open to recall bias. Primary Secondary outcomes: acceptability of the intervention/policy/programme/strategy – content/frequency/location etc. costs of intervention/policy/strategy or programme barriers to or facilitators of effective implementation reduction in number and duration of reported and/or recorded sickness absences associated with (but not limited to) the following: •
musculo‐skeletal injuries including back pain 1 Adapted from Nutbeam’s model (1998). 172
Interventions strategies, programmes and policies to reduce the number of employees
who take long term sickness absence on a recurring basis
•
acute and/or recurring medical conditions •
stress •
mental illness •
alcohol or drug‐related problems •
other long‐term conditions and chronic conditions •
home and family responsibilities increase in number of employers that have introduced policies and procedures to monitor/address sickness absence increase in number of employers who have made reasonable adjustments in the workplace to enable people to return to work increase in number of employees who are appropriately referred to an occupational health service when they are on long‐term sick leave increase in number of people on long‐term sick leave who liaise with general practitioners and/or physiotherapists or other support staff about their ability to return to work reduction in the number of people who initiate claims under the Disability Discrimination Act 2005 Reduction in personal injury claims No effect on any other work related outcome Describe outcome measures •
•
•
•
back pain in general in preceding month back pain related to 12 daily activities self assessment of back function using 100mm visual analogue scale general functional status measured by CIIP/WONCA charts Were baseline measurements of outcomes assessed? Yes ; Were the outcome measure(s) validated? Yes ; No … No ; Not clear … If yes, how? Some validated: COOP/WONCA instrument for measuring general functional status is validated and reliable (referenced in paper), though may not be IES, IWP, ScHARR
173
sensitive enough to detect clinically important differences in patients with LBP in the acute phase. Analyses: Self‐reporting and assessment by investigators (not blinded when recording outcome measures at five and 12 month follow‐up examinations). Describe methods used (intention to treat, descriptive statistics, qualitative analysis etc): Descriptive statistics including means of continuously distributed variables with confidence intervals (95 per cent), contingency tables for categorical variables, Kaplan and Meier plot for time from inclusion to first LBP episode, mean pain scores (in general, and in relation to 12 daily activities). All tests were two‐tailed, significance level of five per cent. ANOVA between groups. Unit of analysis: Individual ; Community/environment … Group ;
Policy/socio‐political
Power Was a power calculation presented? Yes ;No … If yes, describe: Power analysis on the primary end point of the study (incidence of recurrence LBP over 12 months); Required size of study pop. To meet an alpha of 0.05, was 62 patients, at a power of 95 per cent. Was the study powered to detect an effect if one exists? Yes ; Not clear … Any other process details: Results: No … 174
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Briefly describe the results for each of the main outcomes (what size of effect is identified in the study?) List all measures of effects in the units used in the study – for example, absolute or relative risk, number needed to treat, include p values and any confidence intervals that are provided). Also describe results according to individual or population characteristics including age, gender, and other characteristics specifically disability, ethnicity, sexual orientation, religion or belief and socio‐
economic status (if presented)? At 12 months, incidence of LBP significantly less for treatment group (11 of 34) than in the control group (20 of 35); (P<0.05). Trend towards fewer days of sick leave because of LBP but no significant difference between groups. Reduction in pain, improvement in function in both groups, no significant difference between groups. Are there any key criticisms of the conclusions drawn by the author’s?
Self‐selected participants may gave resulted in a study sample with high motivation for physical training, however most secondary prevention programs for LBP are based on voluntary participation. Self‐reported measures for sick leave and LBP episodes may be affected by recall bias, but bias should be similar for both groups. Statistically non‐significant results for pain, back function and general functional status possibly related to relatively low pain levels and good functional status at baseline, thus leaving little room for improvement. Does the paper address or offer any evidence of effect according to either of the following individual/population characteristics? If so, please ensure that evidence is presented in results above. Older people Yes … No … Gender Yes … No … Ethnicity Yes … No … Socio‐economic status Yes … No … People with disabilities Yes … No … Religion or belief Yes … No … IES, IWP, ScHARR
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Other (please specify): People with history of low back pain Yes ; Does the paper demonstrate any evidence of harms or adverse effects associated with the intervention? No Do the authors identify any strengths and/or weaknesses of the evidence presented? Yes, described in discussion. In your opinion, are the results generalisable to the UK? Yes ; No … Why: None of the sample characteristics, intervention components, or outcome measures are specific to the Norwegian study population Do the authors identify any evidence gaps or make any recommendations for further research? No Is there any data on cost‐effectiveness presented? No, but implications for cost‐
effectiveness are discussed/explored Are there policy implications of the work? Yes Are there effective practice implications of the work? Yes Pass to other reviewer for second opinion? Comment: 176
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Quality Assessment: Randomised controlled trials
Study identification:
author: Soukup, MG et al.
title: The Effect of a Mensendieck Exercise Program as Secondary Prophylaxis for
Recurrent Low Back Pain@: A Randomized, Controlled Trial with 12-month Followup
reference: SPINE Volume 24, Number 15, pp 1585-1592
year of publication: 1999
Guideline topic: LTSA
Key question no: Q3
Checklist completed by: Darcy Hill
SECTION 1: INTERNAL VALIDITY
In a well-conducted RCT study:
In this study this criterion is:
(Highlight one option for
each question)
11
The study addresses a clearly focused
question
.
1.2
The assignment of subjects to intervention
groups is randomised.
1.3
An adequate concealment method is used
.
1.4
Subjects and investigators are kept ‘blind’
about intervention allocation.
1.5
The intervention and control groups are
similar at the start of the trial.
Well
addressed
Adequately
addressed
Poorly
addressed
Well
addressed
Adequately
addressed
Poorly
addressed
Well
addressed
Adequately
addressed
Poorly
addressed
Well
addressed
Adequately
addressed
Poorly
addressed
Well
addressed
Adequately
addressed
Poorly
addressed
Not addressed
Not reported
Not applicable
Not addressed
Not reported
Not applicable
Not addressed
Not reported
Not applicable
Not addressed
Not reported
Not applicable
Not addressed
Not reported
Not applicable
IES, IWP, ScHARR
177
1.6
The only difference between groups is the
intervention under investigation.
Well
addressed
Adequately
addressed
Not addressed
Not reported
Not applicable
Poorly addressed
1.7
All relevant outcomes are measured in a
standard, valid and reliable way.
Well
addressed
Adequately
addressed
Poorly
addressed
Not addressed
Not reported
Not applicable
1.8
What percentage of the individuals or
clusters recruited into each intervention
arm of the study dropped out before the
study was completed?
Treatment: 13%
Control: 8%
Total: 10%
1.9
All the subjects are analysed in the groups
to which they were randomly allocated
(often referred to as intention-to-treat
analysis).
Well
addressed
Adequately
addressed
Poorly
addressed
Not addressed
Not reported
Not applicable
1.10
Where the study is carried out at more
than one site, results are comparable for
all sites.
Well
addressed
Adequately
addressed
Poorly
addressed
Not addressed
Not reported
Not applicable
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1
How well was the study done to minimise
bias? Code ++, + or –
-
2.2
If coded as + or – what is the likely
direction in which bias might affect the
study results?
2.3
Taking into account clinical
considerations, your evaluation of the
methodology used, and the statistical
power of the study, are you certain that
the overall effect is due to the study
intervention?
Are the results of this study directly
applicable to the patient group targeted by
this guideline?
Weaknesses in study design
are likely to affect potential
bias in both positive and
negative directions, but are
generally consistent between
groups.
Yes – although the sample
size is quite small
2.4
Yes
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Appendix 7: Economic Data Extraction and
Quality Assessment Form
0.0
Name of study Economic evaluation of a multi‐stage return to work program for workers on sick‐leave due to low back pain 0.1
Authors Steenstra I, Anema J, Tulder M, Bongers P, Vet H, Mechelen W. 0.2
Journal details including year Journal of occupational rehabilitation (2006) 16: 557 ‐ 578 0.3
Country/countries Netherlands, repeat of study previously carried out in Canada. 0.4
Cross reference to data extraction for effectiveness evaluation (where applicable) ? 0.5
Sample sizes of original studies (if applicable and if not cross referenced in 0.4 above) 196 (96 workplace intervention, 100 usual care) 1. Was a full economic evaluation undertaken? Did it include a comparative assessment of costs and health outcomes? Yes 2. Describe the interventions, comparators, population, outcomes, perspective and time horizon included in the economic evaluation. Interventions: IES, IWP, ScHARR
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■ Workplace intervention (work modifications and case management) for eight weeks. ■ If no RTW after workplace intervention for eight weeks, usual care (provided by an occupational physician). ■ If no RTW after workplace intervention for eight weeks, clinical intervention (Physiotherapy based on operant behavioural principles). ■ If no RTW after usual care for 8 weeks, clinical intervention. Comparator: ■ Usual care as outlined by Dutch Occupational Physician guidelines for lower back pain. ■ If no RTW after usual care for eight weeks, continuation of usual care. Population: Workers aged 18 to 65 years sick‐listed for a period of 2‐6 weeks due to low back pain. Outcomes: ■ Cost per Return to work (RTW) day (duration of work absenteeism in calendar days from the first day of sick leave to full return to own or other work with equal earnings, for at least four weeks without drop‐out.) ■ Cost per Point‐increase in pain severity score avoided (10‐point numerical rating scale) ■ Cost per Point‐increase in functional status score avoided (Roland disability questionnaire) ■ Cost per QALY gained (Dutch version of EuroQol) ■ Cost per Point‐increase in general health score avoided (VAS 0‐100mm). Perspective: Societal Time horizon: 52 weeks 3. What form of economic evaluation was undertaken? ■ Cost‐effectiveness analysis ■ Cost‐utility analysis ■ Cost‐benefit analysis ■ Cost consequences analysis 180
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■ Cost‐effectiveness and cost‐utility analysis. 4. What type of modelling approach was used (cohort versus individual‐patient level, dynamic versus static)? Is this appropriate to address the decision problem? What modelling methodology was used (within‐trial evaluation, decision tree, markov, discrete event simulation, other)? Is this appropriate to address the decision problem? An economic evaluation based on a decision analysis using bootstrapping for the cost parameters and for the RTW efficacy parameter. This is appropriate to address the decision problem, although extrapolation of the data over a patient’s lifetime may have been useful. Further, the analysis was carried out using data from one RCT and could have been improved by using data from additional trials. 5. Describe the key structural assumptions employed in the evaluation. Do these appear reasonable? What is the likely impact of these assumptions on the results of the evaluation? NA 6. Describe the assumptions surrounding the effectiveness data and the sources employed in the model. Were all relevant health outcomes included in the model? How were benefits measured and valued? What are the strengths and weaknesses of these data? All effectiveness data is based on one RCT carried out alongside the economic evaluation. Strengths: The evidence is mainly based on one same source which is designed to assess the relevant scope. Weaknesses: There may be biases within the trial. All relevant health outcomes were included in the model. 6.1
Quality of life measure used Dutch version of EuroQol. 6.2
Quality of life for intervention Note: Figures are Means, with standard deviations in brackets. Workplace intervention: 0.53 (0.25) Workplace intervention followed by usual care: 0.55 (0.22) Workplace intervention followed by clinical intervention: 0.47 (0.24) Usual care followed by clinical intervention: 0.58 (0.30) 6.3
Quality of life for comparator Usual care intervention: 0.552 (0.217) IES, IWP, ScHARR
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Usual care intervention followed by usual care intervention: 0.43 (0.28) 6.4
Number of QALYs for intervention The following gives utilities rather than QALYs due to the short timeframe modelled: Workplace intervention: 0.21 (0.27) Workplace intervention followed by usual care: 0.27 (0.30) Workplace intervention followed by clinical intervention: 0.22 (0.25) Usual care followed by clinical intervention: 0.19 (0.21) 6.5
Number of QALYs for comparator The following gives utilities rather than QALYs due to the short timeframe modelled: Usual care intervention: 0.26 (0.29) Usual care intervention followed by usual care intervention: 0.30 (0.31) 7. Describe the assumptions surrounding the resource use and cost data employed in the model. Were all relevant costs included in the model? How were these measured and valued? What are the strengths and weaknesses of these data? ■ Costs measured were direct health care costs (cost of intervention plus additional visits to a health care provider, prescription medication, professional home care and hospitalisation), direct non‐health care costs (out‐of‐pocket expenses, costs of paid and unpaid help) and indirect costs (loss of production due to lower back pain related absence from paid and unpaid work). ■ Partial return to work was measured by the occupational physician and means that if a person is back at work with a productivity of 50 per cent this is equivalent to half a day’s work. ■ Costs of the workplace intervention were based on 8 hours of work multiplied by the fee of an Occupational Health Services’ ergonomist. ■ The price of the clinical intervention was the market price of a similar intervention from the graded activity provider. ■ Every worker in the production process can be replaced and production losses cease to exist after a certain friction period. ■ Production loss is estimated based on age and gender. All costs were taken from Dutch guidelines, Dutch Central Organization for Health Care Charges or from a ‘professional organisation and mean price of different practices’; hence there should be a reasonable consistency between the costs. All relevant costs appear to be included. 7.1
Year to which prices refer 182
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The paper does not state the year to which prices refer. The analysis was carried out between October 2000 and October 2002; hence in order to uplift costs to 2007 it has been assumed that the costs used within the evaluation are based on 2003 prices. It should be noted that prices have been uplifted up to 2005 using the PSSRU price inflation index (ref) throughout and the price increase has been assumed to be constant in subsequent years following the 2004 to 2005 price increase. 7.2
Total costs for intervention in original prices and UK 2007 prices Workplace intervention: €8993 (€6216) [2003] = £7616 (£5262) [2007] Workplace intervention followed by usual care: €11096 (€6720) [2003] = £9397 (£5688) [2007] Workplace intervention followed by clinical intervention: €12391 (€7383) [2003] = £10494 (£6250) [2007] Usual care followed by clinical intervention: €10537 (€3601) [2003] = £8924 (£3049) [2007] 7.3
Total costs for comparator in original prices and UK 2007 prices Usual care intervention: €9109 (€6375) [2003] = £7714 (£5398) [2007] Usual care intervention followed by usual care intervention: €10885 (€7363) [2003] = £9216 (£6236) [2007] 8. Was discounting applied to costs and health outcomes to account for time preferences? Discounting was not applied to costs and health outcomes due to the short timeframe of the model. 9. What were the results of the economic model? Were results presented incrementally? Are the base case results calculated using deterministic parameter values or the expected values? For the analysis comparing workplace intervention to usual care, the cost per RTW for 1 day less sick leave = €19 [2003] = £16 [2007]. The workplace intervention dominates for all other outcomes. Results from the analysis comparing clinical intervention versus usual care following workplace intervention or following usual care suggest that using clinical intervention is dominated by not using clinical intervention. Expected values have been presented. 10. Was a comprehensive uncertainty analysis undertaken? What methods were used to evaluate uncertainty (one‐way, multi‐way, probabilistic). How were the results of the uncertainty analysis presented (cost‐effectiveness planes, cost‐effectiveness acceptability curves)? IES, IWP, ScHARR
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A probabilistic sensitivity analysis using the bootstrapping approach was carried out, presented as expected values and cost‐effectiveness planes. In addition, three different scenarios were tested around three different model assumptions (using production loss cost of €100 per day rather than based on age and gender; using net days on sick leave rather than calendar days; using the human capital approach rather than a friction cost approach to calculate costs). 10.1 Key results of the sensitivity analyses ■ There is a 99 per cent probability that the workplace intervention will be more effective than the usual care. ■ There is 100 per cent chance that the workplace intervention followed by usual care will be more effective than the workplace intervention followed by clinical care ■ There is 84 per cent probability that the usual care followed by usual care will be more effective than usual care followed by clinical care. ■ Limited results were provided in terms of the scenario analysis. 11. Does the study report details of any model validation (concurrence of experts, internal/external consistency, predictive validity)? The model results were compared with the study which it replicated carried out in Canada (ref). In both studies the workplace intervention was effective for lasting RTW; however contrary to this study, there was a small beneficial effect for the combination of workplace intervention and clinical intervention in the Canadian study. 12. What are the author conclusions? Does the study discuss the generalisability of the results of the evaluation? Is it applicable to the UK setting? ■ The workplace intervention was more effective and slightly more costly than usual care in terms of the primary outcome (RTW) and more effective and less costly in improving all secondary outcomes. ■ The clinical intervention was less effective on all primary and secondary outcomes at higher costs. Generalisability: unclear 13. Quality assessment rating ++