Conference Agenda

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Session Overview
Assessments and work rehabilitation
Thursday, 06/Jun/2019:
10:30am - 12:00pm

Session Chair: J.R. Anema
Session Chair: Arif Jetha
Location: Room 99

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Independent Medical Examination For Sick-listed Workers - Experiences Of Participating Stakeholders

Aase Aamland1, Irene Oyeflaten2,3, Elisabeth Husabø3, Silje Maeland1

1Research Unit for General Practice, NORCE Norwegian Research Centre, Norway; 2National Centre for Occupational Rehabilitation, Rauland, Norway; 3NORCE Norwegian Research Centre, Norway

To reduce the high rates of sick leave in Norway, politicians have proposed to use an independent medical examination (IME) by a new doctor. General practitioners (GPs) manage 80% of workers on long-term sick leave and it has been discussed whether a strong doctor/patient relationship may hinder a fast return to work (RTW). IME for sick-listed workers has been tested in a large randomized controlled trial and evaluated through qualitative interviews with participating stakeholders. The aim of the current study was to assess patients, GPs, and IME-doctors expectancies and experiences with participating in an IME.

We conducted individual semi-structured telephone interviews with nine sick listed patients and focus group interviews with 14 GPs and 8 IME doctors. Systematic text condensation was applied for analysis.

The sick-listed patients questioned both the purpose and timing of the IME, but felt a moral obligation to participate. Most appreciated the IME as a positive encounter, even if they felt it had no impact on their RTW process. The GPs welcomed a second opinion from an experienced GP colleague to obtain constructive advice for further sick-leave measures. However, they had mainly negative experiences with the IME reports. The IME doctors reported that the IME provided important second opinions, which they felt empowered the sick-listed workers and provided new insights into their condition. Beneficial IME working conditions and enhanced insight into different sick leave measures were crucial to this perceived usefulness.

According to the sick-listed workers, the IMEs were administered too late and disturbed already initiated treatment processes and RTW efforts. The GPs welcomed IMEs if they could select especially challenging patients for a mandatory second opinion by a peer, but they did not want to be overruled. The IME doctors proposed only some adjustments as necessary for the IME to be implemented nationwide.

What IsTthe Effect Of Independent Medical Evaluation On Return To Work For Long-term Sick Listed Workers In Norway? A Pragmatic Randomized Controlled Trial, The NIME-trial

Silje Maeland1, Tor Helge Honmaas2, Irene Oyeflaten2,4, Elisabeth Husabø2, Erik Werner3, Karin Monstad2

1Research Unit for General Practice, NORCE Norwegian Research Centre, Norway; 2NORCE Norwegian Research Centre, Norway; 3Institute of health and society, Faculty of medicine, University of Oslo; 4National Centre for Occupational Rehabilitation, Rauland, Norway

Independent medical examinations (IME) entail evaluation of a sick listed workers physical or psychological medical condition by a medical practitioner who are required to present an independent opinion, representing neither the compensation insurer nor the injured worker’s interests. Every day 330 workers reach six months continuous sickness absence in Norway. The effect of IMEs on return to work have never been evaluated. To develop a knowledgebase, the Norwegian government ordered an effect evaluation of IME in 2015 asking the following research question: What is the effect of IME on return to work for workers sick listed for six months by their general practitioner in Norway.


We included 5888 sick listed workers (18-65 years), on full or partial sick leave for the past six months in Hordaland county (10% representative sample) to either treatment as usual (regular follow up of the general practitioners and the Norwegian social insurance agency) or treatment as usual and an IME in a randomized controlled trial (RCT). Inclusion period was October 2015-october 2016. Exclusion criteria were pregnancy, cancer, dementia. The IME was a consultation without any medical examinations and it lasted for 30-60 minutes based on a standard protocol published described in published protocol paper. The primary outcome was days on sick leave as an indicator of return to work. Intention to treat (ITT) and treatment on the treated (TT) analyses was performed. This trial is registered at, number NCT02524392.

We found no statistical significant difference between groups on the primary outcome days on sick leave (mean difference ITT: -1.381, p=0.55; TT: -1.246, p=0.49).

Preliminary results show no effect of IME on return to work for Norwegian workers sick listed for six months. These results will provide knowledge-based policy and have consequences for decision on implementation and changes in legislation regarding IMEs in Norway.

Work Capacity Assessments: Beyond Eligibility for Disability Denefits, and Towards Fair Assessments?

Femke Abma1,2, Pepijn Roelofs1, Tialda Hoekstra1

1University Medical Center Groningen, Netherlands, The; 2Research Center for Insurance Medicine, Netherlands, The

Assessing work capacity is one of the most prominent application of disability assessment, since being able to work is key to economic self-sufficiency and social standing. In many high-income countries a shift in social security policies is ongoing from a focus on eligibility for disability benefits towards promoting work reintegration by exploiting the remaining work capacity. Researchers across a range of disciplines, national settings and systems are now exploring these work capacity assessments from different perspectives. Within the UMCG, three research projects are conducted on this topic: one regarding the assessment of (in)ability to work fulltime; second regarding variation between insurance physicians in the assessment of functional limitations; and third a study regarding a new measure to assess work capacity. Current insights from these studies will be presented and related to international findings. We will conclude with a discussion on work capacity assessments across countries, successive steps towards work, and fairness of the work capacity assessment.

Is Integrated Care Effective For Work Participation And Performance Of Activities Among Orthopaedic Surgery Patients?

Pieter Coenen1, Gerben Hulsegge1, Joost Daams2,3, Rutger van Geenen4, Gino Kerkhoffs5,6, Maurits van Tulder7, Judith Huirne8, Johannes Anema1, Paul Kuijer2

1Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam, The Netherlands; 2Amsterdam UMC, University of Amsterdam, Coronel Institute of Occupational Health, Amsterdam Public Health research institute, Amsterdam, the Netherlands; 3Amsterdam UMC, University of Amsterdam, Medical Library, Amsterdam, the Netherlands; 4Amphia Hospital, Department of Orthopaedic Surgery, Foundation FORCE (Foundation for Orthopaedic Research Care and Education), Breda, the Netherlands; 5Amsterdam UMC, University of Amsterdam, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam, the Netherlands; 6Amsterdam UMC, University of Amsterdam, Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam, the Netherlands; 7Amsterdam Public Health research institute, Faculty of Earth & Life Sciences, Department of Health Sciences, VU University, Amsterdam, the Netherlands; 8Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, the Netherlands

Orthopaedic surgery is primarily aimed at pain reduction and restoration of function. Additional care like active referral to case-managers, goal-directed rehabilitation or e/mHealth might enhance work participation or performance of activities. We reviewed the effectiveness of such integrated care interventions on these latter two outcomes in a systematic review that was a-priori registered at Prospero CRD42018089414.

A search in Medline, EMBASE and CINAHL was performed in collaboration with a clinical librarian until February 5th 2018. Studies describing controlled trials evaluating the effectiveness of integrated care interventions on work participation and performance of activities were included. Two reviewers independently screened references and potentially full papers, and performed data-extraction and risk of bias assessment. In case of sufficient homogeneity, a meta-analysis was performed.

After screening 5,941 records, four studies evaluated work participation (n=1,182 patients, mainly spinal surgery) and seven studies performance of activities (n=700 patients, mainly spinal and knee surgery). Work participation was defined as work status or time to return to work (RTW) and performance of activities was mostly measured using questionnaires. Integrated care for work participation was effective in one studies with 10% not returning to work instead of 18% (p=.002). No significant difference was found in two studies reporting on time to RTW: integrated care vs care-as-usual: 29 vs 45 weeks and 7 vs 5 weeks. One study did not report RTW ’due to the large number of participants not working at baseline’. Meta-analyses showed that integrated care was effective in improving performance of activities (Standardized Mean Difference 4.0 95%CI 2.0-6.0).

Integrated care for orthopaedic surgery patients showed positive effects compared to usual care, especially for performance of activities. However, effect sizes were small. High quality studies on work participation are needed to better inform patients, practitioners and policy makers regarding the benefits of integrated care after orthopaedic surgery.

Improving Work Participation By Work-related Medical Rehabilitation In Patients With Chronic Musculoskeletal Diseases

Matthias Bethge1, Miriam Markus1, Marco Streibelt2, Christian Gerlich3, Michael Schuler3

1University of Lübeck, Germany; 2Federal German Pension Insurance, Germany; 3University of Würzburg, Germany

Background: In Germany, work-related medical rehabilitation programs were developed for patients with musculoskeletal disorders to improve work participation outcomes. Randomized controlled trials have shown that return to work rates can be increased by about 20 points compared to common medical rehabilitation programs. Since 2014, the Federal German Pension Insurance has approved several work-related rehabilitation departments to implement these new programs. Our study was launched to assess the effects of these programs under real-life conditions.

Methods: Participants received either a common or a work-related medical rehabilitation program. Propensity score matching was used to create balanced samples. Effects were assessed by patient-reported outcomes 10 months after completing the rehabilitation program.

Results: We included 1282 patients (mean age: 52.4 years; 75.3% women). Work-related medical rehabilitation increased stable return to work (OR = 1.42; 95% CI: 1.02 to 1.96) and self-rated work ability (b = 0.38; 95% CI: 0.05 to 0.72) and decreased time to return to work compared to common medical rehabilitation. Subgroup analyses showed that the effect on stable return to work was affected by the prior risk of not returning to work and the dose received as rated by the participants: In patients with a high initial risk of not returning to work and a high dose received, the absolute risk difference was about 20 points in favor of work-related medical rehabilitation and in line with the effects known from the randomized controlled trials.

Conclusions: Implementation of work-related medical rehabilitation in German rehabilitation centers improved work participation outcomes but the effects were reduced compared to the effects observed in the randomized controlled trials. Reaching patients with a high risk of failing return to work and developing the treatment consistency according to the recommendations of the guideline may enhance outcomes in real care.

Implementing The German Model Of Work-related Medical Rehabilitation: Did The Dose Delivered Of Work-related Treatment Components Increase?

Uwe Egner1, Marco Streibelt1, Michael Schuler2, Matthias Bethge3

1German Federal Pension Insurance, Berlin, Germany; 2Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany; 3Institute of Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany

Purpose: Work-related or vocational treatment components are an essential part of rehabilitation programs in order to support return to work and work participation of patients with musculoskeletal disorders. In Germany, a guideline for work-related medical rehabilitation was developed to increase work-related treatment components. In addition, new departments were approved to implement work-related medical rehabilitation programs. The aim of our study was to explore the state of implementation of the guideline’s recommendations by describing the change in the dose delivered of work-related treatments.

Methods: The treatment dose of work-related therapies was compared for two patient cohorts with musculoskeletal disorders. The first cohort participated in a common medical rehabilitation program in the second half of 2011 before the implementation of the work-related medical rehabilitation departments. The second cohort joined a work-related medical rehabilitation program in the second half of 2014 after the implementation of the new departments. Patients of the cohorts were matched one-to-one by propensity scores.

Results: We included data of 9,046 patients. The mean dose of work-related therapies increased from 2.2 hours (95% CI: 1.6-2.8) to 8.9 hours (95% CI: 7.7-10.1). The mean dose of social counselling increased from 51 to 84 minutes, the mean dose of psychosocial work-related groups from 39 to 216 minutes, and the mean dose of functional capacity training from 39 to 234 minutes. The intraclass correlation of 0.67 (95% CI: 0.58-0.75) for the total dose of work-related therapies indicated that the variance explained by centers was high.

Conclusions: Dose delivered of work-related components was increased. However, there was a discrepancy between the guideline’s recommendations and the actual dose delivered in at least half of the centers. It is very likely that this will affect the effectiveness of work-related medical rehabilitation in practice.

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