Conference Welcome Opening
Welcome from the local organising board
Welcome from Basel
Prof. Dr. Dr. h.c. Andrea Schenker-Wicki, Rector of the University of Basel
Welcome from the Presidents of EUMASS and SIM
Peter Donceel lecture
Social Security in a Globalised World - Experiences and Concepts in the Swiss Context
Thomas Gächter, Prof. Dr. iur.
Abstract: The globalisation of the economy poses a growing challenge to national social security systems. Particularly in connection with digitalisation, it is becoming increasingly difficult to ensure the social protection of all those involved in the economic process. The social security of the future will look different and will have to set different priorities compared to the current systems. The lecture will shed light on the Swiss perspective on these issues. Which approaches can be expanded on in the future, which systems no longer fit into a globalised world?
TOWARDS INTEGRATED HEALTH AND WORK POLICIES. First results from the implementation of an OECD Recommendation.
Dr Christopher Prinz
Abstract: Mental ill-health is a key challenge for education, social and labour market policy. The challenge results from the high prevalence and early onset of mental health problems, and the fact that it has long been neglected because of widespread stigma and misconceptions. Recognising the high costs of this neglect for people, employers and society, in 2015 OECD governments have endorsed a number of policy principles to achieve better social and economic outcomes for people with mental health problems. These policy principles were laid down in the "OECD Recommendation of the Council on Integrated Mental Health, Skills and Work Policy" (https://legalinstruments.oecd.org/en/instruments/334). This presentation will look at the question if, five years later, countries have been successful in promoting a more integrated policy stance and especially a stronger integration between health and employment policies.
Mental Health and Work: Challenges and Solutions for Assessing and Improving Work Capacity
Niklas Baer, PhD, Psychologist
Abstract: Working problems, sick leaves or disability benefits due to mental ill-health have steadily increased over in past decades in most European countries. Because the prevalence of mental disorders has not changed in the same period, there must be other drivers for this development, e.g. an increased awareness of mental health problems, an improved access to the psychiatric service system, a changed behaviour in sick employees, or a reduced tolerance at the workplace. The presentation highlights some major challengeges of the different actors – the people with a mental health problem, the employers, the doctors, and the insurance systems - and provides some possible solutions
Migration, mental disorders and insurance medicine.
Professor Ellenor Mittendorfer-Rutz
Abstract: Many European countries have experienced dramatic demographic changes due to increasing global migration. A considerable proportion of these migrants, particularly refugees, have traumatic experiences, placing them at an elevated risk of developing mental disorders, which in turn may lead to long-term work disability. Despite these recent trends, consideration of transcultural aspects in research on work disability is sparse. The presentation will show recent findings on patterns of and pathways to work disability due to mental disorders in migrant populations resettling in European countries. The need for a research field dealing with transcultural insurance medicine will be highlighted.
SIM Annual Meeting - German Session 1
Stroke: Versorgung und Versicherungsmedizin über die Grenzen (CH,D,A)
Moderation: lic. iur. Y. Bollag, Leitung asim Universitätsspital Basel
Vom ersten Auftreten der Symptome bis zur Rückkehr in den (Arbeits) Alltag
Neurologische Erkrankungen sind die häufigste Ursache von Behinderungen im Erwachsenenalter. Von allen neurologischen Erkrankungen ist der Schlaganfall die häufigste. Trotz Fortschritten bei der Prävention steigt die Prävalenz von Schlaganfällen, weil die Bevölkerung älter wird. Diese Session gibt einen Überblick über die Möglichkeiten moderner Schlaganfallbehandlung von der prähospitalen Phase/Akutphase bis in die Rehabilitation und die zukünftigen Möglichkeiten (z.B. die Telerehabilitation).
Die gesundheitsökonomischen Aspekte werden aus einer Dreiländerperspektive beleuchtet und die gutachtlichen Fragen zur Arbeitsfähigkeit und die Bedürfnisse aus PatientInnensicht diskutiert.
Medizinisches Up to date mit Key-Note Speakers aus D – A – CH
Prof. Heinrich Audebert
Krankheitsbild und Epidemiologie
Prof. Stefan Kiechl
Prävention und Sekundärprophylaxe
Dr. oec. HSG Willy Oggier
Finanzierungsanreize und Neuro-Rehabilitation:
Dr. Michael Brinkmeier
Vorstandsvorsitzender der Stiftung Deutsche Schlaganfall-Hilfe, Gütersloh
Stroke – der Weg zurück ins Erwerbsleben aus Betroffenensicht?
Dr. med. Julia Kejda-Scharler
Scope of the problem: Zentrale Themen in
Return-to-work interventions assessed by register data: Discussing sickness absence and work disability outcomes across countries
K. W. Hara1, S. Gismervik1, L. Aasdahl1, S. Kaspersen1, S. O. Ose1, G. H. Marchand1, K. Alexanderson2 (1Trondheim NO; 2Stockholm NO)
Preventing work disability is a common challenge across countries. Cross-country comparisons are of interest when designing return-to-work (RTW) interventions and evaluating their effect. However, consensus is lacking on how to measure the effect of RTW interventions. It is difficult to access comparative data across countries for several reasons. Benefit schemes and social insurance policy vary across nations as well as access to and quality of register data that can be used to measure RTW outcomes. Sickness absence data and other measures of temporary or permanent work disability vary across countries. Different methods of data collection are used, commonly both administrative and survey data.
The aim of this workshop is to discuss the possibilities of utilizing register data across different countries to assess effects on RTW. Furthermore, to discuss what outcome measures of RTW interventions are the best to use based on such data. We aim to facilitate discussion on this topic towards consensus on best practice.
Description of the outline
To facilitate discussion there will be a 10 minutes introduction followed by discussions interspersed by short presentations. Presentations and discussions will include the following topics:
- What type of sickness absence data are available in European countries? How do the different countries register sickness absence? What does this mean for the possibilities of cross-country comparisons of sickness absence?
- Examples of Norwegian registry data used to generate different sickness absence outcomes in randomized controlled trials. Topics for discussion: What are the possibilities when constructing outcomes? Different types of outcomes (number of sickness absence days, time to return to work, time to part time work) and pros and cons with the different outcomes.
- The Rapid-RTW program in Norwegian specialist health care (2007-2017) – can the construction of natural national experiments with observational registry data (N >3.5 million individuals) bring us closer to assessing effects on sickness absence?
- Towards future best practice: Consensus on best practice – what is realistic? Cross country collaboration? Policy development?
The main component of this workshop will be discussion in smaller groups and in plenum. Interactive components will include the use of interactive online learning tools. Participants will be given online access to the results from interactive sessions and the final consensus discussion.
Working on a Core Outcome Set (COS) for Work Participation
J. Hoving1, M. Ravinskaya1, R. Kunz2, J. Verbeek1 (1Amsterdam NL; 2Basel CH)
Many randomized controlled trials and systematic reviews are conducted to establish the effectiveness of interventions that aim to improve work participation for workers with a health problem. Yet, heterogeneity in outcomes and measurement methods hinders evidence synthesis. Cochrane Insurance Medicine and Cochrane Work are working on the development of a Core Outcome Set for Work Participation. A core outcome set is an agreed minimum set of outcomes that should be measured and reported in all trials in a specific health area.
- To gain insight in the variety of outcomes and measurement instruments on work participation
- To better understand the conceptual and practical implications of deciding what are the most relevant work participation outcomes
- To gain practical experience in COMET methods like Delphi procedure to establish priorities in work participation outcomes/instruments.
The workshop will be suitable for practitioners/researchers with an interest in work participation outcomes/instruments. Participants do not need to have prior experience of COS development.
Description of the outline & interactive elements:
This workshop will comprise a mixture of presentations, exercises and participant discussion to consider methods for COS development as outlined by the Core Outcome Measures in Effectiveness Trials (COMET) handbook.
- Presentation: an introduction to the workshop will introduce methodological issues and considerations involved in developing a COS for work participation, illustrated with examples relevant to insurance medicine.
- Exercises: based on a recent literature review and COMET guidelines participants choose outcomes/ instruments to measure work participation using a mini Delphi procedure. Participants will be provided with copies of evidence summaries on available outcomes/measurement instruments with relevant selection criteria.
- Plenary discussion: participants will discuss their responses in selecting outcomes/ measurement instruments on work participation and conceptual considerations will be provided by the workshop presenters.
The organisers will provide knowledge and practical experience on Core Outcome Set development and provide opportunities for participants to become involved in this COS initiative in collaboration with Cochrane Work and Cochrane Insurance Medicine.
Presenting authors workshop:
- Dr. Jan Hoving - Amsterdam UMC, Academic Medical Center, University of Amsterdam, Coronel Institute of Occupational Health, Amsterdam Public Health research institute, Amsterdam, NL
- Drs. Margarita Ravinskaya - Amsterdam UMC, Academic Medical Center, University of Amsterdam, Coronel Institute of Occupational Health, Amsterdam Public Health research institute, Amsterdam, NL
- Prof. Dr. Regina Kunz, MD - Academic Unit EbIM, Evidence Based Insurance Medicine, Department of Clinical Research, University of Basel, SZ
- Dr. Jos Verbeek, MD - Cochrane Work, Kuopio, FIN
- Dr. Miranda Langendam - Amsterdam UMC, Academic Medical Center, University of Amsterdam, Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Public Health research institute, NL
- Prof. Dr. Carel Hulshof, MD - Amsterdam UMC, Academic Medical Center, University of Amsterdam, Coronel Institute of Occupational Health, Amsterdam Public Health research institute, Amsterdam, NL
- Dr. Ira Madan, MD, FRCP, FFOM - School of Medicine, King’s College London, UK
- Dr. Suzanne Verstappen - Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, University of Manchester, UK
Performance Based Measures: How to Interpret and Use Results in Insurance Medicine and Vocational Rehabilitation
Maurizio Trippolini 1, Michiel Reneman 2, Doug Gross 3, Martin Schindl 4, Peter Oesch 5
(1 Bern, CH; 2 Groningen, NL; 3 Edmonton CA; 4 Klosterneuburg AUT; 5 Valens, CH)
Health care professionals are routinely asked to make determinations about functional ability, such as ability to work. Performance-based measures may be used to inform these determinations e.g. within functional capacity evaluations (FCE) in addition to self-reported measurements or clinician-based evaluations. Clinician-based evaluations within insurance medicine (IM), however, still have major challenges with basic clinimetric properties, including reliability. Several performance-based measures have been shown to be reliable, they have been developed mainly in rehabilitation settings and are used in the IM field. Testing, interpreting and applying the results of performance-based measures in the IM field poses challenges.
This workshop aims to
- Provide the participant an overview of the scientific status of performance-based measures;
- Discuss opportunities and challenges to integrating and using results of performance-based measures in IM.
We will discuss examples from clinical research on performance-based measures used in IM and vocational rehabilitation. Ultimately, the workshop aims to improve the appropriate use and interpretation of the results of performance-based measures within IM.
Format/structure of the workshop
Before the workshop, participants will be asked (through email) to answer questions about the topic, such as, their experiences about: 1) the interpretation and use of performance-based measures; 2) the perceived barriers and facilitators of the interpretation and use of results of performance-based measures; and 3) unanswered questions you have about performance-based measures in IM
Duration: 90 Min
- 10 min: Introduction & discussion of findings of pre-workshop survey (Trippolini)
- 10 min: Presentation 1 - Use of performance-based measures: a global perspective on functional capacity evaluations and its scientific status (Reneman/Gross)
- 10 min: Presentation 2 - Bridging the gap between vocational rehabilitation and insurance medicine with the results of performance-based measures (Oesch)
- 10 min: Presentation 3 - Impact of performance-based measures (FCE) on Patient-Reported Functional Ability in vocational rehabilitation (Schindl)
- 10 min: Presentation 4 - Interpreting performance-based measures: assessor training and effort determination (Trippolini)
- 30 min: How can we better integrate performance-based measures into Insurance Medicine? What are opportunities and pitfalls? (All)
- 10 min: Conclusions: what have we learned from this workshop? Writing-up the a report about the workshop, next steps (All)
- Increasing empirical and clinical knowledge about the interpretation and use of performance-based measures in IM
- Identifying gaps in knowledge that could be answered to improve the interpretation and use of performance-based measures in IM
- Summarize the survey findings, discussion, and learning outcomes from the workshop in a manuscript for submission to a peer-reviewed scientific journal
Congress delegates with an interest in understanding the value of performance-based measures in IM. All participants should be willing and able to think and discuss beyond the commonly used approaches. Participants using 2 sequential words ‘Yes, but …’ should not attend this workshop. Those that use the words ‘Yes, and …’ are absolutely welcome to attend and contribute to this WS.
A NEW JOB TO IMPROVE THE MANAGEMENT OF SICK LEAVES: HEALTH INSURANCE ADVISOR
P. Gaidamour1, K. Bécourt2, B. Bouttet Cavallier2, K. Girard2, M. Morvan1, S. Ruggieri1 (1Orléans FR; 2Tours FR)
While global health expenditure progression is more and more limited, there is a steady increase in certain items. In France, in 2016, the cost of work interruption for sickness represented a total of 10.2 billion euros, an increase of more than 4% compared to 2015.
At the same time, the French Health Insurance Medical Service is suffering the consequences of the decline in medical demography. Therefore, release medical time through the delegation of tasks has become an absolute necessity.
In this aim, an experiment of a new framework has been carried out, based on a new profession: the “Health Insurance Advisor” (HIA).
The purpose of the HIA is to contact the patient in a double goal:
Avoid a time consuming medical consultation by collecting information on the patient status
Initiate, if necessary, the prevention of professional exclusion.
The targeted persons had to be out of work for more than 18 months, with poor information in our medical file.
The assessment of the patient's condition was conducted by the HIA, through a telephone contact, using a specific questionnaire.
According to the information collected, a discussion took place between the medical advisor and the HIA to define the best strategy. When appropriate, the team could contact the treating doctor for further information.
144 telephone interviews were conducted between April and May 2019.
78 medical consultations (54 %) were avoided because of an evolving medical status. However, our medical file was efficiently completed in order to set a follow-up by the HIA.
Of the remaining 66 cases, a decision could be made by the medical advisor 30 times (45 %) without clinical examination: full or part-time return to work, permanent disability admission, stable medical condition after accident at work.
For 17 patients (25 %), the medical advisor has considered that the sick leave was justified after discussion with the treating doctor.
Only 19 patients (29 %) needed a medical consultation by the medical advisor before a return to work decision or a disability admission could be made.
To summarize, nearly 87 % of the physical examinations (125/144) were avoided by this method.
For 26% of all the situations analyzed, a prevention of professional exclusion was initiated in connection with the occupational physician and the social service, in agreement with the patient and his treating physician.
With a follow-up of nearly six months, none of the decisions was contested.
The role of the HIA in the management of sick leave was essential in the medical decision-making. It allowed to "save doctor time", either by avoiding medical examinations or by allowing prevention of professional exclusion.
Role of the nurses in acceptance of denying Sick-leave benefits in depressive disorders
I. Bohn1, A. Pialot1, P. Nicolle1 (1PARIS FR)
The medical service of the French National Health fund (CNAM) has to cope with a physician shortage. Introducing service medical nurse (SMN) in a multidisciplinary approach enables the physician to tackle this situation. The consequences of this task support or shifting on the outcome of sick-leave (SL) assessment has never been extensively studied. They are some questions in the field. Does the task transfert affect the perception of the claimant when denying the provision of benefit, and, beyond the rebuttal rate?
A control study has been carried out in the department of Val d’Oise, from 2018/04/01 to 2019/3/31. The claimants presenting a depressive disorders on sick-leave for less than 180 days and needed an advise to carry on the benefits were divided in two groups. The outcome of the process was a continuation of sick-leave, or a return to work with refusal to pay.
Study group: the SMN collected the data from a standardized form relevant to set up the medical record by interview of claimants. They could suggest an advice towards the physician about the case but not practice any physical examination. The physician had to give the advise from the completed record and could practice any additional examination
Control group: It is a traditional face to face meeting of the claimant with the insurance physician.
A total of 1291 interview by SMN were performed vs 304 by physician in the control group. The reported of work disability assessment could be carried out to the decision from the record by the nurses in 75% of the cases leading to a corresponding saving of medical time (see table).
There was no difference in agreements of the SL benefit between the groups, but there was a much lower rate of challenged and rebuttal rate in the SMN group. (p<0>
The medical skills of nurses who cannot realize a physical examination are limited, but this should not be so awkward in depressive disorders. The rebuttal rate may be underestimated because the decision can be changed through amicable settlement by the physician before a dispute notice. These results overlap another parallel controlled study performed in Long term SL management by phone that had not be presented because of a possible bias in assessment. The challenged decision came down dramatically in the SMN group too.
The synergy of professions enables a saving of medical resources, does not change the refusal rate (for depressive disorder) through a better acceptance of decisions by the claimants. The reasons why is unclear and should need further investigations.
Task transfer in work disability assessments in European social security
A. de Wind1, S. Brage2, F. Latil3, N. Williams4 (1Leuven BE; 2Drammen NO; 3Saint Ouen FR; 4Birmingham GB)
There is a shortage of insurance physicians in several social security administrations in Europe. Transfer of job tasks from the physicians to other professionals can offer a solution to such capacity problems, but it has not been known where, when, and how task transfers have been implemented. EUMASS has carried out an exploratory survey and collected case studies on task transfer (task shifting, delegation, and support) in European social security systems. The results published in 2019-20 indicated two important areas for further study: The quality of assessments before/after task transfer and claimant satisfaction after the reforms.
The objective of the workshop is to increase the knowledge about task transfer, to discuss examples how this has been carried out, to learn about new emerging professional groups for disability assessments, and to discuss ways to measure outcomes, quality of assessments and claimant satisfaction after task transfer.
Description – Outline of workshop
- Introduction (5 min, de Wind)
- Background, definitions and the EUMASS report 2019 (10 min, Brage)
- “A new job to improve the management of sick leaves: health insurance advisor” (15 min, Bécourt)
- “Acting together with the new professions of the medical department of the Assurance Maladie” (15 min, Pialot)
- Comments, reports from other countries (10 min)
- Experiences with quality measurements, presentation of a Dutch method, question to audience, discussion (25 min, de Wind)
- Claimant satisfaction measurements (10 min)
- Is a follow-up survey possible?
The audience is continuously asked to give examples and contribute to knowledge of task transfer in European social security.
Short Orals Session 1
Interventions on cognitions and perceptions that influence work participation of employees with chronic health problems: a scoping review
M. de Wit1, B. Horreh1, J. G. Daams1, C. T. J. Hulshof1, H. Wind1, A. G. E. M. de Boer1 (1Amsterdam NL)
Cognitions and perceptions, such as motivation and expectations regarding recovery or return to work (RTW), can influence work participation of employees with chronic health problems. Therefore, insurance physicians and occupational physicians need to recommend interventions that are focused on these cognitions and perceptions when these factors limit work participation. There is however no overview of interventions that are aimed at increasing work participation by intervening on these cognitions and perceptions.
The purpose of this scoping review is to identify available interventions that are focused on cognitions and perceptions of employees with chronic health problems and aimed at increasing work participation.
A scoping review was carried out following the framework of Arksey and O’Malley. Ovid MEDLINE and PsycINFO were searched for original papers published between January 2013 and November 2018. We included studies that described interventions that focus on work participation and at least one of ten cognitions and perceptions: expectations regarding recovery or RTW, optimism/pessimism, self-efficacy, motivation, feelings of control, perceived health, coping strategies, fear-avoidance beliefs, perceived work-relatedness, and catastrophizing. The quality of the studies included was assessed using quality assessment tools from the Joanna Briggs Institute.
In total, 24 papers were identified that studied interventions aimed at changing at least one of ten cognitions and perceptions in order to increase work participation. No interventions were found that focused on changing motivation or on optimism/pessimism. Four interventions were judged as effective in changing coping, fear-avoidance beliefs, perceived general health or perceived work-relatedness and work participation according to results of randomized controlled trials. Interventions consisted of individual sessions or group sessions. The interventions were given by one provider, such as a nurse, physiotherapist, psychological therapist or occupational physician. The interventions focused on different psychological aspects such as the problem solving process or the vicious circle of pain, but also on physical aspects with for example movement exercises.
This review provides an overview of interventions aimed at increasing work participation by intervening on cognitions and perceptions. Evidence was found for four effective interventions focused on changing some of these cognitions and perceptions and increasing work participation.
Impact on insurance medicine practice
Insurance physicians may use the overview to help employees with chronic health problems to increase work participation by referring them to the right intervention. In addition, this overview of interventions can be used by insurance physicians to judge if meaningful activities were carried out in order to increase work participation.
Barriers for Return-to Work, prevalence and characteristics of multiple problems among work disability benefit recipients.
K. Brongers1, P. Roelofs1, T. Hoekstra1, S. Brouwer1 (1Groningen NL)
Disability benefit recipients face participation restrictions due to health issues. Besides, they often perceive additional problems like financial problems, addiction. Multiple problems may hamper social inclusion and (work) participation and therefore should be taken into account in the return-to-work and rehabilitations guidance. However, up to now it is unknown which (combination) of problems exist beside poor health from claimants’ perspectives.
The aim of this study is to examine the prevalence, type and combinations of multiple problems in a sample of work disability benefit recipients. Furthermore, we studied associations between multiple problems and age, gender, education level, living status, diagnosis and work status.
A cross-sectional study among Dutch disability benefit recipients was conducted. Participants with remaining work capacity were recruited by labour experts from the Dutch Social Security Institute(UWV). Data on diagnosed disorders were retrieved from UWV register data. Additionally, data were collected on socio demographics, the presence (yes/no) and experienced severity (none/mild/moderate/severe) of ten problems that may hinder the participant in daily participation, i.e. physical ill-health, mental ill-health, financial problems, care for family, a too low or not suitable educational level, problems with the Dutch language, contact with police, problems with housing, addiction and domestic violence.
The sample consisted of 208 participants, 95 male (45.5%) with a mean age of 35.7 years (SD 13.0). One third (33.3%) was low educated, 34.8 % lived alone and 16.7% was working.
The majority of the participants were primary diagnosed with a psychiatric or developmental disorder (51.2%), followed by somatic diseases (35.6%) and intellectual disabilities (13.2%). In total, 86% experienced multiple problems, the average number of experienced problems was 3.3 (SD 1.7). Most participants experienced problems with physical health (75.8%) or mental health (75.5%), often combined with problems with educational level (55.4%), financial problems (48%) or care for family (40%). Multiple regression analyses showed associations between a low educational level and a higher number of perceived problems.
Most disability benefit recipients experienced multiple problems that may hinder the return-to-work process. Besides physical and mental health, not suitable educational level, financial problems and care for family were often reported. These findings indicate which barriers should be taken into account in the disability claim assessment, and showed that the focus should not only be on health, but also on additional problems in daily life. These findings may provide directions for interventions to improve social participation, including work.
Psychosocial interventions at the workplace, a systematic literature review
E. Friberg1, P. Lytsy1 (1Stockholm SE)
The psychosocial work environment has been shown to be of importance for the health and wellbeing of individuals as well as for the productivity, sickness absence levels, and wellbeing of an organization. Many different measures have been taken trying to improve this environment.
To map the existing knowledge, as presented in relevant and well performed systematic reviews, that have investigated the effects of work-related interventions, aiming to affect the psychosocial work environment and health related outcomes in workers/employees and in organizations.
A systematic literature review of published systematic literature reviews was performed to map the knowledge on psychosocial interventions at the workplace. The search strategies used several terms and expressions which capture different aspects of the psychosocial interventions aimed at affecting the wellbeing of individuals or the workplace organization. The search was performed in three electronic databases: PubMed, PsycINFO, and Cinahl. Two authors independently screened all references and assessed quality using a validated instrument. Systematic literature reviews of moderate or good quality were included in the systematic review.
A total of 44 relevant and well-executed systematic literature reviews related to studies on effects of workplace-related psychosocial interventions on health-related outcomes of the employees and the organization, respectively, were included. The types of interventions that were carried out mainly concerned different forms of stress-reducing or stress-management programs, or different forms of health-promotion either aimed specifically for mental ill-health or more general. Interventions aimed at bullying, social support, work efficiency and psychosocial climate in the workplace were also identified. A very large variety of outcome measures were identified. The vast majority of outcomes were related to mental or general health. But also stress and work-related issues were common. The majority of the systematic literature reviews reported several different outcome measures. A large proportion of the systematic literature reviews included interventions aimed at a general group of ‘workers’, or healthcare personnel.
A substantial amount of research regarding effects of psychosocial workplace interventions, have been published to date. Much of the existing knowledge indicates that the psychosocial work environment affects the individual and that active workplace interventions may promote health for the individual as well as the organization.
Impact on insurance medicine practice
Active psychosocial workplace interventions can have beneficial effects for the levels of sickness absence both for individuals and organizations.
Predicting return to work after long-term sickness absence for workers with subjective health complaints: a prospective cohort study.
K. Weerdesteijn1, F. Schaafsma2, K. Bonefaas2, M. Heymans2, J. Anema2, A. van der Beek2 (1Den Haag NL; 2Amsterdam NL)
Subjective Health complaints (SHC) are associated with long-term sickness absence. In most European countries, physicians have to support workers with sickness absence in their return to work (RTW) process. Physicians, however, report difficulties in supporting the RTW process of especially workers with SHC due to the lack of objective medical findings and limited knowledge on relevant factors to deal with and to support the RTW for those workers.
The main purpose of this study is to evaluate the prognostic factors for partial or full RTW to a paid job for at least 28 days after long-term sickness absence for workers with SHC and to compare these factors with workers with other disorders (reference group).
Data of 213 participants with SHC, and 1.037 reference participants, were used from a prospective cohort study. These participants answered a questionnaire just before their medical work disability assessment, but after >84 weeks of sickness absence. RTW were measured with questionnaires after one and two years. Univariable logistic regression analyses were performed (p≤0.157) for variables per domain (i.e. demographic, socio-economic and work-related, health-related, and self-perceived ability) with RTW. Subsequently, multivariable logistic regression analyses with backward selection per domain (P≤0.157) were performed. Remaining factors were combined in one multivariable model (P<0>
For workers with SHC as well as for the reference group, non-health-related factors like receiving a partial (OR 0.62, 95% CI 0.26-1.47 respectively OR 0.63, 95% CI 0.39-1.03) or complete (OR 0.24, 95% CI 0.10-0.58 respectively OR 0.12, 95% CI 0.07-0.20) work disability benefit, and having a positive self-perceived possibility for RTW (OR 1.06, 95% CI 1.01-1.11 respectively OR 1.08, 95% CI 1.05-1.11) remained statistically significant in the final model.
Non-health-related factors seem to be more important than health-related factors in predicting RTW. Receiving a work disability benefit and not having positive expectation for RTW seem to complicate RTW most for workers with SHC. With respect to RTW predictors, workers with SHC do not differ compared to the reference group.
Impact on insurance medicine practice
Based on the current study, support of RTW after long-term sickness absence have to be especially based on modifiable non-health-related factors, irrespective of the underlying pathology of the disorder. It is therefore advised to put more effort on the possibilities for changing expectations to RTW of workers themselves, or to change the work disability system, so that permanent work disability may be prevented.
7 years on “back to work” strategies for people with disabilities in Belgium
T. Brunois1, O. Wilmet1, A. Brans1, J. Alves1, S. Decuman1, F. Perl1, W. Gelade1 (1Brussels BE)
For several years now, the number of people who are unable to work due to a disease or private accident has been increasing in Belgium, generating significant social and financial costs. To this end, the Belgian government has taken several measures since 2010 to encourage the return to work (RTW) of disabled people.
The National Institute for Health and Disability Insurance (NIHDI) set up a collaboration with the regional employment services and the social insurance companies. The objective is to give patients the opportunity to undertake qualifying training free of charge on a voluntary basis (under certain conditions) and return to the job market.
The RTW program is launched by the medical advisor. The vocational reintegration projects, undertaken on a voluntary basis, include three phases: the vocational guidance phase (allow a clear idea of the need for vocational rehabilitation and the possibilities of reorientation), the vocational training phase (study program aimed to acquire –new or updated- professional skills) and the vocational reintegration phase (6-month period after the successful training phase, which includes all actions aimed on finding and returning on the job market).
We observe a significant increase in the number of projects started. From just over 1000 in 2012 to over 5300 in 2018, more than 24 500 program have been launched today. The duration of the programme is on average 16 months. Variables such as age, gender, disease and duration of sick leave influence the probability of undertaking a RTW project. In 2017 half of the patients starting a training program and for which we received a final evaluation successfully completed their training, 6% failed, and 44% stopped the program prematurely. 6 months after successfully ending their training, about 1 in 2 returned to the labour market (increasing to 4 in 5 after 18 months).
These findings confirm that training programs to encourage RTW are efficient. A multidisciplinary approach (with employment professionals) and continued support allow the reactivation of patients. In the upcoming years further research is needed to have a full understanding of these programs, their return on investment and critical success factors.
Relevance for an international audience
RTW programs allow to decrease the number of workers on long term in incapacity. Impacts are positive for all: patients can be back to work earlier and the insurance system seems to be sustainable with a reduction in long-term costs.
Short Orals Session 2
The incidence of inability to work fulltime among work disability claimants and its associated factors
H. J. Boersema1, T. Hoekstra1, F. Abma1, S. Brouwer1 (1Groningen NL)
Many chronic diseases are associated with reduced functioning and activity limitations, which may lead to limited work performance and inability to work fulltime (IWF). Inability to work fulltime is an important aspect of work disability claim assessment in European countries. Knowledge on the incidence of IWF and its association with diagnoses and demography might improve the quality of the assessment, but is lacking. Therefore, this study aims to examine incidence of IWF and the association of health and socio-demographic variables with IWF among disability benefit claimants with different types of diagnoses.
The study is a cross-sectional register based cohort study among applicants for a disability benefit according to the Work and Income Act (WIA) in 2016. The data was provided by the Dutch Social Security Institute (UWV). Only WIA claimants with residual work capacity were included in the study. All diagnoses were categorized in diagnosis groups following the ICD-10 chapters.
Descriptive statistics were used to gain insight in the incidence of IWF, defined as being unable to work >6 hours per day. Multivariable logistic regression analyzes were performed, to investigate the associations of health and socio-demographic variables with IWF. All analyses were performed for the total sample and separately for the four ICD-10 diagnosis chapters with the highest frequencies .
The incidence of IWF in the total group (n=30177; mean age: 48.8 +11.0; 53.9% females) was 39.4%. A higher age, female gender, middle and high educational level (compared to low educational level), and multimorbidity were significantly associated with IWF.
The four largest diagnosis chapters comprised 72.5% of the sample and were all significantly associated with IWF: Mental (29.5%, OR 1.13; CI 1.07-1.19), musculoskeletal (28.5%, OR 0.29; CI 0.27-0.30), cardiovascular disorders (7.8%, OR 2.75; CI 2.52- 3.01), and injuries (6.7%, OR 0.56; CI 0.50-0.62). Female gender was positively associated with IWF within all four diagnosis chapters. Higher age was associated with IWF within mental and musculoskeletal disorders, higher education within injuries, musculoskeletal and cardiovascular disorders, and multimorbidity was positively associated within musculoskeletal disorders and injuries, but negatively within cardiovascular disorders.
The incidence of IWF in work disability assessment among claimants with residual work capacity is substantial. Across the ICD-10 diagnosis chapters incidence and associations differ. Especially females, older and higher educated claimants with more than one disorder have a higher risk for IWF.
When assessing work disability attention for IWF and its determinants is important.
The importance of prognostic aspects considered during work disability evaluation.
S. Snoeck - Krygsman1, F. Schaafsma1, B. Donker - Cools1, C. Hulshof1, L. Jansen1, R. Kox2, J. Hoving1 (1Amsterdam NL; 2Eindhoven NL)
The assessment of prognosis is an important part of work disability evaluations and has profound individual and societal consequences. In a previous qualitative study we identified 23 aspects that physicians consider when assessing prognosis during disability evaluations. These aspects were divided into six categories: disease, treatment, course, information, patient-related aspects and physician-related aspects. Although physicians consider a wide range of aspects, we didn’t know the perceived importance of those aspects. We also wanted to know whether physicians need any support for prognosis assessment.
The aim of the current study was to investigate the importance of these aspects and to assess what type of support physicians need in assessing these prognostic aspects during disability evaluations.
Using a mixed-methods survey design, 76 insurance physicians were asked to score the importance (scale 1-10) of the 23 prognostic aspects. In addition, participants were asked to apply the same list of aspects to a case-vignette and again score the importance of these prognostic aspects. They were also asked to motivate their answers, and to reflect on their needs regarding support using open questions. Analyses consisted of both descriptive analysis and qualitative thematic analysis.
Medical categories (‘disease’, ‘treatment’ and ‘course’) and also the category ‘information’ were rated as most important (median scores 7-9, IQR 1-3) during prognostic assessment. Overall, scores within the categories of patient- and physician-related aspects (median scores 4-8, IQR 2-5) were lower and fell within a wider range. The case-vignette concerned a severe neurological disease. Here, medical aspects were scored higher and patient-related aspects scored lower than those aspects in general did.
Open answers pointed out that physician-related aspects were considered noteworthy, but should not be part of the assessment. Physicians mentioned the relevance of the support from a digital prognosis tool, providing them with ‘pre-appraised evidence’, an overview of ‘prognostic factors’ or ‘search strings’, applicable to the individual case.
(1) A prognosis assessment tool should always contain medical aspects. The importance of patient-related aspects varies per case. Physician-related aspects should remain implicit.
(2) Case-specific prognostic evidence, preferably from pre-appraised sources, is desired in a digital format.
Impact on insurance medicine practice
The (conditional) importance of the aspects and the desired support, will serve as input for the development of a prognosis assessment tool. This tool will assist the physician in founding the prognosis by means of case-specific evidence.
Assessment of visual impairments by physicians working in the field of disability evaluation: a qualitative study
R. Daniëls1, E. Noordik2, J. Simons1, J. Hoving1 (1Amsterdam NL; 2Utrecht NL)
Introduction: Work disability assessment of visual impaired patients can be challenging and evidence on this topic is lacking in the field of insurance medicine. This qualitative study aimed to explore problems and solutions experienced by insurance physicians in assessing visual impaired patients during their work capacity evaluation.
Methods: Two focus group interviews were conducted with six insurance physicians in each group. All participants (n=12) work in the field of disability evaluation at the Dutch Social Security Institute (UWV). The interviews were semi-structured with a topic list concerning the knowledge, experience and claims of visual impaired clients. All interviews were typed verbatim. After a member check, acquired data were independently analyzed thematically by two researchers.
Results: The following main problems were found: insufficient knowledge and absence of a guideline, difficulties to interpret, objectify and quantify visual complaints and tests, and the translation of these findings into impairments. The participants also suggested solutions that included more training for insurance physicians, development of a guideline, and opportunities to consult other occupational experts or medical specialists, and more expertises.
Discussion: In conclusion, this study provides first insights in problems and possible solutions concerning assessments of work disability claims of visually impaired patients. Further research on this subject is needed with a focus on developing practical tools for insurance physicians.
The recognition of probable malingering of health complaints: Experiences of Dutch Social Security professionals
N. Tolkacheva1, C. van der Lek1, H. Kroneman1 (1Amsterdam NL)
In the Netherlands, disability benefits are assessed by the Dutch Social Security Institute (SSI). Insurance physicians and labor experts, employed by the SSI, assess the client medical abilities and work capabilities. It is important that the assigned disability benefits match the functional disabilities and work capabilities of the client. Some clients may however exaggerate their symptoms or not report the improvement of medical conditions, causing mismatch between the client’s work activities and his/her true work capacities. Intentional over-reporting of symptoms, motivated by financial or legal benefits, is called malingering. The recognition of probable malingering is a challenge for social insurance organizations.
The objective of this research is gaining insight into experiences of employees of the SSI regarding the recognition of probable malingering by clients, and into ways of dealing with them.
In May 2019 1113 professionals, currently engaged in client’s assessments, filled in anonymous digital surveys, containing general opinion questions about probable malingering, subjective estimates of possible malingering reasons by clients, ways of recognition, actions and barriers to report about suspects.
Most of the SSI employees acknowledge the feeling that some clients might be involved in malingering. Almost half of the employees base that feeling on intuition, inconsistencies within dossiers or implausible exaggerated complaints. Most of the professionals estimate psychological complaints as the most probable health problems for over-reporting. However, they do not always know how to deal with their feelings about suspects and experience barriers to discuss these within a special department, conducting further investigation by clients. The most prevalent barriers are doctor-patient confidentiality, complexity of reporting process, unwillingness to (unfairly) blame or mistrust the client, and unwillingness to act in this role. In most of the cases that professionals feel that a client might be over-reporting, they do not report this.
The results emphasize the complexity of this phenomenon within social security practices, its ethical aspects and the ambivalence of financial disability benefits as a matter of fairness and trust. Developing an evidence-based tool, test or training, supporting the professional in recognition of probable malingering fitting into the context of social security organizations might help creating more clarity when dealing with this subject. The issue of over-reporting or malingering is recognized in the international psychology and psychiatry literature. Addressing this topic within this research can be especially relevant for an international audience representing countries where the social insurance system is an integrated part of welfare.
Short Orals Session 3
The relationship between awarding disability pension and waiting lists in mental health care: a cross-sectional study
A. de Rijk1, L. Roossen1, N. Wijnands2 (1Maastricht NL; 2Heerlen NL)
Waiting lists for mental health care are more prevalent and longer than for somatic health care in the Netherlands. It is unknown whether this affects the outcome of the work capacity evaluation. This study aimed to get insight in: (1) the prevalence of being on a waiting list for care among clients applying for disability pension (DP); (2) differences regarding begin on a waiting list, DP and work incapacity percentages between those with mental disorders and physical disorders; (3) the relationship between being granted DP and being on a waiting list, and if being granted DP, the relationship between being on a waiting list and work incapacity percentage for clients with mental and physical disorders.
During cross-sectional research, 44 insurance physicians completed questionnaires for 145 clients, aged 18-65 years, applying for DP at one Dutch Employee Insurance Agency between February 1- June 15 2018. Obtained information included: demographic variables; type of disorder (mental, physical or both); and being on a waiting list for care. After the assessment for DP, the work incapacity percentage was assessed by the vocational experts and added to the data collection. Chi-square tests as well as logistic regression were used to test relations between independent and dependent variables.
Clients with mental health complaints, who applied for DP, were more often on a waiting list for care compared to clients with physical disorders (Chi⊃2;=6.30, p= 0.02). In addition, for clients with mental disorders, there was an indication that people on a waiting list, more often were being granted DP (Chi⊃2;=2.72, p=0.09), and had a higher work incapacity percentage (Chi⊃2;=2.86, p= 0.06). No significant effects or trends were found for the relationships between physical disorders on the one hand and being on a waiting list, granted DP or work incapacity percentage on the other hand.
Clients with mental disorders applying for disability pension are more often on a waiting list compared to those with physical disorders, and they seem to be granted DP more often, and when granted DP, have a higher work incapacity percentage. No relations were found between physical disorders and being on a waiting list or being granted DP.
Impact on social insurance practice
Waiting lists in mental health care and not in somatic health care affect work capacity evaluation. Social insurance physicians might need to mediate with mental health care to improve access to the necessary treatment.
Adverse outcomes of chronic widespread pain and common mental disorders in sick-listed individuals – a prospective study of Swedish twins
M. Wang1, A. Ropponen1, J. Narusyte1, B. Helgadóttir1, G. Bergström1, V. Blom1, P. Svedberg1 (1Stockholm SE)
Background: Chronic widespread pain (CWP) and common mental disorders (CMDs) are common public health problems, but little is known about the role of CWP and CMDs on future adverse outcomes related to labour market participation and health among individuals with a history of sickness absence (SA).
Objectives: The aims of the study were to investigate the associations between CWP and CMDs with subsequent disability pension (DP), long-term unemployment (>90 days) and all-cause mortality in individuals with SA and whether the associations were confounded by familial factors.
Methods: In this prospective cohort study, 7884 Swedish twins born between 1933 and 1985 were included and baseline data on CWP and CMDs were gathered from surveys in 1998 to 2006. Register data were used for obtaining information regarding demographics, SA, DP, unemployment and mortality. Cox proportional hazards regressions were used to calculate Hazard Ratios (HR) with 95% Confidence Intervals (CI) for the associations between CWP and/or CMDs with DP, unemployment and mortality, while conditional Cox models for twin pairs provided control for familial confounding.
Results: Having either CWP or CMDs among those with a history of SA was associated with a higher risk of DP and all-cause mortality compared to individuals without CWP and CMDs after controlling for socio-demographic and health factors. Moreover, sick-listed individuals with both CWP and CMDs had a higher risk of DP while those who only had CMDs had a higher risk of long-term unemployment compared to those without CWP and CMDs. The associations between CMDs with DP and long-term unemployment was no longer significant when controlling for familial factors.
Conclusions: CMDs was a risk factor for DP, unemployment and mortality among individuals with SA, while CWP seems to be important in relation to future DP and mortality. Familial factors played a role in the associations between CMDs and DP and CMDs and unemployment.
Impact on insurance medicine practice: CWP and CMDs should be considered when monitoring individuals with SA, which may prevent future DP, unemployment and mortality.
Work disability benefit claimants with a mental disorder: incidence and associations with the inability to work full-time
T. Hoekstra1, H. J. Boersema1, F. Abma1, S. Brouwer1 (1Groningen NL)
In work disability assessment, insurance physicians evaluate the work capacity of claimants with a chronic disease. If residual work capacity is established, it is then indicated whether someone can work full-time (i.e. the (in)ability to work full time (IWF)). Employees with mental disorders frequently face challenges to work (full-time). However, up to now there is no insight in the incidence of residual work capacity and IWF among claimants with mental disorders.
To gain insight in the (in)ability to work full-time among disability benefit claimants with a mental disorder.
The study is a cross-sectional register based cohort study including all assessment data, registered by insurance physicians, of claimants for a disability benefit according to the Work and Income Act (WIA) in 2016. Data was provided by the Dutch Social Security Institute (UWV). Descriptive statistics were used to gain insight into the incidence of residual work capacity and IWF (unable to work >6 hours per day) in all claimants with a mental disorder as a primary diagnosis, and additionally for the 10 most prevalent diagnoses within the sample. Multivariable logistic regression analyzes were performed to study the associations of socio-demographic and health variables with IWF in claimants with mental disorders, work capacity and complete data.
Of the 40,263 disability benefit claimants in 2016 (mean age 48.7 years; 53.6% female), 12,901 (32%) were diagnosed with a mental disorder as the primary diagnosis (mean age 44.4 years; 55.4% female). Of the claimants with a mental disorder, the majority (77.2%) was assessed with residual work capacity. Complete data of 8902 claimants with residual work capacity and a mental disorder showed an incidence of IWF of 41.3%. Six out of the 10 most prevalent diagnoses showed similar results on the incidence of IWF as the total sample. Higher incidences were assessed for bipolar disorder (63.5%), post-traumatic stress disorder (49.5%) and depression (48.1%), whereas being overworked showed a lower incidence (16.6%). Multivariable logistic regression analysis (n=8902) indicates that female gender (OR 1.52, 95%CI 1.39-1.66), age (OR 1.004, 95%CI 1.00-1.01), and a high educational level (OR 1.14, 95%CI 1.02-1.29) are associated with IWF.
Conclusions and impact
Our study shows that the majority of disability benefit claimants diagnosed with a mental disorder were evaluated as still having residual work capacity. Within this group, a majority was indicated as still being able to work full time. Inability to work full time differed between specific diagnoses and was associated with gender, age and educational level.
Effects of Case Management after Psychosomatic Rehabilitation: A Propensity Score Matching Analysis
H. Banaschak1, S. Lemke1, M. Bethge1 (1Lübeck DE)
Background: In Germany, 16% of sickness absence and 43% of new disability pensions are due to mental disorders. To support work participation of patients with mental disorders and a high risk of not returning to work, a case management after psychosomatic rehabilitation was implemented by the German Pension Insurance North.
Objective: The aim of our study was to describe the implementation of case management on the basis of perceived professional support for returning to work and to describe effects of the intervention using further outcomes.
Methods: Case management clients were recruited during psychosomatic rehabilitation at three rehabilitation centers (German Clinical Trials Register: DRKS00014564). The intervention group (IG) received case management after rehabilitation. The control group (CG) got no further care. Questionnaire data were assessed at the end of rehabilitation and after six months. The primary outcome was perceived professional support for returning to work (0-24 points). Secondary outcomes were employment, self-rated work ability (0-10 points) and restrictions of participation (0-90 points). Propensity score matching was used in order to generate samples with comparable characteristics. Effects were estimated using regression models.
Results: 343 rehabilitants were included at T1 (IG: n = 54; CG: n = 289). 86 persons, 43 in both treatment arms, were included when analysing the 6-month follow-up. 65.1% were women, mean age was 48.3 years (SD = 9.7), 34.9% were employed and 72.9% had been on sick leave for more than 26 weeks in the 12 months prior to rehabilitation. After 6 months, participants of the case management reported higher perceived professional support than the controls (b = 8.50; 95% CI: 5.63 to 11.36) but were less employed (OR = 0.49; 95% CI: 0.18 to 1.33) and were less frequently returned to work (OR = 0.42; 95% CI: 0.15 to 1.13). Case management clients reported lower self-rated work ability (b = -1.18; 95% CI = -2.10 to -0.26) and stronger restrictions of participation (b = 8.97; 95% CI 0.06 to 17.88).
Conclusions: Our analyses show, that case management is perceived by rehabilitants as supportive for returning to work. However, case management participants did not return to work more frequently after 6 months and reported worse work ability and greater participation restrictions than the control group.
Impact on insurance medicine practice: Case management is discussed as a possible answer to complex supply needs. However, our results suggest that the implemented case management approach had a negative impact on return to work in the short-term.
Short Orals Session 4
What is Belgian medical advisors’ perception about the use of ICF core-sets when assessing work incapacity related to back pain?
T. Otte1, C. Duyver1, S. Decuman1 (1Brussels BE)
There is a willingness in Europe and in Belgium to implement the use of a bio-psycho-social model such as the International Classification of Functioning, Disability and Health (ICF) for assessing work incapacity.
We conducted a preliminary study to measure the perception of medical advisors (MA) about the interest of structuring the client's bio-psycho-social information in an ICF based report when it comes to take a decision regarding work incapacity or the relevance of initiating a reintegration process for clients suffering from back pain.
We first conducted a semi-exhaustive literature review related to our initial theme. After this theoretical part, a practical part was conducted. First of all, we met 4 clients in order to obtain a real clinical case. The latter was built on a medical examination carried out by the MA and an interview with an occupational therapist (OT). The interview was conducted following ICF’s core-sets. Then we proposed a perception questionnaire to a sample composed of 92 MA and 9 paramedics working in Belgian mutual health insurance companies after showing them 2 comparative videos based on the clinical case we made. The first video was the medical examination and the second was the ICF based interview. The perception questionnaire had 22 questions related to 4 axes : the clinical and diagnostic relevance of the ICF, the impact of the ICF on management, its impact on communication as well as its impact on the enhancement of respondents’ role.
The data were analyzed using quantitative methods. Free comments from 48 respondents were also collected and taken into account.
Offering a bio-psycho-social tool for decision support to MA allows a more complete client’s picture. Respondents recognize the relevance of ICF at the clinical and diagnostic level but say it cannot be implemented in the current context for various reasons such as the time required or having a multidisciplinary team and an effective coordination. These should be addressed before a possible implementation of ICF in the assessment work incapacity or in the relevance of initiating a reintegration process. Older doctors are less enthusiastic about the relevance of using ICF than their younger colleagues.
Adaptation and validation of the Work Disability Functional Assessment Battery (WD-FAB) to German (Germany).
Y. Y. S. Feng1, M. Buchholz2, T. Kohlmann2 (1Tübingen DE; 2Greifswald DE)
The Work Disability Functional Assessment Battery (WD-FAB) is a patient-completed measure consisting of eight domains of physical and mental functioning. Initially created to standardize assessments supporting claims adjudication for Social Security in the United States, the WD-FAB was rigorously developed based on the International Classification of Functioning, Disability and Health framework (ICF) and administered using computer adaptive testing (CAT) to minimize respondent burden while maintaining measurement accuracy.
Cultural adaptation and validation of the WD-FAB in Germany.
Two independent forward translations from English to German (Germany) were first conducted by professional translators. Two researchers – a native English and a native German speaker – reconciled the translations into a first German version. Problematic items were 1) presented to a lay panel of seven native German speakers with varying experiences in the field of rehabilitation; 2) discussed with two developers of the original WD-FAB; and/or 3) revisited with the forward translators. The reconciled German items were translated into English by a third translator. Items for which the backward translation differed substantially from the original were revised. All items were then field tested for clarity and feasibility with conveniently sampled rehabilitation patients before being finalized. Validation of the German WD-FAB will sample physical and mental health rehabilitation patients as well as disability claimants. Each participant will complete a subset of 3 to 4 dimensions of the WD-FAB alongside questions about demographics, functional status and comorbidities. Classical test theory and item response theory will be used to analyze the German WD-FAB.
We adapted 405 WD-FAB items into German: 60 presented to the lay panel, 26 revisited by translators, and 49 required consultation with WD-FAB developers. Certain problems in translation (e.g. “flights of stairs”) were anticipated and encountered little problems during the adaptation process. There were reoccurring problems with translations of “stress” and “anger.” Translators were asked to give their assessment for each translation as illustrated by Figures 1-3.
The German translation of the WD-FAB item bank is completed. As of submission of this abstract, field test is underway and the recruitment for the validation is slated to begin in early 2020.
The accurate measurement of functional level with low respondent burden can be used to support disability claims adjudication; evaluate rehabilitation patients’ recovery progress and effectiveness of therapy; and provide a standardized measure for international comparisons as the WD-FAB is adopted by other countries.
Challenges in disability evaluation and the need for a goal-oriented ICF-based approach: A stakeholder analysis at the Swiss accident insurance
U. Schwegler1, B. Trezzini1, B. Schiffmann1 (1Nottwil CH)
Challenges in disability evaluation and the need for a goal-oriented ICF-based approach: A stakeholder analysis at the Swiss accident insurance
Urban Schwegler1,2*, Bruno Trezzini1,2, Barbara Schiffmann1
1 Swiss Paraplegic Research, Nottwil, Switzerland
2 Department of Health Sciences and Health Policy, University of Lucerne, Switzerland
While poor standardization and transparency as well as objectivity and efficiency issues have been addressed as key challenges in disability evaluation, these challenges were hardly empirically explored so far. The same is true for the often ascribed added value of using an approach based on the International Classification of Functioning, Disability and Health (ICF) in the eligibility determination context.
By using the eligibility determination process of the Swiss accident insurance (Suva) as a case in point, the present study examined current challenges and the need for a goal-oriented ICF-based approach in disability evaluation as experienced by different stakeholder groups.
Descriptive qualitative design involving semi-structured expert interviews with five main stakeholder groups of Suva’s eligibility determination process (i.e., Suva insurance officers, Suva insurance physicians, treating physicians, lawyers and judges). The interviews were thematically analyzed and their results reflected upon in focus groups with selected interview participants.
Forty-three interviews and three focus groups were conducted. Participants pointed to challenges related to standardization, transparency, objectivity, efficiency and the assessment of contextual factors. An ICF-based standard documenting claimant-job mismatches and their determinants (see Figure 1) was deemed promising for ensuring comprehensible and valid work and earning capacity decisions, systematic and uniform reporting and a goal-oriented eligibility determination process focusing on claimants’ work integration. Concerns primarily addressed a potential pseudo-accuracy when using the standard for eligibility decisions.
Conclusions and impact on insurance medicine practice:
Implementing a goal-oriented ICF-based standard may help to approach current challenges in disability evaluation such as poor transparency, validity and comparability of work capacity decisions as well as low efficiency of the eligibility determination process . Our findings support the development of such a standard for Suva’s eligibility determination, but also point at the importance of involving key stakeholders to ensure its applicability and cross-disciplinary acceptance.
Schwegler U, Trezzini B, Schiffmann B. Current challenges in disability evaluation and the need for a goal-oriented approach based on the ICF: a qualitative stakeholder analysis in the context of the Swiss accident insurance. Disabil Rehabil. 2019. [Epub ahead of print]
Applying the refined ICF-linking rules on the Ergokit Functional Capacity Evaluation protocol
K. Vermeulen1, S. de Baets1, K. Oostra1, D. van de Velde1 (1Ghent BE)
Linking of the Ergo-Kit Functional Capacity Evaluation (FCE) to the International Classification of Functioning, Disability & Health (ICF; World Health Organization, 2001) provides valuable information.
This study aimed at linking the Ergo-Kit FCE protocol to the ICF (WHO, 2001). The degree in which the Ergo-Kit covers the (comprehensive and brief) core set vocational rehabilitation was also examined. Since observations are a relevant source of information within the Ergo-Kit, observations were also linked to ICF.
The linking rules developed and refined by Cieza and colleagues (2002, 2005, 2016) were used to link the meaningful concepts of the Ergo-Kit standard protocol (composed of 55 parts) to the most precise ICF category. Two independent raters performed the linking process independently; the items for which no consensus was reached, were evaluated by a third rater. By means of summary linkage indicators (Mac Dermid, 2014) it was also assessed to which degree the Ergo-Kit protocol covers the comprehensive and brief core set of vocational rehabilitation. The observations for 65 Ergo-Kit tests were linked to the ICF by one rater.
The 55 components of the Ergokit FCE protocol and 65 observations of FCE tests were linked to the ICF. Items were linked to the 4 components of the ICF model with the highest percentage for the chapter “mobility” within the ICF-component of activities and participation.
The ICF linkage process of the Ergo-Kit adds to the operational definition of FCE (Soer et al, 2008 ) that an FCE is an evaluation of capacity of activities that is used to make recommendations for participation in work while considering the person’s body functions and structures, environmental factors, personal factors and health status.
Impact on insurance medicine practice
These study results can contribute to the further implementation of ICF within the domain of disability evaluation and return to work and the use of FCE to obtain a higher transparency in disability evaluation.
SIM Annual Meeting - German Session 2
Covid-19 Pandemie: Versorgung und Versicherungsmedizin über die Grenzen – Erfahrungen und lessons learned aus der Grenzregion Basel (D – F – CH)
Moderation: lic. iur. Y. Bollag, Leitung asim Universitätsspital Basel
Das Dreiländereck um Basel am Oberrhein war und ist von den gesundheitspolitischen Herausforderungen einer Grenzregion geprägt. Dies hat sich zugespitzt auch in der Coronapandemie gezeigt. Die Session zeigt die aktuellen Erfahrungen und Perspektiven von direkt Beteiligten aus Politik, Gesundheitsbehörden und Wissenschaft auf und diskutiert wichtige Handlungsfelder für die künftige Bewältigung.
• Die Pandemie trifft eine Grenzregion:
Die Epidemiologische Entwicklung am Oberrhein vom Februar 2020 bis heute - Koordination der Public Health Strategien
• Intensivbetten werden knapp:
Die Verlegung von Patienten und Patientinnen über die Grenzen
• Das Personal im Gesundheitswesen wird knapp:
Die Organisation der personellen Gesundheitsversorgung mit GrenzgängerInnen
• Die trinationale Zusammenarbeit im Gesundheitsbereich – lessons learned - Perspektiven
Dr. iur. Lukas Engelberger
Dr. med. Thomas Steffen
Dr. med. Aref Al-Deb`i
Short Orals Session 5
Evolution of the Socio-Economic Position of Belgian Workers with Cancer. A Population-based Cohort Study Using a Life Course Perspective Approach
K. M. Regine1, N. Victoria1, O. Renee1 (1Brussels BE)
The prevalence of cancer survivors increases though in the workforce. The issue of their return-to-work represents an important matter for their quality of life, but also a great challenge for the social security systems. This population-based cohort study aims at quantifying the return-to-work of Belgian cancer survivors and at identifying the determining factors.
We requested data from the Belgian Cancer Registry and the Crossroad Bank for Social Security. We included all socially insured Belgian workers diagnosed between 2004 and 2011 with colorectal, breast, head & neck, prostate, testis, lung and corpus uteri cancer. The end of (administrative) follow-up was 31st December 2012.
After having solved legal, ethical and technical issues for the coupling, we performed group-based modeling for longitudinal data using the ‘proc traj’ package in SAS. We included demographic, health-related and work-related factors in the analysis and observed how these factors interplay to determine the working status.
Among the 38 930 survivors included, after 5 years follow-up, 18% died, 69% were (partially) active, 31% were (pre-)retired, unemployed or disabled.
The group-based modeling revealed the existence of 3 types of work trajectories: high and stable; low and stable and changing across time. Different trajectories appear according to the follow-up time. Among the workers with high working probability, we mainly find women with breast cancer; men with prostate cancer and workers aged 36-50 years old.
The results of our study reported that workers with cancer who resumed work were mainly self- employed and middle-age workers (36-50) with testis or breast cancers. Lung and prostate were negatively associated with the RTW and young workers seem to be at risk of unemployment.
It suggests that an early assessment of the worker’s profile would allow the identification of those who would require support in order to prevent their exclusion from the labour market.
Cancer and inability to work fulltime: incidence and associations among work disability claimants
H. J. Boersema1, T. Hoekstra1, F. Abma1, S. Brouwer1 (1Groningen NL)
In work disability assessment, insurance physicians evaluate the (residual) work capacity of workers with a (chronic) disease. If there is work capacity, it is then indicated whether someone can still work full-time (the (in)ability to work full time). Employees with cancer, a common serious disease, frequently experience such (energy) deficit that they cannot work (full time). However, up to now there is no insight in the incidence of (residual) work capacity and (in)ability to work full time among disability claimants with cancer.
The study is a cross-sectional register based cohort study with claimants for a disability benefit according to the Work and Income Act (WIA), in 2016. The data was provided by the Dutch Social Security Institute (UWV).
Descriptive statistics were used to gain insight into the number of WIA claimants with a primary diagnosis of cancer and residual work capacity. Within this group the incidence of the inability to work fulltime (IWF), defined as being unable to work > 6 hours per day, was studied for the total group and for specific cancer diagnoses. Multivariable logistic regression analyzes were performed, including claimants with cancer and complete data on all variables, to investigate the associations (significance level p <0>
Data from 40,263 people who applied for a WIA benefit in 2016 (average age 48.7 years; 53.6% women) were used. Of these, 3757 (9.3%) had cancer as the primary diagnosis (average age 53.3 years; 60.3% women) from which 57.8% were assessed with residual work capacity.
Complete data of 1908 claimants with cancer and residual work capacity (average age 52.8 years; 63.0% women) showed an incidence of IWF of 69.6%. Incidences of IWF were highest for leukemia (82.5%) and lung cancer (81.9%). In the largest group (breast cancer, n=648) the incidence of IWF was 67.4%. Multivariable logistic regression analyses in total group showed that female gender (OR 1.31, 95% CI 1.07-1.61) and age (OR 1.02, 95% CI 1.01-1.03) were positively associated with IWF.
Our study shows that 58% of the claimants diagnosed with cancer do have residual work capacity, however, almost 70% of this group was indicated by the insurance physician as unable to work full time. Female gender and older claimants have a higher risk of IWF.
Insight in IWF of cancer patients may contribute to evidence based practice in work disability assessment.
Return-to-work after breast cancer: the role of work environment
A. Dumas1, E. Caumette1, S. Pinto1, M. El Mouhebb2, T. Bovagnet1, E. Martin2, A. Di Meglio2, I. Vaz Luis2, G. Menvielle1 (1Paris FR; 2Villejuif FR)
More than 85% of breast cancer (BC) patients live more than five years after diagnosis in Western countries. One-third of BC patients is younger than 55 years old at time of diagnosis, with several years within the workforce ahead before retirement, in an era where the legal retirement age is globally increasing. Employment issues among BC survivors are therefore a major challenge.
The aim of this study was to understand the impact of work environment on return-to-work (RTW) after breast cancer diagnosis.
CANTO is a French multicenter prospective cohort study including patients with stage I-III breast cancer aiming at characterizing long-term toxicities of BC treatment. We used data from 1003 patients enrolled from 2012-15 (First data lock), who were ≥5 years younger than minimum legal retirement age (62) at diagnosis and professionally active. Detailed working conditions were collected at diagnosis and updated work status was collected 2 years post-diagnosis. Working conditions included information on type of contract, size of the firm, working hours, strenuous work conditions, emplyer's accomodation, supportive environment, control over the work situation, and perception of work. Logistic regression models evaluated the impact of pre-diagnosis working conditions on return to work (RTW). Models were adjusted for stage and treatment, socioeconomic characteristics, health status at inclusion and health status at the end of treatment, using the common toxicity criteria adverse events (CTCAE) scale and patient reported outcomes (PROs): EORTC QLQ-BR23 and QLQ-FA12, and the Hospital Anxiety and Depression Scale.
Overall, 21% of survivors had not returned to work 2 years post-diagnosis. In the multivariate models, odds of RTW were reduced among women who had shift working hours (OR=0.47 [95%CI 0.28-0.80]) and who did not work in a supportive environment before diagnosis (OR=0.46 [0.27-0.79] among women without support from colleagues (OR=0.66 [0.36-1.19] among women who received support only from colleagues vs those who received support from colleagues and supervisor). Odds of RTW were elevated among women who did not find their job boring (rather not boring work OR=2.96 [1.29-6.81], not at all boring work 4.26 [2.00-9.07] vs boring work).
Among a set of factors relating to work environment, nature of work, working hours and psychosocial working conditions were strongly associated with RTW.
Impact on insurance medicine practice:
The study shows the importance of working conditions, rather than the characteristics of the firm, on return-to-work after breast cancer. These results highlight the need of accounting for them when designing interventions.
How to read a Cochrane Review: the basics
J. Hoving1, R. Kunz2, F. Schaafsma1, E. Friberg3 (1Amsterdam NL; 2Basel CH; 3Stockholm SE)
Cochrane’s mission aims to make healthcare decisions get better. By conducting systematic reviews Cochrane contributed to transform the way decisions on health are made. Systematic reviews attempt to identify, appraise and synthesize research evidence that meets pre-specified eligibility criteria to answer a medical question.
Practitioners in insurance medicine have reported difficulties navigating through Cochrane reviews which often are extensive documents. However, it is rarely necessary to read a full Cochrane review to find research evidence for a medical decision. Understanding the structure of a review and knowing where to look for the relevant information can substantially shorten the time to find the answer. Cochrane Insurance Medicine strives to enable professionals in insurance medicine to use Cochrane reviews for decision making.
This workshop offered by Cochrane Insurance Medicine takes the participants through a Cochrane review, explains the methodology of a systematic review and how to read the findings. It guides to the relevant parts needed for decision making and demonstrate how to apply the results to a case.
Objectives & interactive elements
In this hands-on workshop participants will learn about the type of questions that can be answered with a Cochrane review. They will learn how to rephrase a specific question arising from the insurance setting into a question that can be answered by scientific literature. They will master the skills to navigate through a Cochrane review and to gather the information relevant for decision making. This way decisions and judgements in the field of insurance medicine can become more evidence-based.
J. Hoving, F. Schaafsma , E. Friberg, R Kunz
J. Verbeek, A. Verbel, R. Kok, S. Brouwer, F. Abma, Yvonne Suikerbuik
Short Orals Session 6
Implementation of a Certified Return to Work Coordinator (CRTWC) in a Belgian social security organization.
F. Wolfs1, H. Désiron2, A. M. Bonroy1, F. de Smet3, S. Decuman1 (1Brussels BE; 2Leuven / Hasselt BE; 3Brussels, Louvain BE)
In 2014 the Belgian National Institute for Health and Disability Insurance acquired the NIDMAR-license (National Institute of Disability Management and Research) to organize a Belgian certified Disability Management (DM) course. Since 2016, legislation initiates a more prominent focus on prevention of work-disability, describing a specific role for social security physicians. Hereby creating an opportunity to implement a DM approach within the social security context of insurance physicians. This study aims to clarify what is needed to enhance prevention of work-disability including how a CRTWC can contribute to that goal within the Belgian social security context.
A combined approach of evidence-based practices (as provided by DM) and practice-based evidence (by case-study) will found development of a guideline for supporting return to work by a CRTWC. By using a mixed method design, analysis of current practices will also be carried out to determine what barriers and opportunities are already present.
A first phase (January – April 2020) will clarify how -when integrated in a health insurance institute - a CRTWC’s contribution supports prevention of work-disability. This will be studied through analysis of the current employed healthcare professionals (except physicians: occupational therapists, physiotherapists, psychologist, nurses,…) within the interdisciplinary team and weighing their educational competencies to requirements of a CRTWC. Furthermore we will describe how this service is currently provided and use this as practice base to develop a conceptual model.
A second phase (may 2020 – October 2021) aims to implement a CRTWC in the interdisciplinary service and to adapt the current practices, based on the evidence gathered in a literature review and by live-prototyping. Resulting in the development of a pilot project that will be applied within the various interdisciplinary teams of the health insurance institute.
Stakeholder inclusive support is expected to create a positive effect on preventing work-disability. By focusing on capacities instead of illness or disabilities, including attention on customization of jobs, people on sick leave will be retained from exclusion from the labor market. A guideline that identifies barriers and opportunities will enhance evidence-based practice of using a CRTWC in a health insurance institute. Moreover, it might have impact on employers’ engagement as well as deliver societal benefits by reducing sick leave costs, removing RTW-barriers, an inclusive organizational policy… On an individual level, positive effects are expected that are linked to the ability to work (participation, recognition, financial improvement…), leading to an increased quality of life.
Disability Case Managers in the rehabilitation teams: a necessary member for a successful return to work process?
E. Lemmens1, D. S. Vonck2, N. Nijs1, D. S. Decuman3, K. van Kelst3, M. Michielsen1, M. Verhoeven4, D. M. Vander Plaetse1, P. D. A. Spooren2 (1Herk-de-Stad BE; 2Hasselt BE; 3Brussels BE; 4Overpelt BE)
Returning to work for patients with an acquired brain injury after an intensive rehabilitation period is sometimes an enormous challenge. It is shown that chances of reintegration decrease with 50% after 4 to 6 months, and decrease further to 20% after one year1. Work has shown to be beneficial on the quality of life and the level of functioning, as persons feel more accepted and integrated in the society. In Jessa Hospital, an early interdisciplinary intervention program (Weer-Werk) is started, which focuses on work-oriented rehabilitation and involves a Disability Case Manager (DCM) to facilitate the patient’s return to work on several aspects. The present study aims to assess the benefits of DCM within the Weer-Werk program with regard to work status, health status and general functioning.
We conducted a quantitative, longitudinal and controlled intervention study on patients, aged between 18-62 years, with neurological conditions and amputations. Patients in the experimental group (Rehabilitation Center Sint-Ursula, Jessa Hospital, Herk-de-Stad) received a rehabilitation therapy according to the Weer-Werk methodology and the involvement of a DCM. Patients in the control group (Revalidation & MS Centre, Overpelt) received the standard rehabilitation therapy. At the start, the end and 6 months after the rehabilitation, participants were asked to complete questionnaires concerning work status, quality of life (Short Form 36), mental functioning (Depression, Anxiety and Stress Scale), functional status (Barthel Index), participation (Nottingham ADL Index), coping (Utrecht Coping List), self-effectivity (Dutch Self-Efficacy Scale) and general satisfaction with the revalidation track.
A total of 80 patients participated in this study. Of these, 60 patients were included in the experimental group and 20 in the control group. For 8 patients, the rehabilitation is still ongoing, and 26 follow up’s needs to be done. At this moment, only preliminary results on work status are available. After 6 months, 50 % of the experimental group is returned to its same or alternative work place, compared to 36% in the control group. Further results are expected around July 2020.
The preliminary results show a promising effect of the DCM on work status. However, more in-depth analyses, associated with the health status, will give a better and more specific insight in the added value of the DCM.
1. Depypere M, Donceel P. Gedeeltelijke werkhervatting bij arbeidsongeschikte werknemers op ziekteverzekering in België: een retrospectieve studie. TIJDSCHRIFT VOOR BEDRIJFS- EN VERZEKERINGSGENEESKUNDE. 2010 2010/04/01;18(4):151-6. Dutch.
Lower sick leave claims with a rehabilitation coordinator for patients with longstanding pain or mild to moderate mental illness.
A. M. Norén1, J. Hagmyr1, J. Bengtner1, S. Landström1 (1Stockholm SE)
Longstanding pain and mild to moderate mental illness cause high sick leave claims, low quality of life and high societal and health care costs. There is a need of better methods to identify and offer the right support to these patients. A distinct focus on work ability is needed and the contacts with employers and Social Security Insurance Agency must be strengthened. International experiences tell us that case management programs can be successful models. In Sweden there are good experiences from patients and care givers of a rehabilitation coordinator for the rehabilitation process in primary care. The effects on these efforts on sick leave claims, life quality and health care consumption are scarce.
To evaluate the effects of rehabilitation coordination and work out a feasible model for the function within primary care.
939 patients were recruited in a randomized controlled study, where effects of the structured model with a rehabilitation coordinator is evaluated on sick leave rates, health care consumption and health related quality of life. Satisfaction of patients, physicians and employers were assessed. The model consisted of (1) identifying patients at risk for long term sick leave (2) individually support to identified patients for return to work from special educated coordinators (3) follow ups to adjust the efforts for the patient.
Patients with previous sick leave and mild to moderate mental illness or longstanding pain in the intervention group had a lower sick leave rate on average in the long run compared to the control group. Small differences were reported on health care consumption between the groups. Patients, physicians and employers were satisfied with the function. Quality of life was increased in the intervention group.
A well-structured model of a rehabilitation coordinator showed good effects on patients with long standing pain or mental health concerning sick leave claims and quality of life. Minimal differences on health care consumption between the groups were reported.
Impact on insurance medicine
The role of a well-educated rehabilitation coordinator can have positive effects on patient support, sick leave claims, collaboration between health professionals in primary care, but also for the employers and the financiers of the social insurances.
The role of a Disability Case Manager in return-to-work: experiences from patients, healthcare professionals and employers.
D. S. Vonck1, E. Lemmens2, N. Nijs2, D. S. Decuman3, K. van Kelst3, M. Michielsen2, D. M. Vander Plaetse2, P. D. A. Spooren1 (1Hasselt BE; 2Herk-de-Stad BE; 3Brussels BE)
Returning to work for patients with an acquired brain injury after an intensive rehabilitation period is often an enormous challenge. It is shown that chances of reintegration decrease with 50 % after 4 to 6 months, and decrease further to 20 % after one year1. In Jessa Hospital, an early interdisciplinary intervention program (Weer-Werk) is started with the involvement of a Disability Case Manager (DCM). The DCM facilitates the patient’s return to work on several aspects, and acts as a tailored contact person for the patient, its family, the healthcare professionals, the employers and other potential stakeholders. This study aims to map all the personal experiences from different stakeholders around the involvement of a DCM in the reintegration process.
For this study, we performed semi-structured interviews in three groups of stakeholders: (1) patients; (2) healthcare professionals from the interdisciplinary intervention program (Weer-Werk); (3) external stakeholders, which included employers, social insurance physicians or occupational physicians, all involved with the reintegration process of 1 or more patients. Questions prompted participants to describe their experiences concerning the involvement of a DCM in the reintegration process. Interviews transcribed verbatim and analyzed with descriptive phenomenology using NVIVO 12.
For now, we included 24 patients in group 1, 7 healthcare professionals in group 2 and 7 external stakeholders in group 3. The semi-structured interviews in group 1 are finished, but for group 2 and 3 more semi-structured interviews will be added in January/February 2020. A preliminary analysis of group 1 showed already a predominantly positive tendency towards the involvement of a DCM in the reintegration process.
An overview of the most relevant experiences in the three different groups, with corresponding conclusions, are expected the first half year of 2020.
1. Depypere M, Donceel P. Gedeeltelijke werkhervatting bij arbeidsongeschikte werknemers op ziekteverzekering in België: een retrospectieve studie. TIJDSCHRIFT VOOR BEDRIJFS- EN VERZEKERINGSGENEESKUNDE. 2010 2010/04/01;18(4):151-6. Dutch.
Establishing a new function within health care for return to work – a Swedish example
A. M. Norén1, C. Emilson1, C. Emilson1 (1Stockholm SE)
The sick leave rates raised during the last decade especially within mental health and long-standing pain, the majority being women. Therefore, the Swedish government over the last years has financially supported the regions to establish coordinating functions within the health care to enhance the sick leave and rehabilitation process.
The coordinating function aims to make the sick leave and rehabilitation process more effective and also enhances the patients returning to work.
Producing the medical certificate and leading the sick leave process is demanding for the physician concerning patients with longstanding health conditions. So are also the follow ups and the external contacts around the patients with the employer and the Social Security Insurance Agency (SSIA), which is the main financier of sick leave costs in Sweden. Assessment of activity limitation in relation to work, has not historically been included in the ordinary Swedish health care. According to the current state of knowledge, early assessment of activity limitations is necessary with patients at risk for long time sick leave. With a rehabilitation coordinator, who often is an occupational-, a physiotherapist or a psychologist with long experience of rehabilitation and understanding functional abilities, this process can be enhanced for all parts. The coordinator early identifies patients at risk through monitoring sick leave rates digitally through the medical record or in dialogue with the physician. Then mapping the level of functioning and work conditions of the patient, assessing the needs of rehabilitation for return to work, and participating in constructing a rehabilitation plan. Further then gives an individual support to the patient encouraging to self-management, coordinates the rehabilitating treatments and activities, promotes collaboration between health care, employers and authorities, mainly the SSIA. Other important parts of the function are to collaborate with the physician and the leader of the unit in sick leave issues as to statistic and educational matters.
The experiences of the function are positive from patients, physicians, health professionals and external actors involved in the sick leave process. Ongoing research in Sweden evaluates the effects and the experiences of the function.
Relevance for an international audience
The rehabilitation coordinator within health care is unusual and new. Experiences show that team work increases and the sick leave process is enhanced with the function. The concept could be of great interest for countries with similar health care system as Sweden.
Short Orals Session 7
Work-related medical rehabilitation in patients with musculoskeletal diseases in Germany: a propensity score analysis
D. Fauser1, M. Vogel2, M. Bethge1 (1Lübeck DE; 2Malente DE)
Musculoskeletal diseases are a leading cause of work absenteeism and work disability. Work-related medical rehabilitation is a multimodal interdisciplinary approach to reduce health-related discrepancies between work capacity and job demands in order to achieve work participation for patients with poor work ability. Randomised controlled trials in patients with musculoskeletal diseases showed that patients who received a work-related medical rehabilitation programme reported higher return to work rates than patients who received a common medical rehabilitation programme.
The study tested the relative effectiveness of a work-related medical rehabilitation programme, implemented in routine care, compared with common medical rehabilitation in patients with musculoskeletal disorders (Funding: German Pension Insurance North).
Questionnaire data were assessed in 2014 and 2015. By means of propensity-score-matching, participants of work-related medical rehabilitation (intervention group) were compared with similar participants of common medical rehabilitation (control group). The primary outcome was work participation one year after discharge of rehabilitation, extracted from administrative data. Treatment effects were analysed by logistic regression models. Moreover, absolute risk reductions (ARR) and the corresponding number needed to treat (NNT) were calculated.
In total, the data of 859 persons having participated in a rehabilitation programme were considered. By means of propensity score matching, samples with comparable characteristics were created. One year after discharge of rehabilitation, the data of 312 patients (IG: n = 156) were included in the analysis. The analysis of the treatment credibility revealed significant differences in the received dose of work-related therapies between the two treatment arms. One year after rehabilitation, work-related medical rehabilitation increased work participation by eleven percentage points (ARR = 0.11, 95% CI: 0.02 to 0.20, p = 0.020) compared to the common medical rehabilitation. Nine persons would have to be treated in a work-related medical rehabilitation programme in order to achieve one additional employed person (NNT = 9.05, 95% CI: 1.40 to 16.70).
Work-related medical rehabilitation achieved better work participation outcomes after one year compared to common medical rehabilitation. The results indicate the effectiveness of work-related medical rehabilitation under real-life conditions.
Impact on insurance medicine practice:
Interventions that work in efficacy studies with carefully selected patients and high treatment fidelity might not necessarily also perform well in real-world settings. Our study showed the effectiveness of an intervention under real-life conditions implemented nationwidely by the Federal German Pension Insurance.
A Delphi Study towards Multidisciplinary Consensus on Return to Work and Normal Activities after Knee Arthroplasty
C. Straat1, P. Coenen1, D. Smit1, G. Hulsegge1, R. van Geenen2, G. Kerkhoffs1, R. Janssen3, T. Boymans4, J. Huirne1, H. Anema1, P. Kuijer1 (1Amsterdam NL; 2Breda NL; 3Veldhoven NL; 4Maastricht NL)
Recommendations concerning return to work and normal activities after total- or unicompartmental knee arthroplasty are often lacking and vary considerably between Dutch hospitals. Evidence is limited, and recommendations are therefore often based on expert opinions of health care professionals. Well-defined recommendations and multidisciplinary consensus regarding return to work and normal activities are important for shared decision making and for improving perioperative care.
We aimed to obtain multidisciplinary consensus on return to work and normal activities after total- and unicompartmental knee arthroplasty.
Using a Delphi procedure, a multidisciplinary panel of six orthopaedic surgeons, three physiotherapists and five occupational physicians – all with special interest and expertise in knee arthroplasty patients - participated to reach consensus on recommendations regarding the resumption of 27 different activities including those regarding return to work. The procedure involved three online questionnaire rounds and one consensus meeting. In each of the four rounds, all experts individually judged when activities could feasibly be resumed after total- and unicompartmental knee surgery by three groups of patients; i.e. those with fast, average and slow recovery. Consensus was reached when at least two-thirds of the experts agreed with the recommendation.
After four Delphi rounds, the expert panel reached consensus for all 27 activities including return to work and normal activities. For example, the expert panel agreed that total knee arthroplasty patients with a fast recovery could resume ‘walking without walking aids’ 2 weeks after surgery, those with an average recovery 4 weeks after surgery, and those with a slow recovery 6 weeks after surgery.
Consensus for multidisciplinary recovery recommendations were reached for 27 activities including return to work and normal activities after total- and unicompartmental knee arthroplasty for patients with fast, average and slow recovery rates.
Impact On Insurance Medicine Practice
Multidisciplinary recommendations support healthcare providers and patients to improve shared decision making and perioperative care. The effectiveness of the recommendations will be evaluated in a randomized controlled trial using the eHealth intervention ‘I Recover’ for which we are currently recruiting patients. We expect the intervention to support knee arthroplasty patients in return to work and normal activities after surgery, thereby improving quality of life.
Predictive validity for a non-return to work of the Modified Spinal Function Sort (M-SFS)
D. Riese1, J. Kool1, M. Trippolini2, B. Jansen3, P. Oesch1, M. Schindl4 (1Valens CH; 2Bern CH; 3Bellikon CH; 4Klosterneuburg AT)
According to the Global Burden of Disease Study, musculoskeletal disorders (MSD) are a major cause of incapacity for work. Long-term disability in patients with MSD is often associated with low perceived self-efficacy (PSE). In addition, lower PSE is associated with poorer health outcomes and return to work (RTW). The Modified Spinal Function Sort (M-SFS) is a patient reported health measure to evaluate work-related PSE. The M-SFS contains 20 drawings of physical activities with simple written descriptions. Each task is rated on a 5-point Likert scale ranging from “able” (4 points), to “restricted” (3, 2 or 1 points) or “unable” (0 points) adding up to a total score from 0 to 80. Previous research supports reliable and validity of the M-SFS. However, the predictive validity of the M-SFS for RTW is unknown and is evaluated in this study.
Multi-centre prospective cohort study in patients with MSD with PSE assessment at baseline and evaluation of work activity at three months follow-up. Inclusion criteria were non-specific MSD > 3 months, no co-morbidity limiting work ability and informed consent. PSE was evaluated with the M-SFS with a total of 0-80 points and higher scores representing higher PSE. RTW was dichotomized depending on the number of work days (0 or 1-90). We investigated the predictive validity of the M-SFS to predict RTW by receiver operating characteristic (ROC) curve analysis. An Area Under the Curve (AUC) was considered acceptable if >0.7 and excellent if >0.8. We determined the cut-off value for the optimal prediction of RTW and non-RTW and determined specificity and sensitivity.
Preliminary results concern 105/164 participants. The mean M-SFS score was 62.7 (SD 13.6). RTW rate was 58%. M-SFS prediction of RTW was excellent, the AUC was 0.828 (95% CI 0.749 – 0.907). M-SFS values <57>
The M-SFS for the evaluation of perceived self-efficacy for work-related tasks has excellent predictive validity for RTW. Scores <57>80% sensitivity and specificity.
Cost-utility analysis of arthroscopic rotator cuff repair: real-world data of reintegration
C. Grobet1, K. Eichler2, M. Flury3, F. Meier2, S. Wieser2, B. Brunner2, H. K. Schwyzer1, L. Audigé1 (1Zürich CH; 2Winterthur CH; 3Wallisellen CH)
Background and Objectives:
To examine the influence of arthroscopic rotator cuff repair (aRCR) on quality of life (QOL), direct medical costs and productivity losses, and evaluate the cost-utility ratio of aRCR compared to an alternative scenario of ongoing nonoperative (nonOP) management from a societal perspective in Switzerland.
Patients indicated for aRCR were included in a prospective study and followed up to two years after surgery (postOP) for all measurements. QOL (EQ-5D-5L) and shoulder function (Constant Score, Oxford Shoulder Score, Subjective Shoulder Value) were assessed. Sixteen major insurance companies provided all-diagnoses direct medical costs and patients reported their loss of productivity using the Work Productivity and Activity Impairment Questionnaire. Baseline data at recruitment and costs sustained over one year before (preOP) surgery served as a proxy for nonOP management. Total direct medical costs to gain one extra quality-adjusted life year (QALY) were calculated as the incremental cost-effectiveness ratio (ICER; mean of 2 years postOP compared to 1 year preOP control period). Subgroup analyses were separately performed for traumatic (Trauma-OP) and degenerative (Degen-OP) rotator cuff tear patients. Sensitivity analyses for aRCR patients included intensive nonOP treatment with corresponding QOL gain. The relationship between QOL and shoulder function was explored using regression analysis.
For 153 aRCR patients (mean age 57 years; 63% male), the mean EQ-5D index improved from 0.71 (preOP) to 0.94 (1 year postOP) and 0.96 (2 years postOP). Mean total costs increased from 5,499 Swiss Francs (CHF) (preOP) to 17,116 CHF (1 year postOP), then decreased to 4,226 CHF (2 years postOP). The ICER for all aRCR patients was 24,924 CHF/QALY (95%CI: 16,742 to 33,106) and 17,357 CHF/QALY (95%CI: 10,951 to 23,763) and 36,474 CHF/QALY (95%CI: 16,301 to 56,648) for the Trauma-OP and Degen-OP groups, respectively. One-hundred-and-six from 110 working patients returned to work on average 77 days after surgery. Mean productivity losses for the aRCR group were 42,001 CHF per patient in the year before surgery and decreased to 5,415 CHF until 2 years after surgery. QOL and shoulder function were significantly associated (p < 0>
For RC patients treated at a specialized Swiss orthopedic clinic, aRCR is a cost-effective intervention associated with clinically relevant improvement in QOL and productivity gains up to 2 years after repair compared to prior nonOP management.
Short Orals Session 8
Functional Impairment and Requirement Analysis (FIRA): A novel quantitative approach for the systematic evaluation of working capacity in insurance medicine
C. Mueller-Pfeiffer1, S. Broicher2, A. Burkhard1, R. Rickenbach3, T. Zeffiro4, L. Goetze5, W. Goetze5 (1Zurich CH; 2Vernier/Geneva CH; 3Stein am Rhein CH; 4Potomac MD US; 5Thalwil CH)
According to the guidelines established by Swiss Insurance Medicine, work incapacity assessment should be based on consideration of both worker functional limitations and workplace requirements. In practice, this process includes generation of neither a detailed functional impairment profile nor a detailed requirement profile for the previous or current workplace, which is outside of the formal training of medical experts. As a result, work capacity is usually estimated by medical experts using heuristic approaches based on personal clinical experience, without incorporating quantitative functional information or using algorithms for deriving work capacity from impairment and job requirement profiles. Although heuristic estimates of work incapacity are faster than systematic ones, they may be more error-prone because of the associated broader range of examiner discretion. Variability in estimates resulting from reliance on heuristic approaches may substantially contribute to poor reliability in work capacity estimation among medical experts.
Functional Impairment and Requirement Analysis (FIRA) is a novel quantitative and systematic approach to work capacity evaluation in insurance medicine across medical disciplines.
The assessment, which is jointly conducted by medical experts and work psychologists, includes A) Administering of a semi-structured interview to determine the claimant's past and current daily life activities; B) Assigning requirement ratings for the daily activities used to designate past and current performance and determine performance decline; C) Assigning causality ratings to determine the degree of symptom-related functional impairment; D) Statistically modelling the association between functional requirement and functional impairment; E) Exploring professional task domains: F) Assigning requirement ratings for professional task domains to determine the degree of functional requirements in the claimant's job; G) Statistically estimating the degree of functional impairment related to the job requirements; H) Deriving global working capability from the functional impairment profiles. The FIRA is based on the International Classification of Functioning, Disability and Health (ICF), a framework and language for describing health-related conditions in a uniform and standardized manner.
Conclusion and Relevance:
The FIRA has the potential to improve reliability among medical experts in work capacity evaluations in insurance medicine, which is one of the major issues in insurance medicine in Switzerland and other countries.
“RE-Toolbox” – a tool providing statistical support in case of incapacity for work, per ICD diagnosis or ICD diagnosis group
D. Camenisch1, F. Bantle2 (1Zürich CH; 2Bern CH)
The application “RE-Toolbox” developed for the Swiss Insurance Association (Schweizerischer Versicherungsverband SVV) enables insurance companies and healthcare professionals to compare specific cases per disease within a given population. Appropriate (re-)integration measures can be planned and realized in a standardized way by the integration of standardized catalogues of measures for each disease and corresponding deflection points. Today, data regarding accidents and daily sickness allowances is already being collected automatically and in a standardized way through the interface between insurance companies and “RE-Toolbox”.
The primary objective is that only those cases are handled which are statistically “conspicuous or abnormal in relation to incapacity for work (IW)”. For each reference population, information regarding gender, age segment, job profile, duration of incapacity for work (IW) and the amount of treatment costs is shown both in a table and graphically. The ICD diagnoses or ICD diagnosis groups are the keys to every comparison. The selected intervention points support the specific measures “return-to-work” or “early intervention”. A methodical comparison between the Swiss IW statistics and the data of absence reporting or the American ODG Guidelines and Return-to-Work Guidelines is possible. ODG stands for Official Disability Guidelines.
The clinical guidelines and analyses of ODG aim to improve and evaluate the profitability of work, as do RE-toolbox and the absence report. This facilitates quality care and simultaneously restricts inappropriate use. The evaluation based on industry data of the risk of damage resulting from interventional triage allows to build up adequate reserves. The German absence report, encompassing all economic sectors, provides information on absences, structure and development of the sickness rates of employees in Germany. This is also the future objective in data collection using RE-Toolbox.
Health & Medical Service AG compares the two methods, ODG as well as data of the absence report with their corresponding country specific attributes and figures, with the Swiss standard reference RE-Toolbox. By doing so, it is shown how statistical figures regarding the incapacity for work and its underlying causes can assist medical experts in Switzerland in making decisions. Furthermore, the tool indicates from which additional key figures medical experts can benefit in the insurance sector as well as in routine medical work, including insurance medicine, and at what time during the disease progression such a support seems reasonable or not.
 ICD-10-GM Version 2019: https://www.dimdi.de/static/de/klassifikationen/icd/icd-10-gm/kode-suche/htmlgm2019/
 Absence report: https://www.wido.de/publikationen-produkte/buchreihen/fehlzeiten-report/
 ODG: https://www.mcg.com/odg/odg-solutions/return-work-guidelines-modeling/
Using administrative data to assess the risk of permanent work disability: a cohort study
M. Bethge1, K. Spanier1, M. Streibelt2 (1Lübeck DE; 2Berlin DE)
Rehabilitation can restore and improve work ability in patients with chronic diseases. In Germany, rehabilitation services are provided by the pension agencies. However, about half of the people receiving a disability pension did not use rehabilitation services before their health-related early retirement.
We developed a risk score using administrative data to assess the risk of permanent work disability. Such a score may support identification of individuals with a high likelihood of receiving a disability pension.
Our sample was a random and stratified 1-percent sample of individuals aged 18 to 65 years paying pension contributions. We extracted socio-demographic data and data about employment and welfare benefits covering 2010 to 2012 from administrative records. Our outcome was a pension due to work disability that was requested between January 2013 and December 2017. We developed a comprehensive logistic regression model and used the model estimates to determine our risk score weights. Our standardized risk score has a mean of 50 points and a standard deviation of 10 points. Several measures of prognostic accuracy were determined.
We included 352,140 individuals and counted 6,360 (1.8%) disability pensions during the 5-year follow-up. The risk score clearly discriminated individuals with and without a disability pension. The area under the receiver operating characteristic curve was 0.84 (95% CI: 0.83 to 0.84). Using a threshold of ≥50 points we correctly classified 80.6% of all individuals (sensitivity: 71.5%; specificity: 80.8%). Using ≥60 points we correctly classified 90.3% (sensitivity: 54.9%; specificity: 91.0%). Individuals with moderate (≥50 to less than 60 points) or high risk scores (≥60 points) had a 5 times or 17 times higher risk of a disability pension compared to individuals with low scores.
The risk score offers an opportunity to screen for people with high risks of permanent work disability. Individuals with a high risk may be invited by rehabilitation providers or rehabilitation funding agencies to discuss which services and strategies can be used to avoid permanent work disability.
Impact on insurance medicine practice:
Our risk index enables us to actively approach people with an increased risk of a health-related exit from the workforce. It can support work capacity evaluation and the assessment of requested rehabilitation and pension benefits. Our risk index can also be used to make the comparison of rehabilitation facilities fairer and to take into account the different case mix of rehabilitation facilities as it is a simple administrative measure of the severity of impairments.
Short Orals Session 9
Hiding your heart: What do heart rate signals tell us about mental effort?
E. Spirig1, H. Jokeit2 (1Luzern CH; 2Zürich CH)
The validity of neuropsychological assessments depends on the subject’s exertion. Exertion can be assessed by symptom validity tests, self-reports and observation. A shortcoming of all three measures is that they cannot provide a continuous monitoring of the associated feeling of mental effort although this is a time dynamic mental state driven by multiple external and internal factors. Theoretically, certain brain- and psychophysiological signals might correlate with mental effort.
Studying the feasibility of monitoring mental effort by heart rate changes in a standardized comprehensive neuropsychological assessment.
We measured heart rate in 40 neurological patients showing maximal performance (NP) and 80 healthy individuals, 40 showing maximal performance (MP) and 40 showing consciously reduced performance (RP).
Random forest analysis was performed to distinguish between MP and RP based on heart rate, which was successful in 90% of the cases. The same algorithm classified more than 50% of NPs as RP, yet NPs were highly committed to the assessment.
Our study shows systematic changes in heart rate driven by mental exertion in healthy individuals but not in NPs. Further analyses will be presented at the conference to clarify whether NPs mental exertion can be inferred from heart rate with a psychophysiological approach.
Partner Loss and its Effect on Frailty Trajectories: Results from the Longitudinal Survey of Health, Ageing and Retirement in Europe (SHARE)
M. Oberndorfer1, C. Mogg1, S. Haider1, I. Grabovac1, D. Drgac1, T. Dorner1 (1Vienna AT)
Frailty is a geriatric syndrome closely linked to a variety of adverse health outcomes such as falls, fractures, hospitalization and institutionalization which also contribute to high health care costs. Thus, it is important to identify factors associated with the development of frailty. Previous studies have focused on physical activity, nutrition and socioeconomic status as risk factors for the development of frailty. However, partner loss and its effect on individual frailty trajectories has not been assessed before.
It was the aim of this study to examine, if, and to what extent partner loss, a highly stressful life event, presents a risk factor for the development of frailty.
Using data from the Survey of Health, Ageing and Retirement in Europe (SHARE), we assessed the effect of partner loss on frailty trajectories applying growth curve models. Our study sample included a longitudinal cohort (2004-2017) of 20,848 community-dwelling individuals aged 50 or older from fifteen European countries. Frailty was measured using the validated sex-specific SHARE-Frailty Instrument including muscular weakness, unintended weight loss, decrease in walking capacity, low physical activity, and exhaustion.
The analysed sample contained 18,723 participants who lived in a partnership during their entire observation period and 2,125 participants who lost their partner during the observation period. On average participants were observed over a period of 7·89 years (SD = 3·76, min.: 3 – max.: 14 years). Women experienced an initial increase in frailty following partner loss (β=0·293, [SE=0·081], p<0 SE=0·009], SE=0·141], SE=0·018],>0·05) (figure 2). However, men’s social network connectedness had a significant compensatory effect on the effect of partner loss on frailty levels (β=-0·129, [SE=0·063], p<0>
Partner loss can lead to a significant worsening of frailty among elderly people. After an initial increase in frailty, only women tended to stabilise. However, especially for men, the compensatory effect of social networks suggests a powerful mediator modifying the response of frailty trajectories to partner loss.
Impact on insurance medicine practice
Being a risk factor for the development of frailty, approaches to mitigate the effect of partner loss on frailty trajectories, especially in men, are needed to curb adverse health outcomes and therefore costs. Notable differences in the response of frailty trajectories to partner loss and the compensatory effect of social networks suggest potential for such approaches.
Short Orals Session 10
Intervention studies regarding physicians’ sickness certification practice – a scoping review
M. Söderman1, A. Wennman-Larsen1, K. Alexanderson1, E. Friberg1 (1Stockholm SE)
Many interventions have been undertaken in order to increase the quality of physician’s work with sickness certification of patients. However, they are seldom scientifically evaluated and the knowledge is limited regarding the content and outcomes of such interventions.
The aim was to map and compile contents and outcomes measured in intervention studies aimed to influence physicians’ sickness certification practices.
For this scoping review, we searched for peer-reviewed studies on controlled interventions aimed at physicians’ sickness certification practices and reporting physician-related outcomes, published in English in January 2009 through February 2019. We searched in PubMed and Web of Science and conducted electronic tracking of citations, references, and author names.
The search resulted in 1399 publications, of these, 37 studies were assessed as relevant. A majority of the studies were from the Netherlands, most (n=26) designed as controlled trials and 11 as randomized controlled trials. The types of interventions were either training, introduction of different guidelines or checklists, collaboration between stakeholders, changes in regulations, or combinations of these four. Follow-up time ranged from immediately after the intervention and up to 4.5 years after. Type of data used were either self-reported, or from registers or medical records. In total, 54 different outcome measures were used, we categorized them as: adherence to and use of guidelines (n=20), competence measured as increase in knowledge or skills regarding sickness certification (n=20), change of attitude to consultation management regarding sickness certification/fit note (n=5), organizational aspects for handling sickness certification e.g. lack of time for such tasks (n=4), and other aspects (n=5). These outcomes were reported as, e.g., frequencies of sickness certification consultations, proportions of information regarding work on sickness certificates (yes/no), or mean score for variation in work capacity assessment, but also as probabilities or ratings. Intended effects were found in most of the interventions.
Most of the interventions measured physicians adherence and use of guidelines as well as competence in terms of increase in knowledge and skills, mainly reported as frequencies and proportions, and it was shown that physicians’ sickness certification practice can be influenced by interventions. However, more studies with comparable outcomes are needed to be able to compile the success factors and the effect sizes of interventions targeted at physicians’ sickness certification practice.
Impact on insurance medicine practice:
The results may provide a basis and an inspiration for other interventions and studies concerning interventions on physicians’ sickness certification practice.
The claimants ´s sick leave diagnosis does not correpsond to what is determined following an independent medical examination.
T. Lundeberg1, M. Jonsson1 (1Stockholm SE)
Sick-leave certification serves as the basis for compensation in Sweden. We have previously reported that there in 2016 was a 22% discrepancy between the diagnose on the sick-leave certificate and the diagnose established after an independent insurance medicine assessment
In the present trial we set out to to investigate the the sick-leave certificates of patients with more than three years sick leave and their diagnoses following an independent insurance medicine assessment.
One hundred and fifty claimants (with a long term sick-leave of 3 years or more) reffered from the Swedish Insurance Agency for an independent medical examination during 2018 were randomly selceted. The diagnoses (ICD-10) on their sick-leave certificate were then compared with the diagnose/diagnosis of the assessing physician.
In 62 out 150 ¨(41%) with a long term sick-leave their diagnose/diagnosis was/were found to be different from the one on their sick-leave certificate. Our findings suggest that there may be fundamental problems relating to the sick-leave certification process in Sweden.
Relevance for an international audience
Sick-leave certificates need to adopt to disease plasticity (feks neuroplastic changes realting to development from a nocicepetive pain state into a nociplastic state) to allow for a better classification.
INDEPENDENT MEDICAL EXAMINATION at 6 months sick leave in Norway. A randomized controlled trial and qualitative evaluations of stakeholders experiences.
Abstract: 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.
Social security disability assessments: how to directly assess work capacity, and the challenges that remain.
Ben Baumberg Geiger
Abstract: There is a strong argument that social security disability assessments should directly assess claimants’ work capacity, rather than relying on proxies such as on functioning. However, there is little academic discussion of how such assessments can occur. Based on case studies of eight countries, I argue that these assessments take three forms: (i) “demonstrated assessments” (using claimants’ experiences in the labour market), (ii) “structured assessments” (matching functional requirements to workplace demands), and (iii) “expert assessments” (the judgement of skilled professionals). However, we must still develop our knowledge – and accept the limitations – of each way of directly assessing capacity.