improving work outcomes in patients with musculoskeletal pain – effectiveness and ... · 2020. 1....
TRANSCRIPT
It’s the Keele difference.
Improving work outcomes in patients with musculoskeletal pain – Effectiveness and costs
of a vocational advice service
Gwenllian Wynne-JonesSenior Research Fellow : Research Institute for Primary Care and
Health Sciences, Keele University, UK
Objectives
The impact of musculoskeletal pain on the working age population
The value of working despite musculoskeletal pain
An overview of findings from a randomised controlled trial comparing a brief, early intervention to support people working with pain to best current care
Musculoskeletal Health
Scale of the impact in the UK
Versus Arthritis: State of Musculoskeletal Health 2018
Musculoskeletal Health – tip of the iceberg
Diagnosed MSK condition < 1.5 % of population
Patients with muscle and joint pain in primary care: 15-30% of population
Workactive with frequent and recurrent MSK pain in 1 or more body regions : > 50% of population
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80.00
100.00
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Rat
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Age category
Back pain
Sciatica
Surgery
General MSKpainKnee pain
Shoulder pain
Wynne-Jones et al 2010
Rates of certified absence for musculoskeletal pain
Lewis et al 2015
Health and work
• Work is generally good for physical and mental health and well-being
• Prolonged sickness absence is generally bad - the longer the duration of absence the more entrenched incapacity becomes
MSK pain
Primary care consultation
Work absence
Intervention to address occupational issues
Faster return to work? Fewer absences?
The problem…..
The key challenge
How to help people with MSK pain to stay at or return to work?
EARLY and BRIEF intervention in primary care
• To test the effectiveness and cost-effectiveness of adding an early VA service to best current primary care for adults with MSK pain
• Key outcomes: Days lost from work andFit Notes– Patient questionnaires– Medical record data
Bishop A et al. Rationale, design and methods of the Study of Work and Pain (SWAP): a cluster randomised controlled trial. ISRCTN 52269669. BMC Musculoskelet Disord 2014;15:232. doi: 10.1186/1471-2474-15-232.
The Study of Work And Pain (SWAP) cluster randomised controlled trial of a vocational advice service
Cluster RCT designs
Hemming K et al. BMJ 2015
6 General practices
338 patients
Participants eligibility criteria
Inclusion criteria Exclusion criteriaAdults consulting with MSK pain in primary care
Serious pathology requiring urgent medical attention
Currently in employment but…
Unable to read and speak English
- absent from work or - struggling at work
Serious mental health problems for whom participation in the study would be detrimental (at the discretion of the GP)
- sickness absence < 6 months
Pregnant or on maternity leave
Interventions: Best current care
• Evidence update session for GPs - best current care for the management of MSK pain and work
• Key messages:– Work is usually good for people with MSK pain– Long periods of absence can be harmful– MSK pain can often be accommodated at work– Planning and supporting RTW are important in good
clinical management• All usual health care continued (data collected)
Clinical Red Flags
Clinical Yellow Flags
Occupational Blue Flags
Occupational Black Flags
Organic pathologyConcurrent medical problems
Iatrogenic factorsBeliefsCoping strategiesDistressIllness behaviourWillingness to change
Family reinforcementWork statusHealth benefits and insuranceLitigation
Work satisfactionWorking conditionsWork characteristicsSocial policy
Biomedical factors
Psychological or behavioural factors
Social and economic factors
Occupational factors
Kendal et al 2009: Tackling musculoskeletal problems: a guide for the clinic and workplace—identifying obstacles using the psychosocial flags framework
Interventions: Vocational advice
Interventions: Vocational advice
Target obstacles to RTWSet new date for RTW
Targeted adviceContact workplace
Involve other servicesSet new date for RTW
Address unhelpful beliefs about working with MSK painDiscuss obstacles to RTW
Set date for RTWRTW
RTW
Step 1:
ALL
Step 2:
not RTW
Step 3:
not RTWRTW
Target obstacles to RTWSet new date for RTW
Targeted adviceContact workplace
Involve other servicesSet new date for RTW
Address unhelpful beliefs about working with MSK painDiscuss obstacles to RTW
Set date for RTWRTW
RTW
Step 1:
ALL
Step 2:
not RTW
Step 3:
not RTWRTW
Interventions: Vocational advice
Delivery of the vocational advice service
Delivered by 3 physiotherapists All experienced MSK physiotherapists Not delivering traditional physiotherapy treatments
Participated in a training programme with further mentoring 4 day training programme, followed by 1 day refresher Monthly mentoring sessions with experts and peers to
discuss individual cases VA service offered from participating GP practices
Feedback about patient cases from VAs to referring clinicians
Outcome measuresPrimary Days off work over 4 months
Secondary Self-reported time off work GP certified time off work Self-efficacy to return-to-work Pain intensity Bothersomeness Global assessment of change Work performance
Powered to detect at least a mean difference of 10 days off work between intervention and control330 participants (165 per arm)
Taking into account clustering and loss to follow-up
Sample size
Wynne-Jones G, Artus M, Bishop A, Lawton SA, Lewis M, Jowett S, Kigozi J, Main C, Sowden G, Wathall S, Burton AK, van der Windt DA, Hay EM, Foster NE; SWAP Study Team. Effectiveness and costs of a vocational advice service to improve work outcomes in patients with musculoskeletal pain in primary care: a cluster RCT (SWAP trial ISRCTN 52269669). Pain. 2018 Jan;159(1):128-138. doi: 10.1097/j.pain.0000000000001075.
Recruitment and follow-up
338 participants recruited(158 intervention arm: 180 control arm)
4 months: 79%12 months: 72%
Baseline characteristics
Measures Intervention ControlAge (mean, SD) 49.5 (9.6) 47.9 (10.7)Gender (n, %)
FemalesMales
89 (56%)69 (44%)
106 (59%)74 (41%)
NRS pain (mean, SD)
Working full-time (n, %)
Days off work (past 12 months), mean (range)
5.5 (1.9)
111 (71%)
15.0 (0-147)
5.4 (1.8)
122 (68%)
17.8 (0-252)
Vocational advice service
Face to face contacts ≥1 = 9%Median (IQR) contact time
= 60 mins (35.0, 63.5)
Workplace visit ≥1 = <1%
Telephone contacts ≥1 = 90%Median (IQR) contact time = 13.3 mins (10.0, 20.0)
RTW
RTW
Step 1:
Step 2:
Step 3: RTW
Days off work
Intervention Control Incidence rate ratio
Days off work over 4 months
(mean, SD)
9.3 (21.7) 14.4 (27.7) 0.51 (0.26, 0.99) p=0.048
Self-certified days absence (mean, SD)
0.85 (4.11) 0.95 (3.81) 1.114 (0.50, 2.56) p=0.759
GP-certified days absence (mean, SD)
8.4 (21.0) 13.5 (27.5) 0.66 (0.46, 0.94) p=0.020
Secondary outcome measures
Intervention Control MD† /OR‡
(95% CI)P-
value
4 months
Stanford Presenteeism Scale, mean (SD) 19.1 (5.9) 21.3 (5.4) 2.23† (0.35, 4.10) 0.020
Self-efficacy – Return to Work, mean
(SD)
81.5 (26.8) 70.1 (27.2) 11.4† (2.97, 19.8) 0.008
Satisfaction with work, mean (SD) 6.4 (2.8) 6.0 (2.3) 0.38† (-0.45, 1.20) 0.369
Performance at work, mean (SD) 4.1 (2.8) 5.1 (3.0) -1.05† (-1.96,-0.14) 0.023
12 months
Stanford Presenteeism Scale, mean (SD) 22.0 (5.6) 20.1 (5.7) 1.89† (-0.24, 4.03) 0.082
Self-efficacy – Return to Work, mean
(SD)
82.6 (27.1) 73.7 (24.1) 8.91† (0.04, 17.8) 0.049
Satisfaction with work, mean (SD) 6.2 (2.6) 6.1 (2.3) 0.06† (-0.83, 0.95) 0.894
Performance at work, mean (SD) 3.4 (3.1) 4.6 (2.9) -1.11† (-2.12,-0.09) 0.032
Cost effectiveness analysis and cost benefit analysis
Analysis method Result
Cost saving £7.20 per sick day avoided
Net societal benefit £763 in favour of VA service
Return-on-investment £49 for every £1 invested
CEA – based on the net monetary benefit (NMB) * Incremental days off work estimated controlling for group and GP Clustering using a GLM regression model, assuming a Gaussian Variance function, an identity Link Function, and clustered standard errors
Qualitative results: GPs
• GPs felt that VAs could provide an alternative way of managing patients with complex work related difficulties, but there was a lack of interaction and engagement between GPs and VAs, and GPs felt the timing was too early for some patients.
I think that’s what really comes over as being very useful, is that they have time to discuss things. I mean we have 12 minutes and it’s really not long enough for people to express their concerns really. (GP 8)
…If you’re only referring one (patient) every 3 or 4
weeks you’re not that confident about what the
service can do…you’re not getting that kind of
feedback. When you start referring a few more you see
that there is positive benefits to it (GP 5)
Qualitative results: VAs
• VAs also noted a lack of interaction with GPs. Early referral to the service meant VAs felt that their skills could not be adequately deployed with some patients, and when they felt unable to help they reverted back to their physiotherapist role.
But I think you do go back to your comfort zone. I just know physio and I know I'm happy with that and I can see the benefit of it. This is such a new role that that’s difficult to see sometimes (QVA3 6 months)
But we also have to demonstrate that we’re adding value to their patients which is difficult to do when the patient is being referred so early down the line… So the difficulty is weeding out those who really need the advice and adding value really to the service itself because essentially if we’re just contacting patients who have already put together a (return-to-work) plan we’re not going to be adding value. (QVA3 6 months)
Qualitative results: Patients
• Patients also reported that the timing of referral was important and where this timing was appropriate they felt that there were real benefits to the service.
I can see obviously it would be of tremendous
help to some people [right]. I think I was quite
lucky that although I’ve got a long term problem
it’s not unmanageable, do you know what I mean?
(Patient 34)
So it was good to have the phone call support, which
was more independent, because that was over the telephone and I felt that he was looking after my best interests rather than work’s. The occupational health lady was looking after work rather than….
(Patient 338)
Qualitative results: Patients
• Patients also reported that the timing of referral was important and where this timing was appropriate they felt that there were real benefits to the service.
You felt that you’d got somebody else on your side, and [yeah] supporting you, really, because, you know, if you’ve got a broken arm they can see it, it’s in a cast and whatever, whereas, you know, they do say a lot of people ‘put on’ the fact that they’ve got back pain, depression, or whatever. (Patient 636)
Conclusions
• Adding an EARLY, BRIEF and LOW INTENSITY vocational advice service for adults with musculoskeletal pain in primary care was associated with significantly fewer days absent over 4 months
• Referral to the vocational advice service was associated with greater economic benefits than best current care alone
• The intervention appeared to improve return to work self-efficacy, presenteeism and performance at work
Key messages 1
• We can offer early and low intensity advice and support– In ways that provides reassurance, supports self-
management and engages individuals in a return-to-work plan
• Those with long-term conditions and/or long-standing work difficulties were felt to particularly benefit (data from the interviews)
• Promising strategy that can reduce days lost from work and increase patients confidence in managing their MSK pain at work
Key messages 2
• Work is part of life for most of us, and integrating work into healthcare consultations has been shown more broadly to have positive effects for individuals, health and societal systems
• Early, primary care orientated initiatives that help people stay in the workforce with their health conditions need to be developed and tested
Further research
iSWAP study• Developing the vocational advice training into an online
course• Testing this with First Contact Practitioners (FCPs)• Funded by the Joint Health and Work DepartmentWAVE trial• Adapting the vocational advice service so it is suitable for
many more patients consulting in primary care with health conditions affecting their ability to work
• Aims to provide good quality advice and support for return to work to patients before their work absence becomes long-term
• Trial funded by NIHR HTA, 2019-2024
.
Acknowledgments
Patients and GP practices.Vocational advisors.SWAP study team: Nadine Foster, Majid Artus, Annette Bishop, SarahLawton, Martyn Lewis, Sue Jowett, Jesse Kigozi, Chris Main, Gail Sowden,Simon Wathall, Kim Burton, Danielle van der Windt, Elaine Hay, RuthBeardmore, Tom Sanders, Bie Nio OngFunding: This presentation presents independent research funded by the NationalInstitute for Health Research (NIHR), under its Programme Grants for Applied Researchfunding scheme: “Optimal management of spinal pain and sciatica in primary care”(NIHR-RP-PG-0707-10131). The views expressed are those of the authors and notnecessarily those of the NHS, the NIHR or the Department of Health
Contact: [email protected]
Thank you
Research Institute for Primary Care and Health SciencesDavid Wetherall Building Keele University Newcaslte-under-LymeST5 5BG Tel: 01782 733905Fax: 01782 734719www.keele.ac.uk/pchs