maetis arbo. werken is gezondfhvmetodik.se/wp-content/uploads/2014/02/hulshof-20140212.pdf · carel...

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MAETIS ARBO. WERKEN IS GEZOND

Seminarium Stockholm 12 February 2014

Evidence-based practice in occupational health care:

how to do it?

Carel Hulshof

AMC, Coronel Institute of Occupational HealthNetherlands Society of Occupational Medicine (NVAB)



The old work The new work

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Life expectancy

Observed, women

Prognosis, women



Labour participation elderly(CBS/TNO 2012)

• 60 years still at work:– 15% in 1996– 60% in 2011

• Would like to work until 65:– 21% in 2005– 45% in 2010

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Workers change

• Ageing workforce

• More workers with chronic diseases, medication, medical devices

• 10.000 people in the Nederlands have an ICD



Increase chronic diseases 2005-2025 in %(Blokstra et al. RIVM 2007)

Men

Women

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job strain and coronary heart disease(Kivimäki M et al. Lancet 2012;380:1491-7)

Work stress associated with a slight but consistently enhanced risk on coronary heart disease

Population attributable risk is 3,4%; smaller than for smoking (36%); abdominal obesity (20%) lack of physical exercise (12%)



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Wat is health?

WHO 1948:

• “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”

Proposal for new definition (Huber M, Knottnerus JA, Green L et al. How should we define health? BMJ 2011;343:d4163):

• “the ability to adapt and self manage in the face of social, physical, and emotional challenges”



In good health?

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Work ↔ Health

• Work Health+ income, contact, learning, raising self

esteem, social functioning+ promotes recovery; platform interventions- injuries, occupational and work-related

diseases

• Health Work+ vitality, inspiration, productivity- sick leave, disability, cost

• Only sustained employability in case of attention for both domains!



Quality of OHS does not meet professional standards (ETUI: ‘crisis in European OHS’)

• Commercialization of OHS• New occupational risks• Growing informal economy (SME), coverage • Shortage of physicians• Scarcity of resources and training• Influence of ‘third parties’ (e.g. insurance companies)• NL: Emphasis on sickness absence management or health

promotion, neglecting preventive tasks

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Are OHS on an inclined plane ?



What is needed to stay on track ?

• Political willingness

• Evidence from scientific research

• Evidence-based practice development (guidelines, tools etc.)

• Implementation

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Information literacy

• ”I hate information, you can’t trust your own prejudice anymore”

Jan Blokker

• “Information literacy is knowing when and why you need information, where to find it, and how to evaluate, use and communicate it in an ethical manner.”

Chartered Institute of Library and Information Professionals (2012)



Sources used for OSH information or advice

0 5 10 15 20 25 30 35 40 45 50 55 60

Experts in law and regulationsExperts from sector or occupational associations

Experts from trade unionsSocial media or internet fora

Other sources of information or adviceMagazins, journals, fact sheets, brochures, books, etc.

Specific pre-known websitesExperts in regural health care

Experts in occupational health serviceSocial or professional network (e.g. family, friends, peers)

In-company OSH-related expertsWebsites found trough Google

% of total respondents who searched for OSHinformation or advice

Rhebergen et al. Amer J Ind Med 2011

(N = 535, response 60%)

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Comparison expert network with GoogleIntervention group, n = 94 answers

Control group, n = 124 answers

Rhebergen MDF et al. Comparing the Use of an Online Expert Health Network against Common Information Sources to Answer Health Questions. J Med Internet Res 2012;14(1):e9



Decisions in OH care should be based on:

Prof. Skills &

Expertise

Research Evidence

Client Preferences/

Values

Evidence-based practice (EBP)

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How do we get knowledge into practice?



The evidence pyramid

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History of guideline development

• 70’s: National Institutes of Health (NIH): systematic development of consensus statements

• 80’s: Agency for Healthcare Research & Quality (AHRQ): evidence-based guideline program

• 90’s: Large national guidelineprograms in many countries

• From 2000: International collaboration (AGREE, GIN, ADAPTE, GRADE)



What is an evidence-based guideline?

• A document with recommendations to support practitioners and care users, aimed at improvement of the quality of care,based on evidence, expertise and experiences of practitioners and care users

(Working Group Guideline for Guidelines, Regieraad 2011)

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Institute of Medicine 2011

To be trustworthy, guidelines should:

• Be based on a systematic review of existing evidence;

• Be developed by a multidisciplinary panel of experts and key representatives;

• Consider patient preferences, as appropriate;

• Be based on an explicit and transparent process that minimizes biases, and conflicts of interest;

• Provide ratings of both the quality of evidence and the strength of recommendations;

• Be reconsidered and revised as appropriate when important new evidence warrants it



Systematic reviews and meta-analyses

Randomised controlled trials

quality assessment

Cohort, case control studies

Uncontrolled studies - clinical relevance

- patient safety- patient preferences- availability of services- organisation of care- impact on costs- legal / ethical consequences

Considered judgement

recommen-dation

(“evidence plus

experience”)

Det går inte att v isa bilden för tillfället.

Det går inte att v isa bilden för tillfället.

Conclusion including Level of evidence

Evidence-based guideline development

Expert opinion

quality assessment

quality assessment

quality assessment

Q

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NVAB-guidelines for occupational physiciansPublished:

• Low back pain• Mental health disorders• Visual acuity of VDU-workers• Upper limb disorders (RSI) • Work-related asthma / COPD • Contact dermatitis • Noise-induced hearing loss• Ischemic Heart disorders• Pregnancy and Work• Influenza• Cancer and Work• Diabetes and Work• OSAS

In preparation:

• Prevention of weight gain• Latex allergy



Involvement NVAB in many multidisciplinary medical guidelines

• Carpal tunnel syndrome• COPD• Alcohol abuse• Inflammatory bowel diseases• Whiplash• Obesity• Cystic fibrosis• Early interventions after disasters• Obstructive sleep apnoea syndrome • Atopic dermatitis• Herniated lumbar disk• Somatoform disorders• Problematic use of drugs• Multiple sclerosis • Ankle injury• Oncologic rehabilitation• Urine incontinence

• Needle stick injuries• Lyme’s disease• Low back pain• Anxiety disorder• Depressive disorder• Chronic fatigue syndrome• Cardiovascular risk management• Heart failure• Adjustment disorder/burnout• Complex regional pain syndrome• Chronic rhino sinusitis• Sub fertility • Rheumatic arthritis• Domestic violence• Treatment smoking addiction• Complaints of arm, neck, shoulder• Lower extremity amputation

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Guidelines with other Occupational Health Professionals

• Lifting• High work load• Agression and violence at work• Safety behaviour in industrial environments• Computer work• Work - private balance• Vibration



An evidence-based multidisciplinary practice guideline to reduce the

workload due to lifting to prevent work-related low back complaints

Jos H.A.M. Verbeek, Lex Burdorf, Leo A.M. Elders, Carel T.J. Hulshof,

P. Paul F.M. Kuijer, Nico van Roden, Bart Visser, Marion E.R. van den Wittenboer

Flowchart from:

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Guidance document on health

surveillance



“Air cycling?” How to make them work?

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To improve implementation

• Educational courses, e-lessons• Employee and employer versions of the guideline, leaflets• Powerpoints• Checklists• Indicators• Audit instruments• Digital versions, software• Inclusion in ‘standards of care’ (?)



Slight change in meeting public health guidelines for physical activity and fruit intake.

Verweij L M et al. Occup Environ Med :doi:10.1136/oemed-2011-100377

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Economic Evaluation of an OH care Guideline ‘Prevention of Weight Gain’

(van Wier et al.JOEM 2013;55:1100-9)



Compliance with guideline on mental health disorders

(Rebergen DS et al. Scand J Work Environ Health 2010;36:488-98)

• Applied by Occupational Physicians for 240 workers

• Mean score per case on performance indicators: 50%

• Statististical significant relation between higher performance score and positive outcome (RTW)

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I think the glass is half empty

You are always so pessimistic



Physically demanding work and preterm birth(van Beukering et al. Int Arch Occup Environ Health 2014)

Study or Subgroup9.1.1 Cohort StudiesCiron-Mereles 1995Niedhammer 2009Omokhodion 2010Tuntiseranee 1998Subtotal (95% CI)Heterogeneity: Tau² = 0.00; Chi² = 0.59, df = 3 (P = 0.90); I² = 0%Test for overall effect: Z = 2.44 (P = 0.01)

9.1.2 Case Control StudiesLuke B 1995Subtotal (95% CI)Heterogeneity: Not applicableTest for overall effect: Z = 3.29 (P = 0.0010)

Total (95% CI)Heterogeneity: Tau² = 0.00; Chi² = 1.90, df = 4 (P = 0.75); I² = 0%Test for overall effect: Z = 3.93 (P < 0.0001)Test for subgroup differences: Chi² = 1.31, df = 1 (P = 0.25), I² = 23.9%

log[Risk Ratio]

0.2231440.1823220.41871

0.182322

0.470004

SE

0.1276690.7958460.2300390.574309

0.142759

Weight

45.8%1.2%

14.1%2.3%

63.4%

36.6%36.6%

100.0%

IV, Random, 95% CI

1.25 [0.97, 1.61]1.20 [0.25, 5.71]1.52 [0.97, 2.39]1.20 [0.39, 3.70]1.30 [1.05, 1.61]

1.60 [1.21, 2.12]1.60 [1.21, 2.12]

1.40 [1.19, 1.66]

Risk Ratio Risk RatioIV, Random, 95% CI

0.01 0.1 1 10 100Favours experimental Favours control

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Updating



Effects of lifestyle interventions on work-related outcomes: meta-analysis of 18 studies

Outcome:N studies Good Quality

studies, effect-size

Nstudies

Less Quality studies,

effect-size

Health 5 0.22 3 0.29

Sick Leave 8 0.11 4 0.37

Productivity 3 0.14 2 0.54

Workability 1 0.10 1 0.41

Total 10 0.14 = small 8 0.41

Meaning of effect-size:• 0.00 - 0.32 = small• 0.33 - 0.55 = moderate• 0.56 - 1.20 = large

Erasmus Mc, 2013, Rongen et al.

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‘Quality visitation’ of Occupational Physicians part of 5-year obligatory re-certification



Future developments

• Personalized Medicine

• Shared Decision making

• ICT: Decision Aids and (digital) feedback systems

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Shared Decion-making: ‘the Cliënt as implementator’

• G-I-N patient & public involvement toolkit- consultation (focus group, enquiry, grey literature)- participation in guideline development group- communication (cliënt version, shared decision making)

• Option grids, conversation starters



Conclusions / Take home messages

• The use of evidence can substantially increase transparency, effectiveness and efficiency of OSH practice.

• Growing number of reviews and guidelines with information on work-related aspects available

• International collaboration has started but needs further endorsement

• For workers and companies more and more specific information and tools become available: visibility and ‘findability’ can be improved

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Questions?

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