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Understanding the core components of RTW programmes for individuals with
musculoskeletal disorders
Kátia Costa‐Black, University of PretoriaAugust 11th , 2014
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Resources
Financial resources: CIHR Knowledge Synthesis grantHuman resources:
• Researchers: Patrick Loisel (PI), myself (PC), Ellen MacEachenand Sophie Soklaridis (Canada); Jean-Baptiste Fassier & Jean François (France); Ute Bültmann & Sandra Van Oostrom (The Netherlands)
• Decision-makers from the following Canadian entities: WSIB, Vancouver Coastal Health, Fraser Health Authority, Health Sciences Ass. of BC and Hospital Employees Union
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Cumulative evidence:Guiding principles of RTW programmes for MSDs
Addressed disability determinants not the disease; Followed interdisciplinary and inter-organisational approach; Placed the rehab process in the workplace;
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Exemple of an effective program for subacute back pain
0 0,5 1 1,5 2 2,5
Sherbrooke
Occupational
Clinical
Standard
Rate ratio (Cox model) of return to regular work
Loisel & al. 1997
Adaptation of similar RTW program in Holland
Again: very effective showing a reduced numbers of days on sickleave for back pain patients.
Anema et al 2007
Lambeek & al, BMJ 2010
Dutch adaptation of SherbrookeModel
Dutch RCT study : Integrated care with the workplace for chronic back pain
Main issue raised during initial consultation with decision makers
The local applicability and transferability of successful RTW interventions:
“Which intervention components are essential to be delivered across RTW programmes implemented in different settings, that can maintain the same level of program effectiveness?”
Research Questions
Which are the core components of RTW interventions for musculoskeletal disorders? How are these components described in the published literature?
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Theoretical framework: Consolidated Framework for Implementation Research
“Interventions can be conceptualized as having ‘core components (theessential and indispensible elements of the intervention) and an ‘adaptableperiphery’ (adaptable elements, structures, and systems related to theintervention and organization) into which it is being implemented”
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(CFIR Damsrocher et al 2009)
Components of an intervention• Medication • Intervention
‘Active principles ’
Local adaptation
‘Active principles’
Local adaptation
Defining the core componentsExtracting the evidence on “the essential and indispensable elements of the intervention” Damschoder et al 2009
“The aspects of an intervention that are central to its theory and logic and that are thought to be responsible for the intervention’s effectiveness.” McKleroy et al 2006
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Methods used to extract intervention core components
WITHIN-PERSON AND WITHIN-ORGANIZATION RESEARCH DESIGNS (PROGRAM PRACTICE) COMBINED WITH INFORMATION FORM PUBLISHED LITERATURE that evaluate the function of individual components of on-going EB practices and programs;TAXONOMY OF COMPONENTS- built from a non-traditional
literature review on theories and characteristics of effective interventions and reputational programmes;
• META-ANALYSIS can be used for those interventions that are supported by a series of RCTs that are theoretically and methodologically consistent across studies (Michie et al 2009);
Identification of components through the use of PROGRAM THEORY OR LOGIC MODELS
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Finding the right method to extract core components
We want to follow a systematic review process (to maintain rigor and quality of appraisal) but at the same time it must be comprehensive and flexible enough with regards to the analysis and interpretation of heterogeneity of study designs and research traditions; Must include decision makers in the review process. Allow a narrative analysis from seminal studies in the field
that could give us more information about core components and their transferability of findings, moving beyond RCTs.
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Meta narrative review
Trisha Greenhalgh (2004). Meta-narrative mapping: a new approach to the systematic review of complex evidence. InNarrative research in health and illness.Key principles:
• Use a historical and philosophical perspective as a pragmatic way of making sense of a diverse literature
• Pragmatism• Pluralism• Historicity• Contestation• Peer review
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Retaining core components IDENTIFICATION Track mechanisms of change – red alert for core
components that have been actually altered (remove them for list)
Look at components of an intervention like the Sherbrookemodel (replicated in a different context)
Was the logic/theory of a intervention explained? INTERPRETATIVE ANALYSIS (Synthesis) Cross-boundaries between the different research traditions,
i.e. moving towards a broader and TD interpretation with a critical look beyond EB medicine
Variations in describing the “core components”. Resolve conflicting findings (by consensus) and keep a narrative log
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Methods:
Description of meta-narrative technique phases: Greenhalgh2004 & Greenhalgh et al 2005 (Storylines of research in diffusion of innovation: a meta-narrative approach to systematic review).
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Planning Search Mapping Appraisal Synthesis Recom.
ReflectiveExploratoryInclusiveOverlap of
phasesEngage
DMs
Methods (Search)
INFORMAL SEARCH: Contacting experts: peer consultation (DMs and researchers
in the team)Manual searching of relevant journal issues (JOR, WORK,
DISABILITY & REHABILITATION)Citation tracking of key papers (seminal contribution to the
field)Sources of grey literature (within key organizations sites and
grey search engines): IWH, NICE, EASHW, ISSA, Google scholars, etc.
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Methods (Search)
FORMAL SEARCH:Databases used:
• CINAHL, Scopus (citation), OVID system (EMBASE + PsycInfo + MEDLINE + Allied and complementary medicine), the Cochrane Library, Social Sciences Abstracts and COMPENDEX (engineering/ergonomics)
RM was used to eliminate overlapping papers
Limited to English and studies from 1990 to 2010Search strategy (sensitive to each database):
• Concept 1 = ‘return to work’ OR ‘stay at work’ (+ other key terms)• Concept 2 = intervention OR program OR strategy • Concept 3 = musculoskeletal OR back (+ key terms)
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Methods (Map and appraisal)
A critical appraisal form was collaboratively developed (modified version from Greenhalgh et al 2005);
Two reviewers independently selected and appraised the relevancy and quality of the papers;Data extraction form (studies on intervention effectiveness)
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First level screening (titles and abstracts)
CRITICAL APPRAISAL FORM
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Full citation [starting with author(s)/year]
REVIEWER DATE A [FIRST SIFT] Is the paper relevant to our research questions and worthy of further consideration?1 Relevance Is the paper about interventions (or intervention components) for
preventing work disability, maintaining work ability, reducing sickness absence, or increasing the chance for RTW?
2 Worth Does the paper go beyond superficial description or commentary – i.e. is it a broadly competent attempt at research, enquiry, investigation or study?
[If a confident ‘no’ to A1 or A2 , reject now and specify the reason for that below]
Main exclusion: interventions for serious MSD conditions (red flags); interventions that focus on pain or injury and not RTW outcomes; or vocational rehab components (e.g. job placement).
Second level screening (titles and abstracts)
B Where does the paper fit into the WDP arena? WDP paradigm What is the predominant system perspective under study? [If more than one, put an X in the dominant one]
1 Personal system
2 Health care system
3 Workplace system
4 Insurance/ compensation system
5 Overall social-cultural context
6 Other [specify]
C Type of paper What is the research design? [mark one]
1 RCT 2 Pre- and post-test design
3 Process (or economical) evaluations
4 Cohort study
5 Case-control study 6 Surveys 7 Qualitative studies 8 Mixed methodology case study
9 Comparative case study
10 Conceptual
11 Other studies [specify]
D Unit of analysis [mark one or more]
1 Individual
2 Group or team
3 Organisation
4 Inter-organisational
5 Regional or national
6 Multi-level
E Bottom line for this review Relevance Does the paper specifically test or reportthe effectiveness and/or cost-effectiveness of a RTW/SAW intervention (or one of its components) for individuals with MSK disorders? [mark one]
1 Essential to include.
2 Relevant but not essential.
3 Marginal or no relevance.
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Results: Review flowchart
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Studies and research reports identified (n = 2446)
Relevant studies (n = 532)
Studies retrieved for more detailed evaluation (n = 138)
Studies excluded (n = 53)
Original studies (effectiveness alone or with costs) = 27
Original studies (complementary) (n= 49 )Literature reviews (n= 7)Research reports (n= 2)
1st level screening (titles and abstracts)
2nd level screening (titles and abstracts)
3rd level of screening (full papers)
Results: Core components’s description
Narrative log created from compiling information on each component by different studies. Core components with interface with workers Core components with interface with the workplace Core components with interface with stakeholders
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Grading of evidence used in this project
A Strong research-based evidence (for the component which has at least ++ ‘effectiveness studies’ and ++ ‘reviews’)
B Moderate research-based evidence (for the component which has at least + ‘effectiveness studies’ and + ‘reviews’)
C Limited research-based evidence (for the component which has at least + in any particular study type)
+ Between 1 and 3 studies clearly support the component + + Between 3 and 5 studies clearly support the component+++ More than 5 studies clearly support the component
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Results: interface with worker
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* At least one study shows that this component has been tested as a single component0 No support was found or studies were not clear on the effects of the component
+ Between 1 and 3 studies clearly support this component + + Between 3 and 5 studies clearly support this component
+++ More than 5 studies clearly support this component
Results: interface with workplace
Results: interface with stakeholders
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Intervention components that are suggested by a large number of complementary studies but not yet tested by high quality effectiveness studies
Early and meaningful return‐to‐work; Proactive disability management
(employer based); These are important components that
should be tested in the future (current research gap)
Which components should be included in a RTW program?
The extent of the different levels of evidence (i.e., from strong to limited evidence) must be interpreted with caution.Naturally the components with grading A or B are the most
desirable to maintain in an RTW program.Although reviews and effectiveness studies are in the high
hierarchy of levels of evidence, one must consider that all components have good supporting evidence coming from other types of studies including economic evaluation studies and relevant complementary studies. This makes an argument for the utilization of any of the 15 components listed on the table.
Limited knowledge of the isolated effect of a single component
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Review of Effectiveness of Workplace Interventions (Carroll & al., 2010)
• « For the same back-pain population, interventions involving stakeholders working together, without anyexercise component, appear to be more consistentlyeffective at helping people to RTW than an intervention involving only exercise »
We start to adquire knowledge on the isolatedeffect of a single component but still we have a long way to determine which components should bepriority for sucessful program implementation.
Conclusion
1. This EB synthesis looked beyond intervention effectiveness studies to withdraw practical recommendations about the applicability of core components in consultation with DMs;
2. Such collaborations encouraged exchange of ideas and can make certain that intervention components are chosen not only based on the cumulative evidence but also by their relevance and acceptance to community agencies and entities with strong considerations about their ethical value and feasibility.
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Conclusion (cont.)
3. The description of the components and the current body of evidence supporting each component should be seeing as communication tools to catalyze adoption of evidence-based RTW strategies.
4. Clear descriptions of components also allow for evaluations of the functions of those procedures in the future.
5. The evolving nature of the evidence and the current research gaps on components suggest that more research should be carried out in the future.
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