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      Return to Work Coordination Programmes for Work Disability: A Meta-Analysis of Randomised Controlled Trials


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          The dramatic rise in chronically ill patients on permanent disability benefits threatens the sustainability of social security in high-income countries. Social insurance organizations have started to invest in promising, but costly return to work (RTW) coordination programmes. The benefit, however, remains uncertain. We conducted a systematic review to determine the long-term effectiveness of RTW coordination compared to usual practice in patients at risk for long-term disability.

          Methods and Findings

          Eligible trials enrolled employees on work absence for at least 4 weeks and randomly assigned them to RTW coordination or to usual practice. We searched 5 databases (to April 2, 2012). Two investigators performed standardised eligibility assessment, study appraisal and data extraction independently and in duplicate. The GRADE framework guided our assessment of confidence in the meta-analytic estimates. We identified 9 trials from 7 countries, 8 focusing on musculoskeletal, and 1 on mental complaints. Most trials followed participants for 12 months or less. No trial assessed permanent disability. Moderate quality evidence suggests a benefit of RTW coordination on proportion at work at end of follow-up (risk ratio = 1.08, 95% CI = 1.03 to 1.13; absolute effect = 5 in 100 additional individuals returning to work, 95% CI = 2 to 8), overall function (mean difference [MD] on a 0 to 100 scale = 5.2, 95% CI = 2.4 to 8.0; minimal important difference [MID] = 10), physical function (MD = 5.3, 95% CI = 1.4 to 9.1; MID = 8.4), mental function (MD = 3.1, 95% CI = 0.7 to 5.6; MID = 7.3) and pain (MD = 6.1, 95% CI = 3.1 to 9.2; MID = 10).


          Moderate quality evidence suggests that RTW coordination results in small relative, but likely important absolute benefits in the likelihood of disabled or sick-listed patients returning to work, and associated small improvements in function and pain. Future research should explore whether the limited effects persist, and whether the programmes are cost effective in the long term.

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          Most cited references31

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          Extracting summary statistics to perform meta-analyses of the published literature for survival endpoints.

          Meta-analyses aim to provide a full and comprehensive summary of related studies which have addressed a similar question. When the studies involve time to event (survival-type) data the most appropriate statistics to use are the log hazard ratio and its variance. However, these are not always explicitly presented for each study. In this paper a number of methods of extracting estimates of these statistics in a variety of situations are presented. Use of these methods should improve the efficiency and reliability of meta-analyses of the published literature with survival-type endpoints.
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            Interpreting the clinical importance of group differences in chronic pain clinical trials: IMMPACT recommendations.

            An essential component of the interpretation of results of randomized clinical trials of treatments for chronic pain involves the determination of their clinical importance or meaningfulness. This involves two distinct processes--interpreting the clinical importance of individual patient improvements and the clinical importance of group differences--which are frequently misunderstood. In this article, we first describe the essential differences between the interpretation of the clinical importance of patient improvements and of group differences. We then discuss the factors to consider when evaluating the clinical importance of group differences, which include the results of responder analyses of the primary outcome measure, the treatment effect size compared to available therapies, analyses of secondary efficacy endpoints, the safety and tolerability of treatment, the rapidity of onset and durability of the treatment benefit, convenience, cost, limitations of existing treatments, and other factors. The clinical importance of individual patient improvements can be determined by assessing what patients themselves consider meaningful improvement using well-described methods. In contrast, the clinical meaningfulness of group differences must be determined by a multi-factorial evaluation of the benefits and risks of the treatment and of other available treatments for the condition in light of the primary goals of therapy. Such determinations must be conducted on a case-by-case basis, and are ideally informed by patients and their significant others, clinicians, researchers, statisticians, and representatives of society at large.
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              Is Open Access

              Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life

              Objective To evaluate the effectiveness of an integrated care programme, combining a patient directed and a workplace directed intervention, for patients with chronic low back pain. Design Population based randomised controlled trial. Setting Primary care (10 physiotherapy practices, one occupational health service, one occupational therapy practice) and secondary care (five hospitals). Participants 134 adults aged 18-65 sick listed for at least 12 weeks owing to low back pain. Intervention Patients were randomly assigned to usual care (n=68) or integrated care (n=66). Integrated care consisted of a workplace intervention based on participatory ergonomics, involving a supervisor, and a graded activity programme based on cognitive behavioural principles. Main outcome measures The primary outcome was the duration of time off work (work disability) due to low back pain until full sustainable return to work. Secondary outcome measures were intensity of pain and functional status. Results The median duration until sustainable return to work was 88 days in the integrated care group compared with 208 days in the usual care group (P=0.003). Integrated care was effective on return to work (hazard ratio 1.9, 95% confidence interval 1.2 to 2.8, P=0.004). After 12 months, patients in the integrated care group improved significantly more on functional status compared with patients in the usual care group (P=0.01). Improvement of pain between the groups did not differ significantly. Conclusion The integrated care programme substantially reduced disability due to chronic low back pain in private and working life. Trial registration Current Controlled Trials ISRCTN28478651.

                Author and article information

                Role: Editor
                PLoS One
                PLoS ONE
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                19 November 2012
                : 7
                : 11
                : e49760
                [1 ]Academy of Swiss Insurance Medicine, University Hospital Basel, Basel, Switzerland
                [2 ]Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
                [3 ]Clinical Trial Unit, University Hospital Basel, Basel, Switzerland
                [4 ]Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
                University of Toronto, Canada
                Author notes

                Competing Interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; asim, the Department of Insurance Medicine at the University Hospital in Basel, is funded in part by donations from public insurance companies and a consortium of private insurance companies (affiliated Authors: SS, SB, WdB, RK); JWB acts as a consultant to Prisma Health Canada, which is a private incorporated company funded by employers and insurers that consults on and manages long-term disability claims; no other relationships or activities that could appear to have influenced the submitted work. There are no patents, products in development or marketed products to declare. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.

                Conceived and designed the experiments: RK SS SB JB GG. Performed the experiments: SS RK SB WdB SE JB. Analyzed the data: TZ SS RK GG. Wrote the paper: SS SE SB WdB TZ JB GG RK. Developed the search strategy: SS RK. Performed the study selection: SS SB RK WdB. Appraised study quality: RK SS. Extracted study characteristics and outcome data: SE RK SS TZ. Performed consensus exercises: SE JWB SS RK WdB. Contributed to the interpretation and discussion of the results: SS SE SB WdB TZ JB GG RK.

                Copyright @ 2012

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                : 10 August 2012
                : 12 October 2012
                Page count
                Pages: 13
                No funding was received for this study. The authors were salaried by their institutions. SE is a recipient of the Canadian Institutes of Health Research doctoral award. JB is supported by a New Investigator Award from the Canadian Institutes of Health Research and the Canadian Chiropractic Research Foundation.
                Research Article
                Clinical Research Design
                Systematic Reviews
                Non-Clinical Medicine
                Health Care Policy
                Comparative Effectiveness Research
                Quality of Life
                Communication in Health Care
                Environmental Health
                Health Care Providers
                Health Services Administration and Management
                Health Services Research
                Socioeconomic Aspects of Health
                Public Health
                Occupational and Industrial Health



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