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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Return to work coordination programmes for work disability: a meta-analysis of randomised controlled trials

S Schandelmaier, S Ebrahim, SC Burkhardt, WE de Boer, T Zumbrunn, GH Guyatt, JW Busse, and R Kunz.

Review published: 2012.

CRD summary

This review of return to work co-ordination programmes found moderate quality evidence that suggested small but possibly important absolute benefits for disabled or sick-listed patients returning to work and small improvements in function and pain. The conclusions of this well-conducted review reflect the quality of evidence and clinical importance of the results and seem to be reliable.

Authors' objectives

To evaluate the effectiveness of return to work co-ordination programmes compared to usual practice in people at risk of long-term disability.

Searching

MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to April 2012 for studies published in any language. Search terms were reported. References lists of relevant articles were screened.

Study selection

Randomised studies that compared return to work co-ordination to usual care in adults where at least 80% were continuously off work (full/part time sick leave or on disability benefit) for at least four weeks and employed at the time of sick listing were eligible for inclusion. Studies had to report return to work or disability status as an outcome. Return to work co-ordination had to involve a direct assessment leading to individually tailored plans implemented by a return to work co-ordinator or team which coordinated services and communication with stakeholders. Employer-initiated return to work co-ordination programmes were excluded.

Patient-reported outcomes were grouped into the categories: overall function, physical function, social function, mental function, general health, pain, depression, anxiety and patient satisfaction. The included participants had an average age range from 39 to 46 years and 22% to 75% were men. Health conditions that caused absence from work included musculoskeletal pain, surgery for lower disc herniation, chronic low back pain, anxiety and depression. Time off work ranged from one to 55 months. Return to work interventions were generally provided by a team of healthcare professionals and/or social workers and psychologists. Control groups received usual care or advice from doctors, nurses or case managers. Intervention durations were between one week and six months; in some studies it was until the participant had returned to work.

Two reviewers independently selected the studies; disagreements were resolved by discussion.

Assessment of study quality

Studies were assessed for: randomisation sequence generation; allocation concealment; blinding of participants, scheme coordinators and outcome assessors; completeness of data; use of intention-to-treat analysis; and selective outcome reporting. Cluster randomised trials were also assessed for recruitment bias and use of appropriate statistical analysis.

Two reviewers independently assessed study quality; disagreements were resolved by discussion.

Data extraction

Risk ratios and risk differences were extracted or calculated for binary data, mean differences for continuous data and hazard ratios for time to event data, all with 95% confidence intervals (CI). Where hazard ratios were not reported they were estimated from survival curves or results of statistical tests. Changes in outcome were preferred to final values but both types of data were extracted. Outcomes reported on different scales were rescaled to match those measured using the most familiar instrument.

Two reviewers independently extracted data; disagreements were resolved by discussion.

Methods of synthesis

Study results were pooled using random-effects meta-analysis. Statistical heterogeneity was assessed with the Ι² statistic. Baseline-adjusted effect sizes were used where available. Sensitivity analyses were performed to compare different definitions of a return to work outcome, such as full and part-time versus full-time only.

Results of the review

Nine studies were included (3,422 participants). Most studies reported adequate randomisation methods, allocation concealment and intention-to-treat analyses. Blinding of personnel, participants and outcome assessment for patient-reported outcomes was impossible. Most studies used intention-to-treat analysis. Loss to follow-up was high in most studies. In five studies some of the participants in the control group may have received return to work co-ordination. Follow-up ranged from six to 60 months.

All return to work outcomes showed significant benefits in favour of return to work co-ordination. The proportion at work at the end of the study increased by 8% with a relative risk of 1.08 (95% CI 1.03 to 1.13; six studies; Ι²=0%). This corresponded to an absolute effect of five in 100 more participants returning to work (95% CI 2 to 8). The pooled hazard ratio of time until stable return to work was 1.34 (95% CI 1.12 to 1.36; five studies; Ι²=13.6%). The relative risk of ever returning to work was 1.07 (95% CI 1.00 to 1.13; eight studies; Ι²=20.5%) which corresponded to four more participants per 100 (95% CI 0 to 8). Mean total sickness absence days decreased by 36 days per year (95% CI, 17 to 56; two studies;Ι²=0%). Sensitivity analysis did not reveal any substantial differences in the pooled estimates or heterogeneity.

For patient-reported outcomes, return to work co-ordination significantly improved mean overall function by 5.2 (95% CI 2.5 to 7.9; four studies; Ι²=5.7%), physical function by 5.2 (95% CI 1.4 to 9.0; five studies; Ι²=40.9%), pain by 5.7 (95% CI 2.7 to 8.8; six studies; Ι²=0%), mental function by 3.1 (95% CI 0.7 to 5.5; two studies; Ι²=0%). No benefits were seen for social function (two studies).

Cost information

Two studies conducted an economic analyses using the outcome cumulative sickness absence after one year. They both concluded that return to work co-ordination was cost effective from a societal perspective compared to usual practice (by considering the cost of the intervention, health care utilisation and loss of productivity).

Authors' conclusions

Moderate quality evidence suggested that return to work co-ordination resulted in small but possibly important absolute benefits in the chances of disabled or sick-listed patients returning to work and associated small improvements in function and pain.

CRD commentary

This review had clear and reproducible inclusion criteria for study design, interventions, participants and outcomes. Relevant databases were searched. There were no language restrictions so the risk of language bias was reduced. Publication bias was a possibility as there were no searches for unpublished research. Study selection, quality assessment and data extraction were conducted by two people independently so the likelihood of errors or bias was low. The statistical methods used for combining studies were appropriate. Heterogeneity was low for most outcomes.

The conclusions of this well-conducted review reflect the quality of the evidence and the clinical importance of the results and seem to be reliable.

Implications of the review for practice and research

Practice: The authors did not state any recommendations for practice.

Research: The authors stated a need for well-designed trials to assess the benefits and cost effectiveness of the programmes. Studies needed to measure long-term outcomes of work force retention and disability (including pensions). There was also a need for studies in specific populations for both musculoskeletal and psychiatric problems and a need for studies to compare different definitions of return to work outcomes.

Funding

None.

Bibliographic details

Schandelmaier S, Ebrahim S, Burkhardt SC, de Boer WE, Zumbrunn T, Guyatt GH, Busse JW, Kunz R. Return to work coordination programmes for work disability: a meta-analysis of randomised controlled trials. PLOS ONE 2012; 7(11): e49760. [PMC free article: PMC3501468] [PubMed: 23185429]

Indexing Status

Subject indexing assigned by NLM

MeSH

Chronic Disease; Cost-Benefit Analysis; Developed Countries; Disabled Persons; Humans; Randomized Controlled Trials as Topic; Return to Work; Social Security

AccessionNumber

12012057004

Database entry date

04/06/2013

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 23185429