Increasing return-to-work among people on sick leave due to common mental disorders: design of a cluster-randomized controlled trial of a problem-solving intervention versus care-as-usual conducted in the Swedish primary health care system (PROSA).

BACKGROUND: Common mental disorders affect about one-third of the European working-age population and are one of the leading causes of sick leave in Sweden and other OECD countries. Besides the individual suffering, the costs for society are high. This paper describes the design of a study to evaluate a work-related, problem-solving intervention provided at primary health care centers for employees on sick leave due to common mental disorders. METHODS: The study has a two-armed cluster randomized design in which the participating rehabilitation coordinators are randomized into delivering the intervention or providing care-as-usual. Employees on sick leave due to common mental disorders will be recruited by an independent research assistant. The intervention aims to improve the employee's return-to-work process by identifying problems perceived as hindering return-to-work and finding solutions. The rehabilitation coordinator facilitates a participatory approach, in which the employee and the employer together identify obstacles and solutions in relation to the work situation. The primary outcome is total number of sick leave days during the 18-month follow-up after inclusion. A long-term follow-up at 36 months is planned. Secondary outcomes are short-term sick leave (min. 2 weeks and max. 12 weeks), psychological symptoms, work ability, presenteeism and health related quality of life assessed at baseline, 6 and 12-month follow-up. Intervention fidelity, reach, dose delivered and dose received will be examined in a process evaluation. An economic evaluation will put health-related quality of life and sick leave in relation to costs from the perspectives of society and health care services. A parallel ethical evaluation will focus on the interventions consequences for patient autonomy, privacy, equality, fairness and professional ethos and integrity. DISCUSSION: The study is a pragmatic trial which will include analyses of the intervention's effectiveness, and a process evaluation in primary health care settings. Methodological strengths and challenges are discussed, such as the risk of selection bias, contamination and detection bias. If the intervention shows promising results for return-to-work, the prospects are good for implementing the intervention in routine primary health care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03346395 Registered January, 12 2018.

Estimating the Effect and Economic Impact of Absenteeism, Presenteeism, and Work Environment-Related Problems on Reductions in Productivity from a Managerial Perspective.

OBJECTIVES: The aim of this study was to propose wage multipliers that can be used to estimate the costs of productivity loss for employers in economic evaluations, using detailed information from managers. METHODS: Data were collected in a survey panel of 758 managers from different sectors of the labor market. Based on assumed scenarios of a period of absenteeism due to sickness, presenteeism and work environment-related problem episodes, and specified job characteristics (i.e., explanatory variables), managers assessed their impact on group productivity and cost (i.e., the dependent variable). In an ordered probit model, the extent of productivity loss resulting from job characteristics is predicted. The predicted values are used to derive wage multipliers based on the cost of productivity estimates provided by the managers. RESULTS: The results indicate that job characteristics (i.e., degree of time sensitivity of output, teamwork, or difficulty in replacing a worker) are linked to productivity loss as a result of health-related and work environment-related problems. The impact of impaired performance on productivity differs among various occupations. The mean wage multiplier is 1.97 for absenteeism, 1.70 for acute presenteeism, 1.54 for chronic presenteeism, and 1.72 for problems related to the work environment. This implies that the costs of health-related and work environment-related problems to organizations can exceed the worker's wage. CONCLUSIONS: The use of wage multipliers is recommended for calculating the cost of health-related and work environment-related productivity loss to properly account for actual costs.

Cost-effectiveness of early interventions for non-specific low back pain: a randomized controlled study investigating medical yoga, exercise therapy and self-care advice.

OBJECTIVE: To evaluate the cost-effectiveness of medical yoga as an early intervention compared with evidence-based exercise therapy and self-care advice for non-specific low back pain. DESIGN: Randomized controlled trial with a cost-effectiveness analysis. SUBJECTS: A total of 159 participants randomized into the medical yoga group (n = 52), the exercise therapy group (n = 52) and the self-care advice group (n = 55). METHODS: The health outcome measure EQ-5D was applied to measure quality of life data combined with cost data collected from treatment groups from baseline to 12 months follow-up. Outcome measure was health-related quality of life (HRQL). Incremental cost per quality adjusted life year (QALY) was also calculated. Cost-effectiveness analysis was conducted primarily from the societal and employer perspectives. RESULTS: Medical yoga is cost-effective compared with self-care advice if an employer considers the significant improvement in the HRQL of an employee with low back pain justifies the additional cost of treatment (i.e. in this study EUR 150). From a societal perspective, medical yoga is a cost-effective treatment compared with exercise therapy and self-care advice if an additional QALY is worth EUR 11,500. Sensitivity analysis suggests that medical yoga is more cost-effective than its alternatives. CONCLUSION: Six weeks of uninterrupted medical yoga thera-py is a cost-effective early intervention for non-specific low back pain, when treatment recommendations are adhered to.

Production loss among employees perceiving work environment problems.

OBJECTIVES: The overall aim of this explorative study was to investigate the relationship between factors in the psychosocial work environment and work environment-related production loss. METHODS: Employees at a Swedish university were invited to answer a workplace questionnaire and were selected for this study if they reported having experienced work environment-related problems in the past 7 days (n = 302). A stepwise logistic regression and a modified Poisson regression were used to identify psychosocial work factors associated with work environment-related production loss as well as to identify at what level those factors are associated with production loss. RESULTS: Employees who reported having experienced work environment problems but also fair leadership, good social climate, role clarity and control of decision had significantly lower levels of production loss, whereas employees who reported inequality and high decision demands reported significantly higher levels of production loss. Never or seldom experiencing fair leadership, role clarity, equality, decision demands and good social climate increase the risk of production loss due to work environment problems, compared to those who experience these circumstances frequently, always or most of the time. CONCLUSIONS: Several psychosocial work factors are identified as factors associated with a reduced risk of production losses among employees despite the nature of the work environment problem. Knowledge of these factors may be important not only to reduce employee ill-health and the corresponding health-related production loss, but also reduce immediate production loss due to work environment-related problems.

A one year pay-as-you-speed trial with economic incentives for not speeding.

OBJECTIVE: The objective was to identify whether it was possible to change driver behavior by economic incentives and thereby reduce crash risk. Furthermore, the objective was to evaluate the participants' attitudes toward the pay-as-you-speed (PAYS) concept. METHODS: A one-year PAYS trial with economic incentives for keeping speed limits using intelligent speed assistance (ISA) was conducted in Sweden during 2011-2012. The full incentive was a 30 percent discount off the insurance premium. The participants were private insurance customers and were randomized into a test group (initial n = 152, final n = 128) and a control group (initial n = 98, final n = 68). When driving, the drivers in the test group were informed and warned visually when the speed limit was exceeded. They could also follow their driving results on a personal website. The control group was not given any feedback at all. To reflect the impact of the PAYS concept the proportion of distance driven above the speed limit was compared between the 2 groups. RESULTS: The introduction of a PAYS concept shows that the test group significantly reduced the proportion of distance driven above the speed limit. The proportion of driving at a speed exceeding 5 km/h over the speed limit was 6 percent for the test group and 14 percent for the control group. It also showed that the effect was higher the higher the violation of speed. The result remained constant over time. CONCLUSIONS: It was shown that a PAYS concept is an effective way to reduce speed violations. Hence, it has the possibility to reduce crash severity and thereby to save lives. This could be an important step toward a safer road transport system. The majority of the participants were in favor of the concept, which indicates the potential of a new insurance product in the future.

Prediction of sickness absenteeism, disability pension and sickness presenteeism among employees with back pain.

PURPOSE: The primary aim of this study was to evaluate the predictive ability of the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) concerning long-term sick leave, sickness presenteeism and disability pension during a follow-up period of 2 years. METHODS: The study group consisted of 195 employees visiting the occupational health service (OHS) due to back pain. RESULTS: Using receiver operating characteristic (ROC) curves, the area under the curve (AUC) varied from 0.67 to 0.93, which was from less accurate for sickness presenteeism to highly accurate for the prediction of disability pension. For registered sick leave during 6 months following the baseline the AUC from the ROC analyses was moderately accurate (0.81) and a cut off score of 90 rendered a high sensitivity of 0.89 but a low specificity of 0.46 whereas a cut off score of 105 improves the specificity substantially but at the cost of some sensitivity. The predictive ability appears to decrease with time. Several workplace factors beyond those included in the ÖMPSQ were considered but only social support at the workplace was significantly related to future long-term sick leave besides the total score of the ÖMPSQ. CONCLUSIONS: The results of this study extend and confirm the findings of earlier research on the ÖMPSQ. Assessment of psychosocial risk factors among employees seeking help for back pain at the OHS could be helpful in the prevention of work disabling problems.

A participatory and capacity-building approach to healthy eating and physical activity- SCIP-school: a 2-year controlled trial.

BACKGROUND: Schools can be effective settings for improving eating habits and physical activity, whereas it is more difficult to prevent obesity. A key challenge is the "implementation gap". Trade-off must be made between expert-driven programmes on the one hand and contextual relevance, flexibility, participation and capacity building on the other. The aim of the Stockholm County Implementation Programme was to improve eating habits, physical activity, self-esteem, and promote a healthy body weight in children aged 6-16 years. We describe the programme, intervention fidelity, impacts and outcomes after two years of intervention. METHODS: Nine out of 18 schools in a middle-class municipality in Sweden agreed to participate whereas the other nine schools served as the comparison group (quasi-experimental study). Tailored action plans were developed by school health teams on the basis of a self-assessment questionnaire called KEY assessing strengths and weaknesses of each school's health practices and environments. Process evaluation was carried out by the research staff. Impacts at school level were assessed yearly by the KEY. Outcome measures at student level were anthropometry (measured), and health behaviours assessed by a questionnaire, at baseline and after 2 years. All children in grade 2, 4 and 7 were invited to participate (n=1359) of which 59.8% consented. The effect of the intervention on health behaviours, self-esteem, weight status and BMIsds was evaluated by unilevel and multilevel regression analysis adjusted for gender and baseline values. RESULTS: Programme fidelity was high demonstrating feasibility, but fidelity to school action plans was only 48% after two years. Positive and significant (p<.05) impacts were noted in school health practices and environments after 2 years. At student level no significant intervention effects were seen for the main outcomes. CONCLUSIONS: School staff has the capacity to create their own solutions and make changes at school level on the basis of self-assessment and facilitation by external agents. However these changes were challenging to sustain over time and had little impact on student behaviours or weight status. Better student outcomes could probably be attained by a more focused and evidence-based approach with stepwise implementation of action plans.

Does multidisciplinary assessment of long-term sickness absentees result in modification of sick-listing diagnoses?

AIMS: The aim was to study whether sick-leave diagnoses of long-term sickness absentees were modified after a multidisciplinary assessment and if modifications differed with type of medical specialty of the latest physician to sick-list the patient. METHODS: A sample of 635 long-term sickness absentees referred to a multidisciplinary assessment by Social Insurance Offices was included. Data were obtained through sickness certificates and medical records. Patients were examined by board-certified specialists in psychiatry, orthopaedic surgery, and rehabilitation medicine. Descriptive statistics were used. RESULTS: The multidisciplinary assessment resulted in an increase from 1-2 to 2-3 diagnoses for most patients. Forty-five per cent of the male and 47% of the female patients had only somatic diagnoses at referral. After the multidisciplinary assessment these percentages were 20% and 29%, respectively. The rate of women and men given both psychiatric and somatic diagnoses increased from 30% at referral to about 55%. The shift from either only psychiatric or only somatic diagnoses to having these diagnoses in combination was associated with type of specialty of the physician who had sick-listed the patient. CONCLUSIONS: The study indicates that many patients on long-term sick-leave with unclear diagnoses may suffer from unrecognized, and therefore probably untreated, medical disorders and co-morbidity.

A 7-year follow-up of multidisciplinary rehabilitation among chronic neck and back pain patients. Is sick leave outcome dependent on psychologically derived patient groups?

A valid method for classifying chronic pain patients into more homogenous groups could be useful for treatment planning, that is, which treatment is effective for which patient, and as a marker when evaluating treatment outcome. One instrument that has been used to derive subgroups of patients is the Multidimensional Pain Inventory (MPI). The primary aim of this study was to evaluate a classification method based on the Swedish version of the MPI, the MPI-S, to predict sick leave among chronic neck and back pain patients for a period of 7 years after vocational rehabilitation. As hypothesized, dysfunctional patients (DYS), according to the MPI-S, showed a higher amount of sickness absence and disability pension expressed in days than adaptive copers (AC) during the 7-years follow-up period, even when adjusting for sickness absence prior to rehabilitation (355.8days, 95% confidence interval, 71.7; 639.9). Forty percent of DYS patients and 26.7% of AC patients received disability pension during the follow-up period. However, this difference was not statistically significant. Further analyses showed that the difference between patient groups was most pronounced among patients with more than 60days of sickness absence prior to rehabilitation. Cost-effectiveness calculations indicated that the DYS patients showed an increase in production loss compared to AC patients. The present study yields support for the prognostic value of this subgroup classification method concerning long-term outcome on sick leave following this type of vocational rehabilitation.

Does sickness presenteeism have an impact on future general health?

PURPOSE: The primary aim of this prospective study was to investigate whether working despite illness, so called "sickness presenteeism", has an impact on the future general health of two different working populations during a follow-up period of 3 years. METHODS: The study was based on two bodies of data collected at a number of Swedish workplaces from 1999 to 2003. The first material comprised 6,901 employees from the public sector and the second 2,862 subjects from the private sector. A comprehensive survey was issued three times: at baseline, after 18 months and after 3 years. Apart from the explanatory variable sickness presenteeism, several potential confounders were considered. The outcome variable was good/excellent versus fair/poor self-reported health. RESULTS: Sickness presenteeism at baseline was consistently found to heighten the risk of fair/poor health at both the 18-month and 3-year follow ups even after adjusting for the detected confounders. CONCLUSIONS: To the best of the authors' knowledge, this study is the first to show that sickness presenteeism appears to be an independent risk factor for future fair/poor general health.

Mortality among disability pensioners in Norway and Sweden 1990--96: comparative prospective cohort study.

AIM: The aim of the study was to assess excess mortality related to disability pension (DP) status and DP diagnoses in Norway and Sweden during 1990-96. METHODS: Representative samples of the population aged 30-59 years, without DP at baseline 1 January 1990, 71,293 women and 76,928 men from Norway, and 68,181 women and 71,950 men from Sweden, were followed up during 1990-96. Granting of DP, DP diagnosis, age and gender were explanatory variables in Cox proportional hazards analysis with death from all causes as the outcome variable. RESULTS: Among women, 10.4% in Sweden and 7.1% in Norway obtained DP, as compared to 7.5% and 5.6% of the men. In Sweden, 66% of female and 49% of male DP recipients had musculoskeletal diagnoses, as compared to 40% and 27% in Norway. In Sweden, 3.0% of the women and 6.1% of the men with DP died, as compared to 4.6% and 8.5% in Norway. Hazard ratios (HRs) for women with DP vs. the non-DP group were 3.2 (95% confidence interval (CI)=2.7-3.8) in Sweden, and 4.9 (95% CI=4.1-5.7) in Norway. Among men with DP, there was no difference in mortality rate between the countries. HRs for men with musculoskeletal diagnoses vs. the non-DP group were 1.5 (95% CI= 1.1-2.0) in Norway and 1.4 (95% CI= 1.1-1.8) in Sweden. In both countries, the mortality rate among female disability pensioners with musculoskeletal diagnoses was not increased. CONCLUSIONS: The study confirmed an increased mortality rate among disability pensioners, except for women with musculoskeletal diagnoses. The mortality pattern related to DP diagnoses was similar in the two countries. A high frequency of musculoskeletal DP diagnoses among women with DP in Sweden explained a lower mortality rate as compared to Norway.

Role of diagnoses and socioeconomic status in mortality among disability pensioners in Norway--a population-based cohort study.

OBJECTIVES: Several studies have shown increased mortality among disability pensioners. This study attempted to determine the causes of such an increase. METHODS: A population-based study was carried out with 148,942 persons followed between 1990 and 1996 in Norway. Of this total, 6285 women and 4113 men [corrected] were on a disability pension at baseline. A Cox proportional hazards analysis was carried out separately for the women and men in which all-cause mortality was the outcome variable. Disability pension status, disability pension diagnosis, age, educational level, and mean annual income were entered as explanatory variables. RESULTS: Persons on a disability pension had a strongly increased mortality rate. The age-adjusted hazard ratio was 3.0 [95% confidence interval (95% CI) 2.4-3.8] for the women and 3.4 (95% CI 2.8-4.1) for the men on a disability pension, when they were compared with those not on a disability pension. When adjusted for education and income levels, the hazard ratios (HR) decreased significantly for the men, to 2.0 (95% CI 1.8-2.4), but not so for women (HR 2.5, 95% CI 2.2-2.9). Except for the men with musculoskeletal diagnoses, all of the diagnostic groups had hazard ratios above unity also after the adjustments were made. CONCLUSIONS: The study confirmed high early mortality among Norwegian disability pensioners in the period 1990-1996. The medical condition seemed to contribute more to the increased mortality among the women, whereas a low socioeconomic status was more important for the men.

Frequency and nature of problems associated with sickness certification tasks: a cross-sectional questionnaire study of 5455 physicians.

OBJECTIVE: To study the frequency and nature of problems associated with physicians' sickness certification practices. DESIGN: Cross-sectional questionnaire study. SETTING: Stockholm and Ostergötland Counties in Sweden. SUBJECTS: Physicians aged < or = 64 years, n =7665, response rate 71% (n =5455). MAIN OUTCOME MEASURES: The frequency of consultations involving sickness certification, the frequency and nature of problems related to sickness certification. RESULTS: A total of 74% (n =4019) of the respondents had consultations including sickness certification at least a few times a year. About half of these physicians had sickness certification cases at least six times a week, and 1 out of 10 (9.4%) had this more than 20 times a week. The items that the highest percentage of physicians rated as very or fairly problematic included: handling conflicts with patients over certification, assessing work ability, estimating optimal length and degree of absence, and managing prolongation of sick leave initially certified by another physician. There were large differences in frequency and nature of problems between different types of clinics/practices. General practitioners had the highest frequency of problems concerning sickness certification while the lowest was found among specialists in internal medicine and surgery. CONCLUSION: Sickness certification should be recognized as an important task also for physicians other than general practitioners. The physicians experienced problems with numerous tasks related to sickness certification and these varied considerably between types of clinics. The high rate of problems experienced may have consequences for the physicians' work situation, for patients, and for society.

Bridges, pathways and valleys: labour market position and risk of hospitalization in a Swedish sample aged 55-63.

BACKGROUND: The combination of population ageing and increasingly early labour market exit (LME) throughout Europe has made older age a key issue in social policy and research. There is increasing awareness that older people are a heterogeneous group in which health inequalities persist. However, the effects of different types of LME on health have received relatively little attention. Existing studies reach different conclusions. This might be due to several reasons: different types of LME are rarely explored in conjuncture; studies often lack objective assessments of health and frequently rely on small populations. This paper aims to test the relative effects of different LME on the risk of hospitalization compared with those who remained in paid employment. METHODS: Using Government register data on pooled cross-section samples of Swedish workers aged 55-63 years (n=7,024) the authors have compared the likelihood of hospitalization for three types of LME - disability pension (fortidpension), unemployment, and early retirement - with those who continue working. RESULTS: Controlling for previous hospitalization, sex, age, social class, and health at work a significant increased risk of hospitalization was found following LME for the unemployed (OR=1.98). CONCLUSION: Early LME is a varied process with mixed effects on health, and hence is of possible importance for policy, which, therefore, requires more attention. Programmes to help older unemployed workers back into work will have positive health effects for individuals and reduce welfare costs of hospitalization.