Don't be late! Postponing cognitive decline and preventing early unemployment in people with multiple sclerosis: a study protocol.

BACKGROUND: Up to 65% of people with multiple sclerosis (PwMS) develop cognitive deficits, which hampers their ability to work, participating in day-to-day life and ultimately reducing quality of life (QoL). Early cognitive symptoms are often less tangible to PwMS and their direct environment and are noticed only when symptoms and work functioning problems become more advanced, i.e., when (brain) damage is already advanced. Treatment of symptoms at a late stage can lead to cognitive impairment and unemployment, highlighting the need for preventative interventions in PwMS. AIMS: This study aims to evaluate the (cost-) effectiveness of two innovative preventative interventions, aimed at postponing cognitive decline and work functioning problems, compared to enhanced usual care in improving health-related QoL (HRQoL). METHODS: Randomised controlled trial including 270 PwMS with mild cognitive impairment, who have paid employment ≥ 12 h per week and are able to participate in physical exercise (Expanded Disability Status Scale < 6.0). Participants are randomised across three study arms: 1) 'strengthening the brain' - a lifestyle intervention combining personal fitness, mental coaching, dietary advice, and cognitive training; 2) 'strengthening the mind' - a work-focused intervention combining the capability approach and the participatory approach in one-on-one coaching by trained work coaches who have MS themselves; 3) Control group-receiving general information about cognitive impairment in MS and receiving care as usual. Intervention duration is four months, with short-term and long-term follow-up measurements at 10 and 16 months, respectively. The primary outcome measure of the Don't be late! intervention study will be HRQoL as measured with the 36-item Short Form. Secondary outcomes include cognition, work related outcomes, physical functioning, structural and functional brain changes, psychological functioning, and societal costs. Semi-structured interviews and focus groups with stakeholders will be organised to qualitatively reflect on the process and outcome of the interventions. DISCUSSION: This study seeks to prevent (further) cognitive decline and job loss due to MS by introducing tailor-made interventions at an early stage of cognitive symptoms, thereby maintaining or improving HRQoL. Qualitative analyses will be performed to allow successful implementation into clinical practice. TRIAL REGISTRATION: Retrospectively registered at ClinicalTrials.gov with reference number NCT06068582 on 10 October 2023.

Don't be late! Timely identification of cognitive impairment in people with multiple sclerosis: a study protocol.

BACKGROUND: Cognitive impairment occurs in up to 65% of people with multiple sclerosis (PwMS), negatively affecting daily functioning and health-related quality of life. In general, neuropsychological testing is not part of standard MS-care due to insufficient time and trained personnel. Consequently, a baseline assessment of cognitive functioning is often lacking, hampering early identification of cognitive decline and change within a person over time. To assess cognitive functioning in PwMS in a time-efficient manner, a BICAMS-based self-explanatory digital screening tool called the Multiple Screener©, has recently been developed. The aim of the current study is to validate the Multiple Screener© in a representative sample of PwMS in the Netherlands. Additionally, we aim to investigate how cognitive functioning is related to psychological factors, and both work and societal participation. METHODS: In this cross-sectional multicentre study, 750 PwMS (aged 18-67 years) are included. To obtain a representative sample, PwMS are recruited via 12 hospitals across the Netherlands. They undergo assessment with the Minimal Assessment of Cognitive Functioning in MS (MACFIMS; reference-standard) and the Multiple Screener©. Sensitivity, specificity, and predictive values for identifying (mild) cognitive impairment are determined in a subset of 300 participants. In a second step, the identified cut-off values are tested in an independent subset of at least 150 PwMS. Moreover, test-retest reliability for the Multiple Screener© is determined in 30 PwMS. Information on psychological and work-related factors is assessed with questionnaires. DISCUSSION: Validating the Multiple Screener© in PwMS and investigating cognition and its determinants will further facilitate early identification and adequate monitoring of cognitive decline in PwMS.

Including 'Work as a Treatment Goal' in the Care for Patients with Chronic Diseases : The Development of a Generic Care Model-A Descriptive Study.

BACKGROUND: The Netherlands faces 60% prevalence of chronic conditions by 2040, impacting societal participation and quality of life. Current clinical care inadequately addresses these consequences, and most hospitals do not integrate occupational health in their care. OBJECTIVES: To develop a generic person- and work-oriented medical care model (WMCM) based on real life experiences with work-oriented care and supporting the chronically ill in active societal participation. METHODS: A qualitative research project with a participative approach in one hospital (November 2019 until March 2020). In an expert meeting, a schematic representation of a work-oriented care model was developed. Subsequent discussion rounds, with professionals from different patient groups, iteratively refined the model to a WMCM. RESULTS: Consensus was reached after seven rounds of discussion, defining the model's core elements (1) a combination of biomedical and biopsychosocial approaches, (2) involvement of a clinical occupational physician in the treatment team, (3) a coordinating role for nursing specialists, and (4) incorporation of a work-oriented intervention plan (WoIP) into the treatment plan. Advocating early attention to societal participation, the model emphasises the WoIP and consensus on monitoring indicators. The final goal is a sustainable return to societal participation, considering both quality of life and work. CONCLUSION: It is feasible to develop a generic person- and work-oriented care model for patients with chronic illness within a hospital care setting. Collaboration between healthcare professionals and a specialised occupational physician, with a central role for nurses, is deemed crucial.

Predictors for work participation of people with visual impairments: A systematic review and meta-analysis.

INTRODUCTION: The aim of this systematic review and meta-analysis was to assess factors associated with work participation in people with visual impairments and to explore how these factors may have changed over time. METHOD: A comprehensive search of PubMed, Embase.com, EBSCO/APA PsycInfo, EBSCO/CINAHL and EBSCO/ERIC from database inception to 1 April 2022 was performed. We included studies with cross-sectional design, case-control, case-series or cohort design, involving visually impaired working-age adults with at least moderate visual impairment, and evaluated the association between visual impairment and work participation. Studies involving participants with deaf-blindness or multiple disabilities were excluded. We assessed study quality (Newcastle-Ottawa Scale [NOS]), examined between-study heterogeneity and performed subgroup analyses. The study protocol was registered in PROSPERO, CRD42021241076. RESULTS: Of 13,585 records, 57 articles described 55 studies including 1,326,091 participants from mostly high-income countries. Sociodemographic factors associated with employment included higher education (odds ratio [OR] 3.34, 95% confidence interval [CI] 2.47 to 4.51, I2 0%), being male (OR 1.59, 95% CI 1.37 to 1.84, I2 95%), having a partner (OR 1.73, 95% CI 1.12 to 2.67, I2 34%), white ethnicity (OR 1.36, 95% CI 1.07 to 1.74, I2 0%) and having financial assistance (OR 0.38, 95% CI 0.26 to 0.55, I2 85%). Disease-related factors included worse visual impairment (OR 0.61, 95% CI 0.46 to 0.80, I2 98%) or having additional disabilities (OR 0.55, 95% CI 0.49 to 0.62, I2 16%). Intervention-related factors included mobility aid utilisation (OR 0.35, 95% CI 0.10 to 1.18, I2 94%). A potential moderating effect of time period and geographical region was observed for some factors. Study quality (NOS) was rated moderate to high. CONCLUSION: Several sociodemographic and disease related factors were associated with employment status. However, the results should be interpreted with caution because of overall high heterogeneity. Future research should focus on the role of workplace factors, technological adjustments and vocational rehabilitation services on work participation.

Evaluation of an implementation strategy for Individual Placement and Support in the Netherlands: a 30-month observational study.

BACKGROUND: Individual Placement and Support (IPS) is an evidence-based, effective approach to help people with severe mental illness (SMI) obtain and maintain competitive employment. The aim of the present study was to examine employment outcomes and associations with an organizational and a financial factor in people with SMI who participated in Individual Placement and Support using a multifaceted implementation strategy (IPS + MIS). The goal of this strategy was to improve IPS implementation by enhancing collaboration among mental health care and vocational rehabilitation stakeholders, and realizing secured IPS funding. METHODS: An observational cohort study including 103 participants was conducted, with a 30-month follow-up. Descriptive analyses were used to examine employment outcomes. Multivariable logistic and linear regression analyses were performed to study associations with an organizational and a financial factor: the level of experience of mental health agencies with providing IPS + MIS and the type of IPS funding (i.e. municipality funding (reference group) and the Dutch Social Security Institute: the Institute for Employee Benefits Schemes (UWV) funding). RESULTS: Forty-six percent of the participants were competitively employed at any time during the 30-month follow-up; the median number of days until competitive job obtainment and in competitive jobs was 201 and 265, respectively. The majority of all jobs obtained (81%) were categorized as 'elementary occupations', 'clerical support workers', and 'service and sales workers'. A higher level of experience of the mental health agencies with providing IPS + MIS was found to be positively associated with job obtainment (OR = 3.83, 95% CI 1.42-10.30, p = 0.01) and the number of days worked in competitive jobs (B = 1.21, 95% CI 0.36-2.07, p = 0.01). UWV funding was found to be negatively associated with job obtainment (OR = 0.30, 95% CI 0.11-0.77, p = 0.01). No association was found for the type of IPS funding and the number of days worked in competitive jobs (B = -0.73, 95% CI -1.48-0.02, p = 0.06). CONCLUSIONS: This study shows that almost half of the people who participate in IPS + MIS obtain a competitive job within 30 months. The results further suggest that both the level of experience of mental health agencies with providing IPS + MIS, and funding may play a role in employment outcomes.

Risk communication about work-related stress disorders in healthcare workers: a scoping review.

PURPOSES: Healthcare workers are at risk of stress-related disorders. Risk communication can be an effective preventive health measure for some health risks, but is not yet common in the prevention of stress-related disorders in an occupational healthcare setting. The overall aim is to examine whether risk communication was part of interventions aimed at the prevention of stress-related disorders in healthcare workers. METHOD: We performed a scoping review using the framework of Arksey and O'Malley. We searched in Medline, Web of Science and PsychInfo for studies reporting on preventive interventions of stress-related disorders in healthcare workers between 2005 and December 2020. Studies were included when the intervention reported on at least one element of risk communication and one goal. We predefined four elements of risk communication: risk perception, communication of early stress symptoms, risk factors and prevention; and three goals: inform, stimulate informed decision-making and motivate action. RESULTS: We included 23 studies that described 17 interventions. None of the included interventions were primarily developed as risk communication interventions, but all addressed the goals. Two interventions used all four elements of risk communication. The prominent mode of delivery was face to face, mostly delivered by researchers. Early stress symptoms and risk factors were measured by surveys. CONCLUSIONS: Risk communication on risk factors and early signs of stress-related disorders is not that well studied and evaluated in an occupational healthcare setting. Overall, the content of the communication was not based on the risk perception of the healthcare workers, which limited the likelihood of them taking action.

Development of the core of an ICF-based instrument for the assessment of work capacity and guidance in return to work of employees on sick leave: a multidisciplinary modified Delphi study.

BACKGROUND: Several occupational health disciplines are involved in return to work guidance, implying that good interdisciplinary collaboration is important. A shared conceptual framework and a common language for the assessment of work capacity and guidance in return to work is expected to be at the benefit of appropriate and sustainable employability of sick employees. The International Classification of Functioning, Disability and Health (ICF) can be considered a shared conceptual framework and is also promising in terms of a common language. The purpose of the current study is to reach multidisciplinary consensus among occupational health professionals on the content of an ICF-based instrument for the assessment of work capacity and guidance in return to work. METHODS: To obtain multidisciplinary consensus we conducted a modified Delphi study among twelve occupational health experts, including four occupational physicians, four insurance physicians and four labour experts. The study included two e-mail rounds and two virtual meetings. In the consecutive rounds the experts assessed ICF items as well as a list of non-ICF-based work-related environmental factors on their relevance for the assessment of the work capacity and guidance in return to work together with their interpretability. RESULTS: The four consecutive Delphi rounds resulted in 20 items that are minimally needed for the assessment of the work capacity and return to work possibilities of employees on sick leave. The final list included six items on personal functioning, seven items on social functioning and seven items on physical functioning. CONCLUSIONS: This set of items forms the core of an ICF-based instrument, which is expected to facilitate interdisciplinary and intradisciplinary communication because of the use of a shared conceptual framework. As such, it should be of help in the guidance in return to work of employees on sick leave and contribute to appropriate and sustainable employability.

Process evaluation of the 'Grip on Health' intervention in general and occupational health practice.

BACKGROUND: For working patients with a lower socioeconomic position, health complaints often result from a combination of problems on multiple life domains. To prevent long-term health complaints and absence from work, it is crucial for general and occupational health professionals to adopt a broad perspective on health and to collaborate when necessary. This study aimed to evaluate how the 'Grip on Health' intervention is implemented in general and occupational health practice to address multi-domain problems and to promote interprofessional collaboration. METHOD: A process evaluation was performed among 28 general and occupational health professionals, who were trained and implemented the Grip on Health intervention during a six-month period. The 'Measurement Instrument for Determinants of Innovations' was used to evaluate facilitators and barriers for implementing Grip on Health. Data included three group interviews with 17 professionals, a questionnaire and five individual interviews. RESULTS: While most health professionals were enthusiastic about the Grip on Health intervention, its implementation was hindered by contextual factors. Barriers in the socio-political context consisted of legal rules and regulations around sickness and disability, professional protocols for interprofessional collaboration, and the Covid-19 pandemic. On the organizational level, lack of consultation time was the main barrier. Facilitators were found on the level of the intervention and the health professional. For instance, professionals described how the intervention supports addressing multi-domain problems and has created awareness of work in each other's healthcare domain. They recognized the relevance of the intervention for a broad target group and experienced benefits of its use. The intervention period was, nevertheless, too short to determine the outcomes of Grip on Health. CONCLUSION: The Grip on Health intervention can be used to address problems on multiple life domains and to stimulate interprofessional collaboration. Visualizing multi-domain problems appeared especially helpful to guide patients with a lower socioeconomic position, and a joint training of general and occupational health professionals promoted their mutual awareness and familiarity. For a wider implementation, stakeholders on all levels, including the government and professional associations, should reflect on ways to address contextual barriers to promote a broad perspective on health as well as on collaborative work.

The perceived importance of prognostic aspects considered by physicians during work disability evaluation: a survey.

BACKGROUND: Assessing prognosis is challenging for many physicians in various medical fields. Research shows that physicians who perform disability assessments consider six areas when evaluating a prognosis: disease, treatment, course of the disease, external information, patient-related and physician-related aspects. We administered a questionnaire to evaluate how physicians rate the importance of these six prognosis areas during work disability evaluation and to explore what kind of support they would like during prognosis assessment. METHODS: Seventy-six physicians scored the importance of 23 prognostic aspects distributed over six prognosis areas. Participants scored the importance of each aspect both "in general" and from the perspective of a case vignette of a worker with a severe degenerative disease. The questionnaire also covered needs and suggestions for support during the evaluation of prognoses. RESULTS: Medical areas that are related to the disease, or the treatment or course of the disease, appeared important (scores of 7.0-9.0), with less differing opinions among participants (IQR 1.0-3.0). Corresponding verbatim remarks supported the importance of disease and treatment as prognostic aspects. In comparison, patient- and physician-related aspects scored somewhat lower, with more variability (range 4.0-8.0, with IQR 2.0-5.0 for patient- and physician-related considerations). Participants indicated a need for a tool or online database that includes prognostic aspects and prognostic evidence. CONCLUSIONS: Despite some variation in scores, the physicians rated all six prognosis areas as important for work disability evaluations. This study provides suggested aids to prognosis assessment, including an online support tool based on evidence-based medicine features.

Experiences with Individual Placement and Support and employment - a qualitative study among clients and employment specialists.

BACKGROUND: Individual Placement and Support (IPS) is an evidence-based, effective approach to help people with severe mental illness (SMI) achieve competitive employment. The aim of the present study is to explore experiences with Individual Placement and Support using a multifaceted implementation strategy (IPS + MIS), and competitive employment. The goal of this strategy was to improve IPS implementation by enhancing collaboration between mental health care and vocational rehabilitation stakeholders, and realizing a secured IPS funding with a 'pay for performance' element. METHODS: A qualitative, exploratory study was performed using semi-structured interviews with IPS clients (n = 10) and two focus groups with IPS employment specialists (n = 7 and n = 8) to collect rich information about their experiences with IPS + MIS and competitive employment. Thematic content analysis was used to analyse the data. RESULTS: Themes related to experiences with IPS and the multifaceted implementation strategy were identified, including the importance of discussing the client's motivation and motives to work, facilitators and barriers to obtaining and maintaining employment, facilitators to collaboration between stakeholders, barriers to benefits counselling, organizational barriers to IPS execution and collaboration between stakeholders, financial barriers to IPS execution and experiences with the pay for performance element. CONCLUSIONS: Although the multifaceted implementation strategy seems to contribute to an improved IPS implementation, the barriers identified in this study suggest that further steps are necessary to promote IPS execution and to help people with SMI obtain and maintain competitive employment.

Personalised perioperative care by e-health after intermediate-grade abdominal surgery: a multicentre, single-blind, randomised, placebo-controlled trial.

BACKGROUND: Instructing and guiding patients after surgery is essential for successful recovery. However, the time that health-care professionals can spend with their patients postoperatively has been reduced because of efficiency-driven, shortened hospital stays. We evaluated the effect of a personalised e-health-care programme on return to normal activities after surgery. METHODS: A multicentre, single-blind, randomised controlled trial was done at seven teaching hospitals in the Netherlands. Patients aged 18-75 years who were scheduled for laparoscopic cholecystectomy, inguinal hernia surgery, or laparoscopic adnexal surgery for a benign indication were recruited. An independent researcher randomly allocated participants to either the intervention or control group using computer-based randomisation lists, with stratification by sex, type of surgery, and hospital. Participants in the intervention group had access to a perioperative, personalised, e-health-care programme, which managed recovery expectations and provided postoperative guidance tailored to the patient. The control group received usual care and access to a placebo website containing standard general recovery advice. Participants were unaware of the study hypothesis and were asked to complete questionnaires at five timepoints during the 6-month period after surgery. The primary outcome was time between surgery and return to normal activities, measured using personalised patient-reported outcome measures. Intention-to-treat and per-protocol analyses were done. This trial is registered in the Netherlands National Trial Register, number NTR4699. FINDINGS: Between Aug 24, 2015, and Aug 12, 2016, 344 participants were enrolled and randomly allocated to either the intervention (n=173) or control (n=171) group. 14 participants (4%) were lost to follow-up, with 330 participants included in the primary outcome analysis. Median time until return to normal activities was 21 days (95% CI 17-25) in the intervention group and 26 days (20-32) in the control group (hazard ratio 1·38, 95% CI 1·09-1·73; p=0·007). Complications did not differ between groups. INTERPRETATION: A personalised e-health intervention after abdominal surgery speeds up the return to normal activities compared with usual care. Implementation of this e-health programme is recommended in patients undergoing intermediate-grade abdominal, gynaecological, or general surgical procedures. FUNDING: ZonMw.

Electronic Health Program to Empower Patients in Returning to Normal Activities After Colorectal Surgical Procedures: Mixed-Methods Process Evaluation Alongside a Randomized Controlled Trial.

BACKGROUND: Long-term recovery takes longer than expected despite improved surgical techniques and Enhanced Recovery After Surgery programs. An electronic health (eHealth) care program ("ikherstel") was developed to partially substitute perioperative care for patients undergoing colorectal surgical procedures. Successfully tested eHealth programs are not always implemented in usual care, and it is, therefore, important to evaluate the process to optimize future implementation. OBJECTIVE: The aim of this study was to evaluate whether the eHealth intervention was executed as planned. METHODS: A mixed-methods process evaluation was carried out alongside a multicenter randomized controlled trial (RCT). This evaluation was performed using the Linnan and Steckler framework for the quantitative part of this study, measuring the components reach, dose delivered, dose received, fidelity, and participants' attitudes. Total implementation scores were calculated using the averaging approach, in which the sum of all data points is divided by the number of data points and the total adherence to the protocol is measured. For the qualitative part, the Unified Theory of Acceptance and Use of Technology framework was used. The quantitative data were based on participants' questionnaires, a logistic database, a weblog, and participants' medical files and were obtained by performing semistructured interviews with participants of the RCT. RESULTS: A total of 151 participants of 340 eligible patients were included in the RCT, of which 73 participants were allocated to the intervention group. On the basis of the quantitative process data, total implementation scores for the website, mobile app, electronic consult, and activity tracker were 64%, 63%, 44%, and 67%, respectively. Participants in the qualitative part experienced the program as supportive and provided guidance on their recovery process after colorectal surgery. Most frequently mentioned barriers were the limited interaction with and feedback from health care professionals and the lack of tailoring of the convalescence plan in case of a different course of recovery. CONCLUSIONS: The intervention needs more interaction with and feedback from health care professionals and needs more tailored guidance in case of different recovery or treatment courses. To ensure a successful implementation of the program in daily practice, some adjustments are required to optimize the program in a blended care form. TRIAL REGISTRATION: Netherlands Trial Registry NTR5686; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC= 5686 (Archieved by WebCite at http://www.webcitation.org/75LrJaHrr).

Electronic Health Program to Empower Patients in Returning to Normal Activities After General Surgical and Gynecological Procedures: Intervention Mapping as a Useful Method for Further Development.

BACKGROUND: Support for guiding and monitoring postoperative recovery and resumption of activities is usually not provided to patients after discharge from the hospital. Therefore, a perioperative electronic health (eHealth) intervention ("ikherstel" intervention or "I recover" intervention) was developed to empower gynecological patients during the perioperative period. This eHealth intervention requires a need for further development for patients who will undergo various types of general surgical and gynecological procedures. OBJECTIVE: This study aimed to further develop the "ikherstel" eHealth intervention using Intervention Mapping (IM) to fit a broader patient population. METHODS: The IM protocol was used to guide further development of the "ikherstel" intervention. First, patients' needs were identified using (1) the information of a process evaluation of the earlier performed "ikherstel" study, (2) a review of the literature, (3) a survey study, and (4) focus group discussions (FGDs) among stakeholders. Next, program outcomes and change objectives were defined. Third, behavior change theories and practical tools were selected for the intervention program. Finally, an implementation and evaluation plan was developed. RESULTS: The outcome for an eHealth intervention tool for patients recovering from abdominal general surgical and gynecological procedures was redefined as "achieving earlier recovery including return to normal activities and work." The Attitude-Social Influence-Self-Efficacy model was used as a theoretical framework to transform personal and external determinants into change objectives of personal behavior. The knowledge gathered by needs assessment and using the theoretical framework in the preparatory steps of the IM protocol resulted in additional tools. A mobile app, an activity tracker, and an electronic consultation (eConsult) will be incorporated in the further developed eHealth intervention. This intervention will be evaluated in a multicenter, single-blinded randomized controlled trial with 18 departments in 11 participating hospitals in the Netherlands. CONCLUSIONS: The intervention is extended to patients undergoing general surgical procedures and for malignant indications. New intervention tools such as a mobile app, an activity tracker, and an eConsult were developed. TRIAL REGISTRATION: Netherlands Trial Registry NTR5686; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5686.

Work Motivation and Employment Outcomes in People with Severe Mental Illness.

Purpose To study associations between the level of self-reported work motivation and employment outcomes in people with severe mental illness (SMI) enrolled in a vocational rehabilitation program. Methods Data of 151 study participants, collected from a randomised controlled trial with a 30-month follow-up period, were used for a secondary data analysis. Multiple logistic regression, linear regression and cox regression analyses were performed to analyse the association between the level of work motivation at baseline and job obtainment, duration of job, and time until job obtainment during the 30-month follow-up period. Results No statistically significant associations were found between the level of work motivation and job obtainment (OR 1.83, 95% CI 0.55-6.06, p = 0.32), job duration (B = - 0.74, 95% CI - 2.37 to 0.89, p = 0.37, R-squared = 0.03), or time until job obtainment (HR = 1.53, 95% CI 0.64-3.68, p = 0.34). Conclusions The results of this study show no statistically significant associations between the level of work motivation and employment outcomes in people with SMI enrolled in a vocational rehabilitation program. These associations may be underestimated due to range restriction of the work motivation's level. Further research is recommended to increase knowledge on the associations between work motivation and employment outcomes, as it could be relevant for further understanding success in vocational rehabilitation.

Experiences with the implementation of Individual Placement and Support for people with severe mental illness: a qualitative study among stakeholders.

BACKGROUND: Individual Placement and Support (IPS) is an evidence-based approach to help people with severe mental illness achieve competitive employment. This article provides insight into an organizational and a financial implementation strategy for IPS in the Netherlands by exploring the perceived facilitators and barriers among participating stakeholders. The goal of this multifaceted strategy was to improve IPS implementation by improving the collaboration between all organizations involved, and realising secured IPS funding with a 'pay for performance' element. METHODS: A qualitative, explorative study among practitioners (n = 8) and decision makers (n = 7) in mental health care and vocational rehabilitation was performed using semi-structured interviews to collect rich information about the possible facilitators and barriers with regard to the organizational and financial implementation strategy for IPS. RESULTS: Important perceived facilitators were the key principles of the IPS model, regular meetings of stakeholders in mental health care and vocational rehabilitation, stakeholders' experienced ownership of IPS and collaboration, the mandate and influence of the decision makers involved and secured IPS funding. Important perceived barriers included the experienced rigidity of the IPS model fidelity scale and lack of independent fidelity reviewers, the temporary and fragmented character of the secured funding, lack of communication between decision makers and practitioners and negative attitudes and beliefs among mental health clinicians. Changes in legislation were experienced as a facilitator as well as a barrier. CONCLUSIONS: The results of this study suggest that the collaboration and IPS funding were experienced as improved by applying an organizational and a financial implementation strategy. However, considerable effort is still necessary to overcome the remaining barriers identified and to make the implementation of IPS a success in practice.

Effectiveness of a multifaceted implementation strategy compared to usual care on low back pain guideline adherence among general practitioners.

BACKGROUND: To improve patient care, and to reduce unnecessary referrals for diagnostic imaging and medical specialist care for low back pain, an evidence-based guideline for low back pain was developed in the Netherlands in 2010. The current study evaluated the effect of a multifaceted implementation strategy on guideline adherence among Dutch general practitioners. METHODS: The implementation strategy included a multidisciplinary training, provision of educational material and an interactive website for healthcare professionals, supported by a multimedia eHealth intervention for patients with low back pain. Adherence was measured using performance indicators based on 3 months data extracted from the contacts with patients with low back pain recorded in the electronic medical records of participating general practitioners. Performance indicators were compared between two groups: a usual care group and an implementation group. Performance indicators were referrals to consultations with medical specialists, to diagnostic imaging, and to psychosocial and/or occupational physician consultations, and inquiries about psychosocial and occupational risk factors. RESULTS: The electronic medical records of 5130 patient contacts for LBP were analysed; 2453 patient contacts in the usual care group and 2677 patient contacts in the implementation group. Overall, rates of referral and of recorded inquiries regarding psychosocial and occupational risk factors remained low in both groups over time. The only statistically significant difference found was a reduction in the number of referrals to neurologists in the implementation group (from 100 (7%) to 50 (4%)) compared to the usual care group (from 48 (4%) to 50 (4%), (p < 0.01)). There were no other between-group differences in referrals. CONCLUSION: In the short term, the strategy did not result in improved guideline adherence among general practitioners, and it is not recommended for widespread use. However, baseline referral rates in participating practices were already low, possibly leaving only little room for improvement. Inquiries for psychosocial and occupational risk factors remained low and this leaves room for improvement. TRIAL REGISTRATION: This trial is registered in the Netherlands Trial Register (NTR): NTR4329 . Registration date: December 20th, 2013.

Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta-analysis.

BACKGROUND: People with severe mental illness show high rates of unemployment and work disability, however, they often have a desire to participate in employment. People with severe mental illness used to be placed in sheltered employment or were enrolled in prevocational training to facilitate transition to a competitive job. Now, there are also interventions focusing on rapid search for a competitive job, with ongoing support to keep the job, known as supported employment. Recently, there has been a growing interest in combining supported employment with other prevocational or psychiatric interventions. OBJECTIVES: To assess the comparative effectiveness of various types of vocational rehabilitation interventions and to rank these interventions according to their effectiveness to facilitate competitive employment in adults with severe mental illness. SEARCH METHODS: In November 2016 we searched CENTRAL, MEDLINE, Embase, PsychINFO, and CINAHL, and reference lists of articles for randomised controlled trials and systematic reviews. We identified systematic reviews from which to extract randomised controlled trials. SELECTION CRITERIA: We included randomised controlled trials and cluster-randomised controlled trials evaluating the effect of interventions on obtaining competitive employment for adults with severe mental illness. We included trials with competitive employment outcomes. The main intervention groups were prevocational training programmes, transitional employment interventions, supported employment, supported employment augmented with other specific interventions, and psychiatric care only. DATA COLLECTION AND ANALYSIS: Two authors independently identified trials, performed data extraction, including adverse events, and assessed trial quality. We performed direct meta-analyses and a network meta-analysis including measurements of the surface under the cumulative ranking curve (SUCRA). We assessed the quality of the evidence for outcomes within the network meta-analysis according to GRADE. MAIN RESULTS: We included 48 randomised controlled trials involving 8743 participants. Of these, 30 studied supported employment, 13 augmented supported employment, 17 prevocational training, and 6 transitional employment. Psychiatric care only was the control condition in 13 studies. Direct comparison meta-analysis of obtaining competitive employmentWe could include 18 trials with short-term follow-up in a direct meta-analysis (N = 2291) of the following comparisons. Supported employment was more effective than prevocational training (RR 2.52, 95% CI 1.21 to 5.24) and transitional employment (RR 3.49, 95% CI 1.77 to 6.89) and prevocational training was more effective than psychiatric care only (RR 8.96, 95% CI 1.77 to 45.51) in obtaining competitive employment.For the long-term follow-up direct meta-analysis, we could include 22 trials (N = 5233). Augmented supported employment (RR 4.32, 95% CI 1.49 to 12.48), supported employment (RR 1.51, 95% CI 1.36 to 1.68) and prevocational training (RR 2.19, 95% CI 1.07 to 4.46) were more effective than psychiatric care only. Augmented supported employment was more effective than supported employment (RR 1.94, 95% CI 1.03 to 3.65), transitional employment (RR 2.45, 95% CI 1.69 to 3.55) and prevocational training (RR 5.42, 95% CI 1.08 to 27.11). Supported employment was more effective than transitional employment (RR 3.28, 95% CI 2.13 to 5.04) and prevocational training (RR 2.31, 95% CI 1.85 to 2.89). Network meta-analysis of obtaining competitive employmentWe could include 22 trials with long-term follow-up in a network meta-analysis.Augmented supported employment was the most effective intervention versus psychiatric care only in obtaining competitive employment (RR 3.81, 95% CI 1.99 to 7.31, SUCRA 98.5, moderate-quality evidence), followed by supported employment (RR 2.72 95% CI 1.55 to 4.76; SUCRA 76.5, low-quality evidence).Prevocational training (RR 1.26, 95% CI 0.73 to 2.19; SUCRA 40.3, very low-quality evidence) and transitional employment were not considerably different from psychiatric care only (RR 1.00,95% CI 0.51 to 1.96; SUCRA 17.2, low-quality evidence) in achieving competitive employment, but prevocational training stood out in the SUCRA value and rank.Augmented supported employment was slightly better than supported employment, but not significantly (RR 1.40, 95% CI 0.92 to 2.14). The SUCRA value and mean rank were higher for augmented supported employment.The results of the network meta-analysis of the intervention subgroups favoured augmented supported employment interventions, but also cognitive training. However, supported employment augmented with symptom-related skills training showed the best results (RR compared to psychiatric care only 3.61 with 95% CI 1.03 to 12.63, SUCRA 80.3).We graded the quality of the evidence of the network ranking as very low because of potential risk of bias in the included studies, inconsistency and publication bias. Direct meta-analysis of maintaining competitive employment Based on the direct meta-analysis of the short-term follow-up of maintaining employment, supported employment was more effective than: psychiatric care only, transitional employment, prevocational training, and augmented supported employment.In the long-term follow-up direct meta-analysis, augmented supported employment was more effective than prevocational training (MD 22.79 weeks, 95% CI 15.96 to 29.62) and supported employment (MD 10.09, 95% CI 0.32 to 19.85) in maintaining competitive employment. Participants receiving supported employment worked more weeks than those receiving transitional employment (MD 17.36, 95% CI 11.53 to 23.18) or prevocational training (MD 11.56, 95% CI 5.99 to 17.13).We did not find differences between interventions in the risk of dropouts or hospital admissions. AUTHORS' CONCLUSIONS: Supported employment and augmented supported employment were the most effective interventions for people with severe mental illness in terms of obtaining and maintaining employment, based on both the direct comparison analysis and the network meta-analysis, without increasing the risk of adverse events. These results are based on moderate- to low-quality evidence, meaning that future studies with lower risk of bias could change these results. Augmented supported employment may be slightly more effective compared to supported employment alone. However, this difference was small, based on the direct comparison analysis, and further decreased with the network meta-analysis meaning that this difference should be interpreted cautiously. More studies on maintaining competitive employment are needed to get a better understanding of whether the costs and efforts are worthwhile in the long term for both the individual and society.

Associations between measures of socio-economic status, beliefs about back pain, and exposure to a mass media campaign to improve back beliefs.

BACKGROUND: Low back pain (LBP) is one of the most common and costly healthcare problems worldwide. Disability from LBP is associated with maladaptive beliefs about the condition, and such beliefs can be influenced by public health interventions. While socioeconomic status (SES) has been identified as an important factor in health literacy and inequalities, not much is known about the association between SES and beliefs about LBP. Therefore, this study examined the relationship between measures of SES and the belief that one should stay active through LBP in a representative sample of the general population in Alberta, Canada. We also examined the association between measures of SES and self-reported exposure to a LBP mass media health education campaign. METHODS: Population-based surveys from 2010 through 2014 were conducted among 9572 randomly selected Alberta residents aged 18-65 years. Several methods for measuring SES, including first language, education, employment status, occupation, and annual household income, were included in multivariable logistic regression modeling to test associations between measures of SES and outcomes. RESULTS: Univariable analysis showed that age, language, education, employment, marital status, and annual household income were significantly associated with the belief that one should stay active through LBP. In multivariable analysis, income was the variable most strongly correlated with this belief (odds ratios ranged from 1.04 to 1.62 for the highest income category, p = 0.005). Univariable analysis for exposure to the campaign showed age, language, education, employment, and occupation to be significantly associated with self-reported exposure, while only education (p = 0.01) and age (p = 0.001) remained significant in multivariable analysis. CONCLUSIONS: Individuals with higher annual income appear more likely to believe that one should stay active during an episode of LBP. Additionally, targeted information campaigns are recalled more by low SES groups and may thus assist in reducing health disparities. More research is needed to fully understand the association between socioeconomic factors and LBP and to target campaigns accordingly.

A participatory supportive return to work program for workers without an employment contract, sick-listed due to a common mental disorder: an economic evaluation alongside a randomized controlled trial.

BACKGROUND: Mental disorders are associated with high costs for productivity loss, sickness absence and unemployment. A participatory supportive return to work (RTW) program was developed in order to improve RTW among workers without an employment contract, sick-listed due to a common mental disorder. The program contained a participatory approach, integrated care and direct placement in a competitive job. The aim of this study was to evaluate the cost-effectiveness and cost-utility of this new program, compared to usual care. In addition, its return on investment was evaluated. METHODS: An economic evaluation was conducted alongside a 12-month randomized controlled trial. A total of 186 participants was randomly allocated to the new program (n = 94) or to usual care (n = 92). Effect measures were the duration until sustainable RTW in competitive employment and quality-adjusted life years (QALYs) gained. Costs included intervention costs, medical costs and absenteeism costs. Registered data of the Dutch Social Security Agency were used to assess the duration until sustainable RTW, intervention costs and absenteeism costs. QALYs and medical costs were assessed using three- or six-monthly questionnaires. Missing data were imputed using multiple imputations. Cost-effectiveness analysis and cost-utility analysis were conducted from the societal perspective. A return on investment analysis was conducted from the social insurer's perspective. Various sensitivity analyses were performed to assess the robustness of the results. RESULTS: The new program had no significant effect on the duration until sustainable RTW and QALYs gained. Intervention costs and medical costs were significantly higher in the intervention group. From the societal perspective, the maximum probability of cost-effectiveness for duration until sustainable RTW was 0.64 at a willingness to pay of about €10 000/day, and 0.27 for QALYs gained, regardless of the willingness to pay. From the social insurer's perspective, the probability of financial return was 0.18. CONCLUSIONS: From the societal perspective, the new program was neither cost-effective in improving sustainable RTW nor in gaining QALYs. From the social insurer's perspective, the program did not result in a positive financial return. Therefore, the present study provided no evidence to support its implementation. TRIAL REGISTRATION: The trial was listed at the Dutch Trial Register (NTR) under NTR3563 on August 7, 2012.