Effectiveness of a tailored implementation strategy to improve adherence to a guideline on mental health problems in occupational health care.

BACKGROUND: As compliance to guidelines is generally low among health care providers, little is known about the impact of guidelines on the quality of delivery of care. To improve adherence to guideline recommendations on mental health problems, an implementation strategy was developed for Dutch occupational physicians (OPs). The aims were 1) to assess adherence to a mental health guideline in occupational health care and 2) to evaluate the effect of a tailored implementation strategy on guideline adherence compared to traditional guideline dissemination. METHODS: An audit of medical records was conducted as part of a larger RCT study. Participants were 66 OPs (32 intervention and 34 control) employed at one of six sites of an Occupational Health Service in southern Netherlands. OPs in the intervention group received multiple-session peer group training which focused on identifying and addressing barriers to using the guideline, using a Plan-Do-Check-Act approach. The control group did not receive training. Medical records of 114 workers sick-listed with mental health problems were assessed (56 intervention and 58 control). Guideline adherence was determined by auditing the records using 12 guideline-based performance indicators (PI), grouped into 5 PIs: process diagnosis, problem orientation, interventions/treatment, relapse prevention, and continuity of care. Differences in performance rates of the PIs between the intervention and control groups were analyzed, taking into account the cluster study design. RESULTS: OPs who received the training showed significantly greater adherence compared to the controls (p < .028) in 4 out of 5 grouped PIs, i.e. process diagnosis, problem orientation, interventions/treatment and relapse prevention. In one out of 12 PIs adherence was found adequate (53% of the medical records), in 6 PIs adherence was found minimal, and in 5 PIs the majority of the records showed no adherence. CONCLUSIONS: An implementation strategy which addressed key barriers for change and tailor-made interventions improves adherence to an occupational health guideline for mental health problems compared to traditional guideline dissemination. However, adherence to the guideline recommendations is still far from optimal. To optimize adherence, it is recommended that implementation strategies focus on the workers level, organizational level, and the professional level. TRIAL REGISTRATION: ISRCTN86605310 . Registered 30 June 2010.

Interventions to facilitate return to work in adults with adjustment disorders.

BACKGROUND: Adjustment disorders are a frequent cause of sick leave and various interventions have been developed to expedite the return to work (RTW) of individuals on sick leave due to adjustment disorders. OBJECTIVES: To assess the effects of interventions facilitating RTW for workers with acute or chronic adjustment disorders. SEARCH METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to October 2011; the Cochrane Central Register of Controlled Trials (CENTRAL) to Issue 4, 2011; MEDLINE, EMBASE, PsycINFO and ISI Web of Science, all years to February 2011; the WHO trials portal (ICTRP) and ClinicalTrials.gov in March 2011. We also screened reference lists of included studies and relevant reviews. SELECTION CRITERIA: We selected randomised controlled trials (RCTs) evaluating the effectiveness of interventions to facilitate RTW of workers with adjustment disorders compared to no or other treatment. Eligible interventions were pharmacological interventions, psychological interventions (such as cognitive behavioural therapy (CBT) and problem solving therapy), relaxation techniques, exercise programmes, employee assistance programmes or combinations of these interventions. The primary outcomes were time to partial and time to full RTW, and secondary outcomes were severity of symptoms of adjustment disorder, work functioning, generic functional status (i.e. the overall functional capabilities of an individual, such as physical functioning, social function, general mental health) and quality of life. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies, assessed risk of bias and extracted data. We pooled studies that we deemed sufficiently clinically homogeneous in different comparison groups, and assessed the overall quality of the evidence using the GRADE approach. MAIN RESULTS: We included nine studies reporting on 10 psychological interventions and one combined intervention. The studies included 1546 participants. No RCTs were found of pharmacological interventions, exercise programmes or employee assistance programmes. We assessed seven studies as having low risk of bias and the studies that were pooled together were comparable. For those who received no treatment, compared with CBT, the assumed time to partial and full RTW was 88 and 252 days respectively. Based on two studies with a total of 159 participants, moderate-quality evidence showed that CBT had similar results for time (measured in days) until partial RTW compared to no treatment at one-year follow-up (mean difference (MD) -8.78, 95% confidence interval (CI) -23.26 to 5.71). We found low-quality evidence of similar results for CBT and no treatment on the reduction of days until full RTW at one-year follow-up (MD -35.73, 95% CI -113.15 to 41.69) (one study with 105 participants included in the analysis). Based on moderate-quality evidence, problem solving therapy (PST) significantly reduced time until partial RTW at one-year follow-up compared to non-guideline based care (MD -17.00, 95% CI -26.48 to -7.52) (one study with 192 participants clustered among 33 treatment providers included in the analysis), but we found moderate-quality evidence of no significant effect on reducing days until full RTW at one-year follow-up (MD -17.73, 95% CI -37.35 to 1.90) (two studies with 342 participants included in the analysis). AUTHORS' CONCLUSIONS: We found moderate-quality evidence that CBT did not significantly reduce time until partial RTW and low-quality evidence that it did not significantly reduce time to full RTW compared with no treatment. Moderate-quality evidence showed that PST significantly enhanced partial RTW at one-year follow-up compared to non-guideline based care but did not significantly enhance time to full RTW at one-year follow-up. An important limitation was the small number of studies included in the meta-analyses and the small number of participants, which lowered the power of the analyses.

Return to work and occupational physicians' management of common mental health problems--process evaluation of a randomized controlled trial.

OBJECTIVE: The aim of this study was to examine the adherence of occupational physicians (OP) to the Dutch guideline on the management of common mental health problems and its effect on return to work as part of the process evaluation of a trial comparing adherence to the guideline to care as usual. The first hypothesis was that guideline adherence among the "guideline group" will be higher compared to the "usual care group". The second hypothesis was that better guideline adherence by the occupational physician will be associated with earlier return to work. METHODS: In a randomized controlled trial, five participating OP had to provide care based on the Dutch guideline to 240 police workers with common mental health problems (the "guideline group"). The same OP had to provide usual care to the participants in the control group (the "usual care" group), including minimal involvement and easy access to a psychologist. In evaluating the process, we assessed guideline adherence via an audit of medical files, using 20 guideline-based performance indicators. Mean rates of guideline adherence were related to the duration until first and full return to work, using a Cox proportional hazards model. RESULTS: The mean rate of the sum score of guideline adherence was 10 in a range of 0-20 [standard deviation (SD) 1.8] and did not significantly differ between the intervention and control group. Mean better guideline adherence showed a statistically significant association with a shorter time to first and full return to work [hazard ratio 1.1; 95% confidence interval (95% CI) 1.0-1.2], which was explained by keeping more regular contact with the worker and the work system and better monitoring of stagnation or return to work. CONCLUSIONS: No contrast in guideline adherence was found between guideline-based versus usual care. This can be explained by contamination between the guideline and usual care group. Even though guideline adherence was only average, better adherence predicted earlier return to work. Guidelines for management of common mental health problems and return to work should focus on regular contact with the worker and the work organisation.

Design of a randomized controlled trial on the effects of counseling of mental health problems by occupational physicians on return to work: the CO-OP-study.

BACKGROUND: Mental health problems often lead to prolonged sick leave. In primary care, the usual approach towards these patients was the advice to take rest and not return to work before all complaints had disappeared. When complaints persist, these patients are often referred to psychologists from primary and specialized secondary care. As an alternative, ways have been sought to activate the Dutch occupational physician (OP) in primary care. Early 2000, the Dutch Association of Occupational Physicians (NVAB) published a guideline concerning the management by OPs of employees with mental health problems. The guideline received positive reactions from employees, employers and Dutch OPs. This manuscript describes the design of a study, which aims to assess the effects of the guideline, compared with usual care. METHODS/DESIGN: In a randomized controlled trial (RCT), subjects in the intervention group were treated according to the guideline. The control group received usual care, with minimal involvement of the OP and easy access to a psychologist. Subjects were recruited from two Dutch police departments. The primary outcomes of the study are return to work and treatment satisfaction by the employee, employer, and OP. A secondary outcome is cost-effectiveness of the intervention, compared with usual care. Furthermore, prognostic measures are taken into account as potential confounders. A process evaluation will be done by means of performance indicators, based on the guideline. DISCUSSION: In this pragmatic trial, effectiveness instead of efficacy is studied. We will evaluate what is possible in real clinical practice, rather than under ideal circumstances. Many requirements for a high quality trial are being met. Results of this study will contribute to treatment options in occupational health practice for employees on sick leave due to mental health problems. Additionally, they may contribute to new and better-suited guidelines and stepped care. Results will become available during 2007. TRIAL REGISTRATION: Current Controlled Trials ISRCTN34887348.