It’s the Keele difference.

Improving work outcomes in patients with musculoskeletal pain – Effectiveness and costs

of a vocational advice service

Gwenllian Wynne-JonesSenior Research Fellow : Research Institute for Primary Care and

Health Sciences, Keele University, UK

Objectives

The impact of musculoskeletal pain on the working age population

The value of working despite musculoskeletal pain

An overview of findings from a randomised controlled trial comparing a brief, early intervention to support people working with pain to best current care

Musculoskeletal Health

Scale of the impact in the UK

Versus Arthritis: State of Musculoskeletal Health 2018

Musculoskeletal Health – tip of the iceberg

Diagnosed MSK condition < 1.5 % of population

Patients with muscle and joint pain in primary care: 15-30% of population

Workactive with frequent and recurrent MSK pain in 1 or more body regions : > 50% of population

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20.00

40.00

60.00

80.00

100.00

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Rat

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Age category

Back pain

Sciatica

Surgery

General MSKpainKnee pain

Shoulder pain

Wynne-Jones et al 2010

Rates of certified absence for musculoskeletal pain

Lewis et al 2015

Health and work

• Work is generally good for physical and mental health and well-being

• Prolonged sickness absence is generally bad - the longer the duration of absence the more entrenched incapacity becomes

MSK pain

Primary care consultation

Work absence

Intervention to address occupational issues

Faster return to work? Fewer absences?

The problem…..

The key challenge

How to help people with MSK pain to stay at or return to work?

EARLY and BRIEF intervention in primary care

• To test the effectiveness and cost-effectiveness of adding an early VA service to best current primary care for adults with MSK pain

• Key outcomes: Days lost from work andFit Notes– Patient questionnaires– Medical record data

Bishop A et al. Rationale, design and methods of the Study of Work and Pain (SWAP): a cluster randomised controlled trial. ISRCTN 52269669. BMC Musculoskelet Disord 2014;15:232. doi: 10.1186/1471-2474-15-232.

The Study of Work And Pain (SWAP) cluster randomised controlled trial of a vocational advice service

Cluster RCT designs

Hemming K et al. BMJ 2015

6 General practices

338 patients

Participants eligibility criteria

Inclusion criteria Exclusion criteriaAdults consulting with MSK pain in primary care

Serious pathology requiring urgent medical attention

Currently in employment but…

Unable to read and speak English

- absent from work or - struggling at work

Serious mental health problems for whom participation in the study would be detrimental (at the discretion of the GP)

- sickness absence < 6 months

Pregnant or on maternity leave

Interventions: Best current care

• Evidence update session for GPs - best current care for the management of MSK pain and work

• Key messages:– Work is usually good for people with MSK pain– Long periods of absence can be harmful– MSK pain can often be accommodated at work– Planning and supporting RTW are important in good

clinical management• All usual health care continued (data collected)

Clinical Red Flags

Clinical Yellow Flags

Occupational Blue Flags

Occupational Black Flags

Organic pathologyConcurrent medical problems

Iatrogenic factorsBeliefsCoping strategiesDistressIllness behaviourWillingness to change

Family reinforcementWork statusHealth benefits and insuranceLitigation

Work satisfactionWorking conditionsWork characteristicsSocial policy

Biomedical factors

Psychological or behavioural factors

Social and economic factors

Occupational factors

Kendal et al 2009: Tackling musculoskeletal problems: a guide for the clinic and workplace—identifying obstacles using the psychosocial flags framework

Interventions: Vocational advice

Interventions: Vocational advice

Target obstacles to RTWSet new date for RTW

Targeted adviceContact workplace

Involve other servicesSet new date for RTW

Address unhelpful beliefs about working with MSK painDiscuss obstacles to RTW

Set date for RTWRTW

RTW

Step 1:

ALL

Step 2:

not RTW

Step 3:

not RTWRTW

Target obstacles to RTWSet new date for RTW

Targeted adviceContact workplace

Involve other servicesSet new date for RTW

Address unhelpful beliefs about working with MSK painDiscuss obstacles to RTW

Set date for RTWRTW

RTW

Step 1:

ALL

Step 2:

not RTW

Step 3:

not RTWRTW

Interventions: Vocational advice

Delivery of the vocational advice service

Delivered by 3 physiotherapists All experienced MSK physiotherapists Not delivering traditional physiotherapy treatments

Participated in a training programme with further mentoring 4 day training programme, followed by 1 day refresher Monthly mentoring sessions with experts and peers to

discuss individual cases VA service offered from participating GP practices

Feedback about patient cases from VAs to referring clinicians

Outcome measuresPrimary Days off work over 4 months

Secondary Self-reported time off work GP certified time off work Self-efficacy to return-to-work Pain intensity Bothersomeness Global assessment of change Work performance

Powered to detect at least a mean difference of 10 days off work between intervention and control330 participants (165 per arm)

Taking into account clustering and loss to follow-up

Sample size

Wynne-Jones G, Artus M, Bishop A, Lawton SA, Lewis M, Jowett S, Kigozi J, Main C, Sowden G, Wathall S, Burton AK, van der Windt DA, Hay EM, Foster NE; SWAP Study Team. Effectiveness and costs of a vocational advice service to improve work outcomes in patients with musculoskeletal pain in primary care: a cluster RCT (SWAP trial ISRCTN 52269669). Pain. 2018 Jan;159(1):128-138. doi: 10.1097/j.pain.0000000000001075.

Recruitment and follow-up

338 participants recruited(158 intervention arm: 180 control arm)

4 months: 79%12 months: 72%

Baseline characteristics

Measures Intervention ControlAge (mean, SD) 49.5 (9.6) 47.9 (10.7)Gender (n, %)

FemalesMales

89 (56%)69 (44%)

106 (59%)74 (41%)

NRS pain (mean, SD)

Working full-time (n, %)

Days off work (past 12 months), mean (range)

5.5 (1.9)

111 (71%)

15.0 (0-147)

5.4 (1.8)

122 (68%)

17.8 (0-252)

Vocational advice service

Face to face contacts ≥1 = 9%Median (IQR) contact time

= 60 mins (35.0, 63.5)

Workplace visit ≥1 = <1%

Telephone contacts ≥1 = 90%Median (IQR) contact time = 13.3 mins (10.0, 20.0)

RTW

RTW

Step 1:

Step 2:

Step 3: RTW

Days off work

Intervention Control Incidence rate ratio

Days off work over 4 months

(mean, SD)

9.3 (21.7) 14.4 (27.7) 0.51 (0.26, 0.99) p=0.048

Self-certified days absence (mean, SD)

0.85 (4.11) 0.95 (3.81) 1.114 (0.50, 2.56) p=0.759

GP-certified days absence (mean, SD)

8.4 (21.0) 13.5 (27.5) 0.66 (0.46, 0.94) p=0.020

Secondary outcome measures

Intervention Control MD† /OR‡

(95% CI)P-

value

4 months

Stanford Presenteeism Scale, mean (SD) 19.1 (5.9) 21.3 (5.4) 2.23† (0.35, 4.10) 0.020

Self-efficacy – Return to Work, mean

(SD)

81.5 (26.8) 70.1 (27.2) 11.4† (2.97, 19.8) 0.008

Satisfaction with work, mean (SD) 6.4 (2.8) 6.0 (2.3) 0.38† (-0.45, 1.20) 0.369

Performance at work, mean (SD) 4.1 (2.8) 5.1 (3.0) -1.05† (-1.96,-0.14) 0.023

12 months

Stanford Presenteeism Scale, mean (SD) 22.0 (5.6) 20.1 (5.7) 1.89† (-0.24, 4.03) 0.082

Self-efficacy – Return to Work, mean

(SD)

82.6 (27.1) 73.7 (24.1) 8.91† (0.04, 17.8) 0.049

Satisfaction with work, mean (SD) 6.2 (2.6) 6.1 (2.3) 0.06† (-0.83, 0.95) 0.894

Performance at work, mean (SD) 3.4 (3.1) 4.6 (2.9) -1.11† (-2.12,-0.09) 0.032

Cost effectiveness analysis and cost benefit analysis

Analysis method Result

Cost saving £7.20 per sick day avoided

Net societal benefit £763 in favour of VA service

Return-on-investment £49 for every £1 invested

CEA – based on the net monetary benefit (NMB) * Incremental days off work estimated controlling for group and GP Clustering using a GLM regression model, assuming a Gaussian Variance function, an identity Link Function, and clustered standard errors

Qualitative results: GPs

• GPs felt that VAs could provide an alternative way of managing patients with complex work related difficulties, but there was a lack of interaction and engagement between GPs and VAs, and GPs felt the timing was too early for some patients.

I think that’s what really comes over as being very useful, is that they have time to discuss things. I mean we have 12 minutes and it’s really not long enough for people to express their concerns really. (GP 8)

…If you’re only referring one (patient) every 3 or 4

weeks you’re not that confident about what the

service can do…you’re not getting that kind of

feedback. When you start referring a few more you see

that there is positive benefits to it (GP 5)

Qualitative results: VAs

• VAs also noted a lack of interaction with GPs. Early referral to the service meant VAs felt that their skills could not be adequately deployed with some patients, and when they felt unable to help they reverted back to their physiotherapist role.

But I think you do go back to your comfort zone. I just know physio and I know I'm happy with that and I can see the benefit of it. This is such a new role that that’s difficult to see sometimes (QVA3 6 months)

But we also have to demonstrate that we’re adding value to their patients which is difficult to do when the patient is being referred so early down the line… So the difficulty is weeding out those who really need the advice and adding value really to the service itself because essentially if we’re just contacting patients who have already put together a (return-to-work) plan we’re not going to be adding value. (QVA3 6 months)

Qualitative results: Patients

• Patients also reported that the timing of referral was important and where this timing was appropriate they felt that there were real benefits to the service.

I can see obviously it would be of tremendous

help to some people [right]. I think I was quite

lucky that although I’ve got a long term problem

it’s not unmanageable, do you know what I mean?

(Patient 34)

So it was good to have the phone call support, which

was more independent, because that was over the telephone and I felt that he was looking after my best interests rather than work’s. The occupational health lady was looking after work rather than….

(Patient 338)

Qualitative results: Patients

• Patients also reported that the timing of referral was important and where this timing was appropriate they felt that there were real benefits to the service.

You felt that you’d got somebody else on your side, and [yeah] supporting you, really, because, you know, if you’ve got a broken arm they can see it, it’s in a cast and whatever, whereas, you know, they do say a lot of people ‘put on’ the fact that they’ve got back pain, depression, or whatever. (Patient 636)

Conclusions

• Adding an EARLY, BRIEF and LOW INTENSITY vocational advice service for adults with musculoskeletal pain in primary care was associated with significantly fewer days absent over 4 months

• Referral to the vocational advice service was associated with greater economic benefits than best current care alone

• The intervention appeared to improve return to work self-efficacy, presenteeism and performance at work

Key messages 1

• We can offer early and low intensity advice and support– In ways that provides reassurance, supports self-

management and engages individuals in a return-to-work plan

• Those with long-term conditions and/or long-standing work difficulties were felt to particularly benefit (data from the interviews)

• Promising strategy that can reduce days lost from work and increase patients confidence in managing their MSK pain at work

Key messages 2

• Work is part of life for most of us, and integrating work into healthcare consultations has been shown more broadly to have positive effects for individuals, health and societal systems

• Early, primary care orientated initiatives that help people stay in the workforce with their health conditions need to be developed and tested

Further research

iSWAP study• Developing the vocational advice training into an online

course• Testing this with First Contact Practitioners (FCPs)• Funded by the Joint Health and Work DepartmentWAVE trial• Adapting the vocational advice service so it is suitable for

many more patients consulting in primary care with health conditions affecting their ability to work

• Aims to provide good quality advice and support for return to work to patients before their work absence becomes long-term

• Trial funded by NIHR HTA, 2019-2024

.

Acknowledgments

Patients and GP practices.Vocational advisors.SWAP study team: Nadine Foster, Majid Artus, Annette Bishop, SarahLawton, Martyn Lewis, Sue Jowett, Jesse Kigozi, Chris Main, Gail Sowden,Simon Wathall, Kim Burton, Danielle van der Windt, Elaine Hay, RuthBeardmore, Tom Sanders, Bie Nio OngFunding: This presentation presents independent research funded by the NationalInstitute for Health Research (NIHR), under its Programme Grants for Applied Researchfunding scheme: “Optimal management of spinal pain and sciatica in primary care”(NIHR-RP-PG-0707-10131). The views expressed are those of the authors and notnecessarily those of the NHS, the NIHR or the Department of Health

Contact: g.wynne-jones@keele.ac.uk

Thank you

Research Institute for Primary Care and Health SciencesDavid Wetherall Building Keele University Newcaslte-under-LymeST5 5BG Tel: 01782 733905Fax: 01782 734719www.keele.ac.uk/pchs