Early identification and intervention in patients with MSK ... · The University of Sydney . Page 1 . Early identification and intervention in patients with MSK injuries in workplace

The University of Sydney Page 1

Early identification

and intervention in

patients with MSK

injuries in workplace

Presented by

Professor Michael Nicholas, PhD Director, Pain Education and Pain Management Programs

Pain Management Research Institute

Kolling Institute of Medical Research

University of Sydney and Royal North Shore Hospital


2

Main Collaborators/Research Team

Dr Garry Pearce, Dr Mick Gleeson, Dr Rafael Pinto,

Dr Dan Costa

Karen Munk, Tamara Sprod, Rachel Elmes, and

Claims managers & staff at EML

Robert Lloyd, Susan Rafty

Michele Murphy and RTW coordinators at each

hospital

International and Australian partners: Steven Linton (Sweden); William Shaw (USA); Chris

Main (UK); Rob Smeets (Netherlands); Chris Maher (USyd); James McAuley (UNSW); Fiona Blyth

(USyd); Andrew McGarity (NSW Fire & Rescue)


General agreement that work is good for your health

3

Australasian Faculty of Occupational &

Environmental Medicine (AFOEM) Royal Australasian College of Physicians

Consensus Statement (2011)

• Work is generally good for health and wellbeing …

• Long term work absence, work disability and unemployment

generally have a negative impact on health and wellbeing


More time off = higher risk of no RTW 4

• The longer an injured worker is away from work, the

less their chances of RTW

• Australian data: the chance of ever RTW after a

workplace injury are: 70%

• 70% if off for 20 days

• 50 % if off for 45 days

• 35% if off for 70 days 35%

20 45 70 Days

Johnson D, Fry T. Factors Affecting Return to Work after Injury: A study for the Victorian

WorkCover Authority. Melbourne. Melbourne Institute of Applied Economic and Social

Research; 2002

50%


5

Common RTW rate after back injury (Henschke et al, BMJ, 2008)

6 wee

ks

3 mon

ths

6 mon

ths

9 mon

ths1 y

ear

Cum

ulat

ive

prob

abili

ty o

fre

duce

d w

ork

stat

us

0.2

0.4

0.6

0.8

1.0 • Vast majority not a

problem

• But for a small

proportion, little

change after 3mths


6

Increased risk for delayed RTW after injury – 2008

Biological • Serious pathology (injury requiring surgery)

Psychosocial (Personal and environmental factors)

• Depression • PTSD • Unhelpful (eg. avoidant) coping

strategies (eg. resting) • Emotional distress • Passive role in recovery

• Perceived low social support at wk • Perceived unpleasant work • Low job satisfaction • Perception of excessive demands

Systemic/context

(Main, Sullivan, Watson, 2008)

• Legislative criteria for compensation • Nature of workplace (eg. heavy work) • Compensation system


Selecting high psychosocial risk patients vs no selection (RCTs from 2000) (Nicholas et al., Physical Therapy, 2011)

Study Intervention & Outcomes (bold) Comment

Linton & Andersson, 2000

6 x 2-hr grp sessions with Clin. Psychologist + Rehab > Information + Rehab (on lost time from work) +

Loisel et al., 2002

All interventions achieved gains, but comprehensive ‘Sherbrooke’ model (combined occupational and clinical interventions) had fewer days on benefits. (RTW) +

Van den Hout et al. 2003

Graded activities (behavioural principles) + problem-solving training > Graded activities + education (on longer-term work status) +

Gatchel, et al . 2003

‘high risk’ acute patients in functional restoration group (CBT approach) >a treatment-as-usual group. (on indices of disability; work, healthcare utilization, medication use and self-reported pain). +

Linton et al., 2005 CBT grp = CBT + exercise grp >> minimal tmt grp (examination, reassurance, advice on activities). (lost time) + Schiltenwolf et al., 2005

The addition of the behavioural therapy for dealing with stress and problems generally seems to have added significantly to exercise/activity program. (Lost time) +

Verbeek et al., 2002 Many similarities in content of control grp and treatment grp. No difference between grps on disability & RTW outcome (both improved). (-) Low distress in initially

Jelema et al., 2005 Psychosocial intervention = standard care (both by GP only) (on disability) (-) Low risk factors initially

Hay et al., 2005 CBT (pain management) and manual therapy (+ home exercise) achieved similar results (disability) (-) Low distress initially

Sullivan et al., 2006

Psychosocial risk factors reduced in both groups (Physio + CBT vs Physio only), but catastrophizing reduced more in combined group. Combined group had better RTW 4-wks after end of treatment.

+ Reduced catastrophizing associated with better outcomes


Implications of early intervention trials

• Low psychosocial risk factors, usual care sufficient

(Usual care seems effective in “uncomplicated cases of LBP” – Jallema et al., 2006)

• High psychosocial risk factors, need to target these aspects more than usual care

• So, you don’t have to intervene early in most cases • Just those in higher risk category • But, you have to identify them


9

To identify high risk cases:

Brief OMPSQ - developed and published 2011

• 24-item version promoted by WorkCover since 2005 • New version: 10-items • High correlation with long form of OMPSQ (24 items) • Scores > 50 able to predict 85% long-term sick leave

within next year


But problem of delayed RTW not just to do with

injured worker – the workplace important too

Supporting evidence strongest for treatment providers engaging with workplace – RTW as part of treatment, not after treatment


More recent systematic review (2017) similar to

Franche et al (2005), but stronger evidence (more than

just the worker)

Strong level of evidence for multidomain interventions (service coordination, work modification and improving worker health) for reducing lost time from injuries. Moderate level of evidence for improving work functioning after RTW and reducing costs

Recommendation:

Implement a multi-domain intervention to help reduce lost time for MSK and pain-related conditions.


What does that look like? [Cullen, Irvin, Collie, et al. JOOR 2017]


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New study (WISE) launched mid-2013

• Soft-tissue injuries account for a significant proportion of workers compensation injuries (53% for 2011–12).

• For NSW Health (69% for 2011–12). • Vast majority RTW rapidly, but those who don’t = higher

costs • NSW Health’s 2012–13 workers compensation premium

increased by $24m to $181m (15%) A key reason: Increased time away from work!

Background - in NSW


Key feature of the WISE study

• It was not about treatment as such

• But a protocol for stratified responses to

workplace injuries

• Theoretical basis in implementation science

The Consolidated Framework For Implementation Research (CFIR) (Damshroder et al., 2009)


Using Damshroder’s

framework with

Cullen et al. findings

Workplace: Managers,

Supervisors, RTW Co-

ordinators, Workplace

Culture

Treatment

providers

Insurer:

Managers; Claims

Managers,

Claims Culture

Legislation,

Regulators (SIRA, icare)

Society/Government

Injured worker


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• The statutory organisation responsible for public sector workers compensation in NSW (icare) (under Ministry for Finance, Services & Property)

• The regulator (was Workcover, now SIRA) • The employer (NSW Health + Hospital management),

with support from Unions • The Insurance agent (EML) – managers, claims teams • Individual psychologists (recruited for study) • Independent occupational physicians • Independent specialist physiotherapist • General Practitioners (for each injured worker)

Framework for the WISE Study: we engaged


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1. Time lost from work over two years post-injury

2. Cost of claims

Primary outcomes for WISE Study


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WISE Study : selection criteria

• Injured health workers • ‘Significant’ soft tissue injuries (work-related) • Off work with medical approval • No injuries that required surgery • Claim accepted by EML • Injured worker had to agree to participate

(voluntary) – explained by Claims manager • If agreeable, screening questions delivered over

phone within 7 days of injury • Screening (OMPSQ-10: Linton et al., Spine 2011),

cut off: scores >50/100


Eligible

claims

Eligible

claims

High-risk Low-risk

< week 1

24 mo

Time

Intervention

Protocol

Standard

Care

12 & 24

mo follow-

up

12 & 24

mo follow-

up

Intervention Hospitals Control Hospitals

High-risk Low-risk

Standard

Care (under 2008

guidelines)

Standard

Care

12 & 24

mo follow-

up

12 & 24

mo follow-

up

Study – plan


20

•

Intervention protocol for high risk cases only

1. Usual treatment by GP, physio, etc (no one denied)

2. Plus:

Regular liaison: GP, Claims Manager

Assessment by

psychologist

Treatment by

psychologist

Case conference if not RTW

Week 1-2 Week 2-3 Week 3-8 Week 8-9

Review by Independent Occ Physician

Review by Independent Physio (prn)

Workplace responses

IW meets with RTWC at workplace


Characteristics of injured workers studied

0

5

10

15

20

25

30

35

40

Head & Face Trunk &Limbs

Neck &Upper Back

Back Lower Limbs Upper Limbs Other

Per

cen

tage

of

Tota

l

Body Parts

Main Injury Sites

TOTAL SCREENED = 580 Control Hospitals (6) = 214 Intervention Hospitals (11) = 366 High risk = 208 (35.9%) Ages: 23-75; Mean age: 45 Gender: Male 20%; female 80% (Health employees mostly women)


Distribution of OMPSQ-SF scores for Control Gp

(Paper under review)


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Screening with OMPSQ-SF = early detection of who is

likely to have more lost days: Control (usual care) Gp

Cut-off score > 50/100 predicted time off work, t(165)=4.78, p < .0005,

0

20

40

60

80

100

120

Mean d

ays

paid

High risk Low risk

[Note: only screened those who had stopped work, not all those with a claim]


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Psychologists’ outcomes?

(Average: 5 sessions; Average Cost: $1,004.00)

No longer in high risk range

OMPSQ-SF DASS BPI-I PSEQ PCS

[SMDs all in high effect range]


Ave. Days to Pre-Injury Duties (PID) (2 yr f/u)

>90 Days to PID • Intervention: 3/54 (5.5%) • Control: 11/57 (19.3%) - ‘Tail’ still wagging

0

10

20

30

40

50

60

70

80

90

Mean d

ays

paid

Control Intervention

Intervention: 31 days (SD: 116) Control: 66 days (SD: 37)


Ave. Costs by Month for WISE Protocol vs Usual care (out to

45 months) for High Risk Cases

0

1000

2000

3000

4000

5000

6000

7000

8000

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45

Dollars

Months of claim

Control Intervention


WISE Average Total Costs of Claims at 24-36 months

$0

$5,000

$10,000

$15,000

$20,000

$25,000

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Development Months

Control Total Average Intervention Total Average


Summary of overall outcomes

• Average savings (on total costs) at 2 years: 30%

Outcomes are not just about the numbers: • All Intervention sites wanted to maintain WISE protocol • Since June 2015, NSWHealth has implemented WISE

protocol across state for all public hospitals • In 2016 NSWHealth premiums declined


29

WISE study – key lessons: A system intervention

Key features:

• Use of agreed protocol (closely monitored /reinforced)

• Identify those at risk due to psychosocial factors

• Access to help for modifying these risk factors

• Coordinated support and input by all stakeholders

(insurer, workplace, health care providers, injured

workers)

In essence:

• Helping the injured worker and workplace (vs treating

the injury alone) – consistent with Cullen et al (2017)


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To describe it graphically But, if one player doesn’t do their bit ….???


31

Acknowledgements

Steve Hunt

John Roach

Hospitals and Area Health Management

Westmead Sutherland Dubbo Base

Blacktown Wagga Wagga Nowra

Mt Druitt Orange Base Sydney

Nepean St George Royal Hospital

St Vincents Prince of Wales for Women

Wollongong Royal Prince Alfred Broken Hill Base

Bega District

And, all those injured health workers who agreed to participate

Independent Physiotherapy Consultant: Dr Rob Boland

Research Assistant: Leigh-Anne Funnell

Documents

Early identification and intervention in patients with MSK ... · The University of Sydney . Page 1 . Early identification and intervention in patients with MSK injuries in workplace