Health care interventions in case of long-term sick leave

A systematic review and assessment of medical, economic, social and ethical aspects

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SBU Assessment

Presents a comprehensive, systematic assessment of available scientific evidence for effects on health, social welfare or disability. Full assessments include economic, social and ethical impact analyses. Assessment teams include professional practitioners and academics. Before publication the report is reviewed by external experts, and scientific conclusions approved by the SBU Board of Directors.

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Published: Report no: 359 Registration no: SBU 2021/89 ISBN: 978-91-987553-3-6 https://int.sbu.se/359e

Conclusions

  • Unimodal and multimodal interventions and interventions that involve workplace contact or coordination activities towards the workplace may have a positive effect on return to work in the short time perspective (up to 12 months) for persons on sick leave for mental or musculoskeletal disorders. The certainty of the evidence was assessed to be low. It was not possible to estimate the size of the effect.
  • It was not possible to determine the effect on return to work for interventions targeting health care professionals or health care organizations. The certainty of the evidence was assessed to be very low.
  • It was not possible to determine intervention effects on return to work in the long-time perspective for any type of intervention. The certainty of the evidence was assessed to be very low.
  • It was not possible to determine the effect of interventions on participants’ health or function for any type of intervention. The certainty of the evidence was assessed to be very low.
  • It was not possible to determine the effect on return to work, health or functioning for persons on sick leave for breast cancer diagnosis.
  • There were no studies investigating return to work interventions for patients on sick leave for post covid or bipolar disorder.

Background

Persons on long term sick leave (defined as longer than 3 months) may benefit from interventions facilitating return to work.

Aim

The aim of this systematic review was to evaluate effects of interventions that may be initiated within the health care system. The primary outcome of interest was return to work. Secondary outcomes included intervention's effects on health and functioning. The aim was also to examine the cost-effectiveness of the evaluated interventions, highlight ethical aspects and identify scientific evidence gaps to guide future research.

Method

A systematic review was conducted in accordance with the PRISMA statement. The protocol is registered in Prospero (CRD42022315330). The certainty of evidence was assessed with the GRADE framework. Studies considered for inclusion were targeting populations on sick leave due to the most common diagnoses for long term sick leave based on Swedish statistics. All types of interventions were considered and were characterized as unimodal (one treatment), multimodal (several treatment modalities), intervention including workplace contact or workplace coordination, and interventions aiming at health care personnel /organizations.

Results were summarized for short time (≤12 months) and long-time (>12 months) effects on return to work. Effects on health and/or function were assessed regardless of follow-up time.

Effects on costs and cost effectiveness were assessed based on results in included studies.

Ethical analysis was performed by the project group, which included an academic scholar in ethics. The method was mainly based on discussion, aimed at identifying conflicts of interest between different agents involved, and potential ethical dilemmas.

Inclusion criteria:

Population

Persons on sick leave for a condition that is common when on long term sick leave according to Swedish statistics.

Intervention

Any intervention that could be initiated within health care practice with the overall aim of facilitating return to work. Interventions could be unimodal or multimodal. Furthermore, it could be collaborative with other organisations, such as employer, occupational health care, or social insurance agency.

Control

Any control, which could be no treatment, treatment as usual, wait list or other active treatment.

Outcome

Primary: measures of sick leave, work participation and/or return to work.

Secondary: measures on health and or functioning.

Health economic outcomes: effects on cost and cost effectiveness

Study design

Randomized controlled studies, including cluster randomized studies.

Other criteria

At least 6 months follow-up.

We performed risk of bias assessments and included studies with low or moderate risk of bias in the analysis.

Due to extensive heterogeneity, we performed a synthesis without meta-analysis investigating effects for each intervention category (unimodal, multimodal, workplace contact or coordination, and interventions targeting heath care staff) and study populations on sick leave for mental disorder, musculoskeletal disorders, or both.

Language: English, Swedish, Norwegian or Danish.

Search period: From 2000 to 2022. Final search May, 2022.

Databases searched: Cochrane Library, EMBASE, PsycINFO (EBSCO) and Medline.

Client/patient involvement: No

Results

We included 95 articles based on 68 unique studies. A total of 40 000 persons were evaluated for the return-to-work outcome. We included 10 studies that evaluated effects on costs and cost effectiveness.

Most of the studies included did not report significant findings on return to work.

We found low certainty evidence that unimodal, multimodal and workplace/coordination interventions may improve return to work.

Table 1 Summarized results of interventions having positive effects for populations with mental or musculoskeletal disorders as compared to treatment as usual.
RTW = return to work; short = short period, 12 months or shorter; long = long period, longer than 12 months; HoF = Health or functioning.
⊕◯◯◯ = very low certainty, the effect is uncleart; ⊕⊕◯◯ = low certainty, the intervention may have a positive effect; Green colour = Positiv effect of the intervention; Orange colour = Unclear effect of the intervention
    Population
    Mental or muskuloskeletal disorder Mental disorder Muskuloskeletal disorder
Outcome RTW short RTW
long		 HoF RTW short RTW
long		 HoF RTW short RTW
long		 HoF
Type of intervention Unimodal intervention ⊕⊕◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕⊕◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯
Multimodal
intervention		 ⊕⊕◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕⊕◯◯ ⊕◯◯◯ ⊕◯◯◯
Coordination/
Workplace intervention		 ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕⊕◯◯ ⊕◯◯◯ ⊕◯◯◯
Interventions targeting health care personnel ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯ ⊕◯◯◯

Health Economic Assessment

Ten studies evaluating intervention effects on costs or cost effectiveness were included. It was not possible to assess overall effects based on categories of intervention types, due to the low number of studies in each category. It was concluded that also a small positive effect on return to work (> 5 days relative reduction in one year per person), would result in positive effects on a societal level.

Ethics

The practice of sick leave and return to work is a complex ethical situation where patients may be vulnerable in terms of reduced autonomy and integrity.

Discussion

Despite lots of well conducted research, few studies presented robust support of the relative effectiveness of the investigated intervention. Our results are in line with other systematic reviews in the area. We advise that well conducted research studies with positive findings is replicated in future research. There is a need present outcomes and results in a way that makes it possible to perform meta analyses.

Conflicts of Interest

In accordance with SBU’s requirements, the experts and scientific reviewers participating in this project have submitted statements about conflicts of interest. These documents are available at SBU’s secretariat. SBU has determined that the conditions described in the submissions are compatible with SBU’s requirements for objectivity and impartiality.

The full report in Swedish

The full report in Swedish, Insatser i vården vid långtidssjukskrivning

Project group

Experts

  • Professor Gunnar Bergström. University of Gävle
  • Assistant/Associate Professor Emilie Friberg. Karolinska Institutet
  • Dr Therese Eskilsson. University of Umeå
  • Assistant/Associate Professor Sara Holmberg. Linneaus University
  • Assistant/Associate Professor Lars Lindblom. University of Linköping

SBU

External reviewers

  • Henna Hasson, professor, LIME, Karolinska institutet, Swedan
  • Sigmund Østgård Gismervik, associate professor, NTNU, Norway.

Flow Chart

Figure 1 Flow Chart

 

 

Figure 1 Flow Chart

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