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Special Edition | August 2016
How to increase work participation in mentally ill employees? How to search for prognostic studies? … and much more in our special edition newsletter

This year two large international insurance medicine conferences took place within a short period of time. At the end of May the tri-annual ICLAM conference took place in Maastricht, and only three weeks later the bi-annual EUMASS conference was held in Ljubljana. Many CIM members attended the conferences and were positively surprised by the interest in evidence-based insurance medicine and the many systematic reviews reported on during EUMASS both in plenary and special sessions.
In this special edition of our Newsletter we summarized the findings of the systematic reviews presented at the conferences and provided a link to the abstract or full-article where available. For a better understanding, we compiled a glossary with epidemiological terms.
Picture: Workshop at ICLAM introducing Cochrane Insurance Medicine


Systematic reviews on return to work, ICF and work participation at the EUMASS conference

This year’s EUMASS conference was held jointly with the International Congress of Medical Assessors, hosting over 660 European participants. Below we present systematic reviews on sick leave, return to work, and instruments for practitioners which were presented at the conference.

1. Enhancing work participation in chronically-ill employees. A systematic review of reviews.* Employees with chronic diseases have problems in performing physical tasks (like heavy lifting) or coping with psychological factors (like stress or night shifts) at work. The interventions in the nine systematic reviews focused on changes at work, such as changes in work organisation, working conditions and work environment to improve work participation. Three reviews reported beneficial effects of the intervention on first return to work (RTW) (HR: 1.55, 95%CI: 1.32-2.16), higher RTW rate (OR: 2.2, 95%CI: 1.04-4.80), faster RTW (OR: 1.9, 95%CI: 1.18-3.10), maintaining employment (OR: 0.58, 95%CI: 0.34-0.99) and increasing employment rate (OR: 5.61, 95%CI: 2.23-14.09). Hence, work-directed interventions can be considered effective to increase work participation in the chronically ill.
(Vooijs, M. et al. Interventions to enhance work participation of workers with a chronic disease: a systematic review of reviews)
2. Personal and activity-related factors are associated with return-to-work after traumatic or non-traumatic brain injury. A systematic review.*
Little is known about prognostic factors facilitating or impeding return to work for patients with acquired brain injury. This review on 27 studies examines the impact of personal and activity-related factors.  This study provides strong evidence that personal factors (like education level) after traumatic brain injury and activity-related factors after non-traumatic brain injury are significantly associated with RTW. After traumatic brain injury, level of education proves to be significantly associated with RTW. High school graduates are 2.3 times more likely to RTW than non-graduates. The odds of not being competitively employed post-injury were significantly higher for individuals with less than high school pre-injury than for those with at least high school education (OR 2.34, 95% CI 1.86–2.94). In patients after non-traumatic ABI, activity-related factors show a significantly positive association with return to work.
(Donker-Cools, B. et al. Prognostic factors of return to work after traumatic or non-traumatic acquired brain injury: a systematic review)
3. An overview of ICF-based measurement tools (preliminary results)
Work disability assessment keeps shifting from a compensation driven to a participation driven approach. Many assessment instruments based on the WHO’s ICF framework exist, but a comprehensive overview is missing. This systematic review identified 24 ICF-based instruments in 160 studies, 5 focused on a specific setting (e.g. work, disability assessment), 9 were disease specific (e.g. stroke, head and neck cancer and 9 were generic measures of participation or functioning. This overview can help professionals and researchers choose an appropriate measurement tool of function.
(Luijters, K. et al. A systematic review of existing ICF-based instruments measuring functioning and/or participation. Towards an evidence-based assessment. unpublished)
4. A Pubmed filter for prognostic studies in work disability evaluation
In the field of work disability, complex prognostic predictions require complex search strategies to identify relevant evidence. This study developed and evaluated a comprehensive and efficient search strategy in PubMed that may be used by researchers or practitioners to identify relevant studies. The result is the Work Disability Prognosis filter designed to find prognostic studies in the area of work disability evaluation. The filter is available here.
(Kok R, Verbeek JA, Faber B,. et al. Searching PubMed to identify studies on the prognosis of work disability)
5. Reintegration of the mentally-ill through combined (vocational) interventions. Protocol of a network-meta-analysis.*
In people with severe mental illness, unemployment and work disability are common despite their desire to obtain employment. There has been a shift in reintegrating those people into the labour market – decades ago through prevocational training, nowadays through vocational rehabilitation. This network meta-analysis will assess the effects of vocational rehabilitation interventions on obtaining and maintaining competitive employment in adults between 18 and 70 years with severe mental illness. The authors define severe mental illness e.g. as schizophrenia, bipolar disorder, personality disorder, severe anxiety disorder, PTSD, or major depression. Study participants should be unemployed due to severe mental illness. The meta-analysis will include trials of all types of vocational rehabilitation compared to each other or to no intervention or medical care only.
(Suijkerbuijk, Y. et al. Interventions for obtaining and maintaining employment in adults with severe mental illness, the protocol of a network meta-analysis)
(Source: EUMASS-Programme)

Picture: Members of the EUMASS council and of Cochrane Insurance Medicine
Bert Cornelius (NL), Gert Lindenger (S), Kristina Alexanderson (S), Sandra Brouwer (NL), Wout de Boer (CH), Rebecca Weida (CH), Anette de Wind (NL), Regina Kunz (CH), Rob Kok (NL), Frederieke Schaafsma (NL), Emilie Friberg (S), Jean Pierre Bronckaers (BE), Marjan Rus (SLO)

Evidence-based underwriting, credibility of evidence  and chronic pain after breast cancer surgery at this year's ICLAM-conference

Is evidence-based underwriting the future of underwriting? Insurance physicians in the ICLAM community are examining the credibility of evidence, are reviewing the use of evidence in the process of underwriting and the notion of evidence-based underwriting seems to gain ground. While systematic reviews and meta-analysis were rather low in numbers, the use of scientific evidence received substantial attention in both plenary sessions and other presentations at this year’s ICLAM conference in Maastricht, the Netherlands.
Summary: Chronic pain after breast cancer surgery
The review includes 30 cohort and case–control studies that explored risk factors for persistent pain after breast cancer surgery. The 10-year survival rate for breast cancer patients is 83%, but up to 60% of women who undergo surgery to remove their tumor develop chronic pain.
High-quality evidence showed increased odds of persistent pain with younger age (OR for every 10-yr decrement 1.36, 95% confidence interval CI 1.24–1.48), radiotherapy (OR 1.35, 95% CI 1.16–1.57), axillary lymph node dissection (OR 2.41, 95% CI 1.73–3.35) and greater acute postoperative pain (OR for every 1 cm on a 10-cm visual analogue scale 1.16, 95% CI 1.03–1.30)
The analysis found that women who undergo surgery for breast cancer have a 21% increase in the risk of chronic pain if surgeons cut through nerves when performing axillary lymph node dissection to remove their tumor.

(Source: ICLAM-Programme)

Picture: CIM members and members of the ICLAM organising team
left to right: Rebecca Weida (CH), Jan Buitenhuis (NL), Regina Kunz (CH), Detloff Rump (HK), Jan Bronsema (NL), Kristina Alexanderson (SE), Fabrice Chouty (FR), Jan Hoving (NL)

 * Terminology

A systematic review is a literature review that uses a systematic approach to collect and critically analyse multiple research studies.

A network meta-analysis provides a global estimate of comparative treatment effectiveness combining both direct and indirect evidence.

Overviews of reviews are done in areas with multiple systematic reviews addressing the effects of two or more interventions applied for a single condition or health problem.
An Odds Ratio (OR) is a measure of association between an exposure and an outcome. The OR represents the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. If the OR is above 1 it means there is a positive relationship between the exposure and the outcome, if it lies below 1 this means there is a negative relationship. E.g. if examining chances of return to work if exposed to an intervention and the OR is 2.0, this means the chances of return to work are 2 times higher with this intervention. If the OR in this example was 0.5 then the chances of return to work were decreased by 50% by the intervention.
Hazard Ratio (HR) is commonly used when presenting results in clinical trials involving survival data, and allow hypothesis testing. They should not be considered the same as relative risk ratios. A hazard is the rate at which events happen, so that the probability of an event happening in a short time interval is the length of time multiplied by the hazard. Although the hazard may vary with time, the assumption in proportional hazard models for survival analysis is that the hazard in one group is a constant proportion of the hazard in the other group. This proportion is the hazard ratio.
Confidence Interval (CI) is an estimate interval. The value of your e.g. OR or HR will lie between the lower and upper value of the CI. The percentage in front of the CI indicates within which values X% of random samples you take in the future will lie. E.g. if you have a 95% CI interval, then 95% of the samples taken in the future will lie within the same interval. Moreover, the closer the upper and lower value are to each other, the more reliable is the value of the OR, HR or any other ratio.

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Our next newsletter will be published in November 2016.

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Cochrane Insurance Medicine · asim / University Hospital Basel · Petersgraben 4 · Basel 4055 · Switzerland

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