New program reduces work disability from musculoskeletal disorders

A controlled trial comparing usual care for musculoskeletal disorders with a rheumatologist-administered program combining education with protocol-based clinical management shows that patients randomized to the intervention had significantly shorter lost work time due to disability and were much less likely to receive long-term disability compensation, Dr Lydia Abasolo (Hospital Clínico San Carlos, Madrid, Spain) and colleagues report in the September 20, 2005 issue of the Annals of Internal Medicine Each dollar the program cost saved $11.00, for a total net benefit in excess of $5 million.

“We found that patients on temporary work disability do not need brilliant diagnosis. They need a prompt functional recovery. For rheumatologists, this means trying to improve your clinical skills regarding specific exercises for different anatomical areas, aerobic exercises, and communication with the patient,” senior author Dr Juan A Jover (Hospital Clinico San Carlos) tells rheumawire.Fast, aggressive program gets patients back to workThis study included 13 077 patients from three health districts in Madrid, Spain. Patients were randomized to the intervention group (n=5272) or to the control group (n=7805). The study was not blinded. The musculoskeletal-disease-related causes of recent-onset temporary work disability included “all arthropathies, connective-tissue disorders, back disorders, soft-tissue rheumatisms, bone and cartilage disorders, musculoskeletal pain not caused by cancer, and nerve entrapment syndromes.” The study did not include patients with disability resulting from trauma or surgery.The intervention-group care was delivered by rheumatologists according to three-level clinical treatment protocols for low-back, neck, shoulder, arm and hand, knee, and foot pain. Patients who did not return to work or have substantial clinical improvement after a predetermined time at level-1 care were moved to upper levels for further diagnostic or therapeutic intervention. Most patients spent two to six weeks in level-1 care. Those who did not improve after level-2 care were examined for the presence of “psychiatric illness, family problems, sociolabor conflicts, unemployment, and occupational causes of disability.” At the first 45-minute visit, the intervention program included: “A specific diagnosis, reassurance that no serious disease was present, instructions on self-management, instructions on taking medications on a fixed schedule, and information on indications for return to work before complete symptom remission.” Self-care instructions included avoiding bed rest, promoting early mobilization of the painful regions, restrictions on the use of splint and neck collars, training in stretching and strengthening exercises, ergonomic care, and information on optimal levels of physical activity. Drug treatment for pain, inflammation, anxiety, and depression was given as defined in the protocols and included peripheral intra-articular and periarticular injections.Patients with more serious disability or pain received “immediate extra reassurance, information on pain-relieving positions, and a telephone call or second visit within 72 hours.” The control-group patients received standard care from a primary-care physician, who could call in specialty consults as needed and order routine laboratory tests and radiography. Some control-group physicians also had physiotherapists available.Mean follow-up time was 554 days for the intervention group and 555 days for the control group. Median duration of temporary work disability was about 39% less in the intervention group compared with the control group. Most patients in both groups returned to work within the first two months, but survival curves showed that patients in the intervention returned to work significantly sooner than controls. “Compared with a patient in the intervention group, a patient in the control group had twice the probability of receiving permanent compensation payments four years after the trial ended (p<0.01)," the authors write.Intervention saves millions in health costsThese differences had major economic implications that more than compensated for the cost of the program. Jover says that direct and indirect costs were both significantly lower in the intervention group, with the difference ranging from 58% to 88%, depending on the type of cost. The investigators estimate that every dollar invested in the program produced savings between $8 and $20 at the end of the second year, for a net benefit of over $5 million."We did not expect such a great response!" Jover says. "Our hypothesis was that the intervention would reduce the duration of temporary work disability episodes by 10%." Jover also says that the researchers were surprised to find relatively few malingerers in the program. "Many people warned us regarding 'cheaters' and 'disease simulators.' After only one week of running the program, we realized that this was a myth and that most patients had real health problems," he says.(Source: Abasolo L, Blanco M, Bachiller J, et al. A health system program to reduce work disability related to musculoskeletal disorders. Ann Intern Med 2005; 143:404-414: Joint and Bone: September 2005 Rheumawire.)