Effect of return-to-work coordination programmes for workers on sick leave

What is the aim of this review?

The aim of this review was to compare the effect of return-to-work coordination programmes to usual practice in workers on sick leave or disability.

Key messages

We found that return-to-work coordination programmes had no effects compared to usual practice on return-to-work outcomes. These outcomes were time to return to work, cumulative sickness absence, the proportion of workers at work at the end of the follow-up and the proportion who had ever returned to work. We found no benefits in the short term, long term or very long term.

We found only small benefits in patient-reported outcomes. All these effects were smaller than the so-called minimal clinically important difference.

What was studied in the review?

Returning long-term sick-leave workers back to work is important for society, employers and certainly for workers themselves. Possible interventions for this purpose are return-to-work coordination programmes, also described as case management or collaborative care. These programmes involve a number of health professionals collaborating with the workers to help them overcome their incapacity to work. Return-to-work coordination programmes vary in duration and design. In general, they include an assessment of the obstacles impeding a return to work and an individualised plan to eliminate barriers and return workers to employment. Treatment components may include counselling, physical or occupational therapy, and specialist care.

Return-to-work coordination programmes require substantial resources. However, it is uncertain how effective they are.

What are the main results of the review?

We included 14 randomised controlled trials involving 12,568 workers with musculoskeletal or mental health problems. Workers had to be on sick leave for a minimum of four weeks.

At short-term follow-up of six months, return-to-work coordination programmes may make little or no difference to time to return to work (low-quality evidence), probably make little or no difference to cumulative sickness absence (moderate-quality evidence), may make little or no difference to the proportion of participants at work at end of the follow-up (low-quality evidence). Finally, we are uncertain whether the programmes improve the proportion of participants who had ever returned to work as the quality of the evidence has been assessed as very low.

At long-term follow-up of 12 months, return-to-work coordination programmes may make little or no difference to time to return to work, cumulative sickness absence or the proportion of participants at work at end of the follow-up (all low-quality evidence) and they probably make little or no difference to the proportion of participants who had ever returned to work (moderate-quality evidence).

At very long-term follow-up of longer than 12 months, return-to-work coordination programmes may make little or no difference to time to return to work (low-quality evidence), probably make little or no difference to cumulative sickness absence (moderate-quality evidence), and may make little or no difference to the proportion of participants at work at end of the follow-up and to the proportion of participants who had ever returned to work (both low-quality evidence).

We found only small benefits in patient-reported outcomes including pain, ability to function, depression and anxiety. All these effects were smaller than the so-called minimal clinically important difference.

As we found so much low- and very low-quality evidence it means that new research is likely to change the results.

How up-to-date is this review?

We searched scientific literature until 1 November 2016.

Authors' conclusions: 

Offering return-to-work coordination programmes for workers on sick leave for at least four weeks results in no benefits when compared to usual practice. We found no significant differences for the outcomes time to return to work, cumulative sickness absence, the proportion of participants at work at end of the follow-up or the proportion of participants who had ever returned to work at short-term, long-term or very long-term follow-up. For patient-reported outcomes, we found only marginal effects below the MID. The quality of the evidence ranged from very low to moderate across all outcomes.

Read the full abstract...
Background: 

To limit long-term sick leave and associated consequences, insurers, healthcare providers and employers provide programmes to facilitate disabled people's return to work. These programmes include a variety of coordinated and individualised interventions. Despite the increasing popularity of such programmes, their benefits remain uncertain. We conducted a systematic review to determine the long-term effectiveness of return-to-work coordination programmes compared to usual practice in workers at risk for long-term disability.

Objectives: 

To assess the effects of return-to-work coordination programmes versus usual practice for workers on sick leave or disability.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), MEDLINE, Embase, CINAHL and PsycINFO up to 1 November 2016.

Selection criteria: 

We included randomised controlled trials (RCTs) that enrolled workers absent from work for at least four weeks and randomly assigned them to return-to-work coordination programmes or usual practice.

Data collection and analysis: 

Two review authors independently screened titles, abstracts and full-text articles for study eligibility; extracted data; and assessed risk of bias from eligible trials. We contacted authors for additional data where required. We conducted random-effects meta-analyses and used the GRADE approach to rate the quality of the evidence.

Main results: 

We identified 14 studies from nine countries that enrolled 12,568 workers. Eleven studies focused on musculoskeletal problems, two on mental health and one on both. Most studies (11 of 14) followed workers 12 months or longer. Risk of bias was low in 10 and high in 4 studies, but findings were not sensitive to their exclusion.

We found no benefits for return-to-work coordination programmes on return-to-work outcomes.

For short-term follow-up of six months, we found no effect on time to return to work (hazard ratio (HR) 1.32, 95% confidence interval (CI) 0.93 to 1.88, low-quality evidence), cumulative sickness absence (mean difference (MD) −16.18 work days per year, 95% CI −32.42 to 0.06, moderate-quality evidence), the proportion of participants at work at end of the follow-up (risk ratio (RR) 1.06, 95% CI 0.86 to 1.30, low-quality evidence) or on the proportion of participants who had ever returned to work, that is, regardless of whether they had remained at work until last follow-up (RR 0.87, 95% CI 0.63 to 1.19, very low-quality evidence).

For long-term follow-up of 12 months, we found no effect on time to return to work (HR 1.25, 95% CI 0.95 to 1.66, low-quality evidence), cumulative sickness absence (MD −14.84 work days per year, 95% CI −38.56 to 8.88, low-quality evidence), the proportion of participants at work at end of the follow-up (RR 1.06, 95% CI 0.99 to 1.15, low-quality evidence) or on the proportion of participants who had ever returned to work (RR 1.03, 95% CI 0.97 to 1.09, moderate-quality evidence).

For very long-term follow-up of longer than 12 months, we found no effect on time to return to work (HR 0.93, 95% CI 0.74 to 1.17, low-quality evidence), cumulative sickness absence (MD 7.00 work days per year, 95% CI −15.17 to 29.17, moderate-quality evidence), the proportion of participants at work at end of the follow-up (RR 0.94, 95% CI 0.82 to 1.07, low-quality evidence) or on the proportion of participants who had ever returned to work (RR 0.95, 95% CI 0.88 to 1.02, low-quality evidence).

We found only small benefits for return-to-work coordination programmes on patient-reported outcomes. All differences were below the minimal clinically important difference (MID).

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