Kate Radford return to work

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Return to work after TBI; a cohort study

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Kate Radford return to work

  1. 1. Return to work after Background Traumatic Brain Injury (TBI): • Evidence-based practice is intrinsic to modern healthcare A cohort comparison delivery and in recognition of this building research evidence Kate Radford PhD • Development of Occupational Therapy interventions has been Associate Professor in Rehabilitation Research identified as a major research priority for the profession (COT University of Nottingham 2007). Phillips J1, Drummond A1, Walker MF1, Sach T 2, Tyerman A3, • Occupational Therapy is a complex intervention (Creek 2003) Haboubi N4, Jones T 5 and evaluating it is not straight forward. 1University of Nottingham, 2University of East Anglia, 3Cambourne Centre, Aylesbury, 4Nottingham University Hospitals, 5Service User, Nottingham College of Occupational College of Occupational Therapists Therapists MRC guidelines 2000 MRC guidance 2008 Sequential phases of developing randomised controlled Key elements of the development and evaluation process trials of complex interventions. Campbell M et al. BMJ 2000;321:694-696 Craig P et al. BMJ 2008;337:bmj.a1655 College of Occupational College of Occupational Therapists Therapists ©2000 by British Medical Journal Publishing Group ©2008 by British Medical Journal Publishing Group Feasibility andFeasibility Studies answer the pilotingquestion Development Evaluation Pilot Studies“Can this study be done?” Implementation • version of the main study run in miniature -tests whether components of the main study can all work together• Standard deviation of primary outcome measure to estimate • focus on the processes of the main study, e.g. ensure sample size; recruitment, randomisation, treatment, and follow-up• willingness of participants to be randomised assessments all run smoothly.• willingness of clinicians to recruit participants • resemble main study in many respects, including an• number of eligible patients; assessment of the primary outcome.• characteristics of the proposed outcome measure and in some • Sometimes the first phase of the substantive study (internal cases feasibility studies might involve designing a suitable outcome pilot) Or data analysed separately (external pilot). measure;• follow-up rates, response rates to questionnaires, adherence/compliance rates College of Occupational College of Occupational Therapists Therapists 1
  2. 2. Feasibility and piloting Background Aims: Development EvaluationReturn to work after traumatic brain injury (TBI) Implementation• Primary goal (Carlson et al. 2006) • Is TBI specialist VR delivered by an OT part• Low rates of post injury employment: of a specialist TBI team more effective at 41% (range 0-85%) in work at 1 and 2 years (Van Velzen supporting work return and retention 12 et al. 2009)• Failing Rehabilitation? months after injury in people with TBI• Economic Impact -2.8 Billion Euros (Rickels et al. 2010) than usual care?• Patchy UK provision (Deshpande and Turner Stokes, 2004, Playford et al .2011) • What is the feasibility of collecting and evaluating economic data? College of Occupational College of Occupational Therapists Therapists Method TBI survivors all severities Recruitment ≤ 4 weeks post discharge Specialist Service = Routine Care = Nottingham Traumatic Brain Injury Service Patients outside the Minor TBI = OT Only catchment area Postal follow up, 3, 6 and 12 months College of Occupational College of Occupational Therapists Therapists College of Occupational College of Occupational Therapists Therapists 2
  3. 3. Recruitment (22 months) Baseline difference 252 Non- Intervention group in hospital for 11 days less 382 potential people identified eligible people Intervention group = mean12 days (sd 20)* Non intervention group = mean 23 days (sd 21)* 130 eligible 36 (27.4%) (Mann Whitney U p=0.004) declined 94 in study 40 Intervention group 54 Non-intervention group 32 Men (80%) 45 men (83%)33 Mean 34 years (18-66) Mean 34 years (16-68) Mean GCS 9.4 Mean GCS 10.3 College of Occupational College of Occupational Therapists Therapists Return to work – all participants Return to work – moderate/severe TBI 27% 100% difference Percentage at work 100% 15% OR 3.05 (0.9,10.6) 80%Percentage in work 80% difference 8% χ2= p= 0.07 60% 12% difference 60% 40% more in 40% work 20% 20% 0% 0% Pre-injury 4 weeks 3 months 6 months 12 months Pre-injury 4 weeks 3 months 6 months 12 months Time since injury Time since injury Interventon group Non intervention Interventon group Non intervention College of Occupational College of Occupational Therapists Therapists Return to Work – minor TBI Pilot 12 month - cost effectiveness analysis 37% 120% difference 10% Fischers p=0.03 difference Mean Intervention Non- Mean 100% costs group intervention difference Percentage in work 80% per group per person 60% person 40% 20% Health £2107 £2032 +£75 0% costs Pre-injury 4 w eeks 3 months 6 months 12 months Time since injury Society £8786 £10648 -£1862 costs Intervention group Non intervention College of Occupational Therapists College of Occupational Therapists 3
  4. 4. Incremental Cost Effectiveness Ratio Conclusions Clinical: - Intervention group had increased work rates at all time points - People with moderate and severe TBI showed greatest difference in RTW rates at 12 months - Early intervention needed Cost - effectiveness - Uncertain if health perspective taken at 1 year Research - Results suggest a larger RCT is warranted College of Occupational Therapists College of Occupational Therapists The International Classification of Functioning (WHO) What did the OT do? E.g. Confidence, Experience etc. College of Occupational College of Occupational Therapists Therapists Some key points Aim + Method• Recognises the importance of both health and social Aim factors in influencing success of vocational • To determine the content of OT intervention rehabilitation programmes Method• Programmes need to address impairment, activity, • Designed a proforma personal and social / environmental factors to be • Had 15 sections effective • Recorded OT treatment in 10 min units after every session College of Occupational College of Occupational Therapists Therapists 4
  5. 5. Sections on the proforma Work Preparation 10 RTW process 10 min min• Where seen • Cognitive/Executive Routines/time keeping RTW planning meeting• Assessment skills Discuss work options Work assessment meeting• Current issues • Work preparation Patient contact with work Monitoring and grading• Goals • Return to work process place meetings• Personal ADL • Miscellaneous Detailed job analysis Maintenance meetings• Education about TBI • Liaison Identify potential Written information to• Instrumental ADL problems/solutions employers • General issues• Physical issues Pacing/fatigue Statutory issues• Psychological issues Other Other College of Occupational College of Occupational Therapists Therapists Participants = 29Results Glasgow Coma Score Severe 14 (48%), Moderate 7 (24%) Minor 8 (28%) Gender Males 24 (83%), Females 5 (17%) Mean Age 36 (19-66) Cause Fall 11 (38%), RTA 7 (24%), Assault 9 (31%), Other 2 (7%) Work status Full time 21 (72%), Part time 8 (28%) Job category Professional 4 (14%), Skilled 6 (21%), College of Occupational Semi-skilled 10 (34%), Unskilled 9 (31%) Therapists College of Occupational Therapists Outcome of Intervention Style of Intervention• At discharge 25/29 (86%) = work/study 16 14 Number of participants 14 12 10 – 22/29 (76%) returned to previous 8 8 employer/college in some capacity 6 4 5 2 – 3/29 (10%) had started a new job 2 0 – 4/29 (14%) were not working (2 disengaged) Advice only 7% Treatment only Treatment and Treatment and - no direct employer involvement of employer involvement others* 17% involvement 28%• Everyone remained in work for 18 48% months *DEA’s, Occ health doctor, pathway providers College of Occupational College of Occupational Therapists Therapists 5
  6. 6. Intervention content Top 5 work concessions• 66% of the OT intervention directly • Flexible extra breaks (18%) focused on RTW: • Decreased hours (18%) – Work preparation (23%) • Reduced duties (15%) – Assessment (15%) • Reduced days (15%) – RTW process (13%) • Flexible start/finish times (13%) – Current issues (15%) • Graded return to work = 88% participants• No intervention on PADL College of Occupational College of Occupational Therapists Therapists Distribution of OT time per participant Amount of Treatment Summary of OT • 65% of treatment in people’s homes time • 17% of treatment in the work place OT travel OT non 21% • Average session approx 1 hour participant 1/3 = face to face face to face intervention • Mean no. OT sessions – OT admin liasion 36% 11% – mod/severe TBI 7 (1-23) 1/3 = Liaison – minor TBI 4 (2-7) 1/3 = Admin and • Mean length of intervention OT face to face with travel – mod/severe TBI = 9 ½ months (21-838 days) participant 31% – minor TBI = 4 ½ months (23-188 days) College of Occupational College of Occupational Therapists Therapists Clinical Implications Use of the proforma Key messages InterventionPositive Negative • Job Brokerage and re- • Important to be work• Quick to use training is hard - more focused • Some interventions• Captured main difficult to categorise likely to return to • Clinicians need liaison treatment focus previous employer and travel time • Redundant categories • Advise patients to keep options open Conclusion Proforma has potential for development Work site visits: Need flexibility College of Occupational College of Occupational Therapists Therapists 6
  7. 7. Lack of consensus Limitations and lessons• What is outcomesMeasuring work?• What counts as success? • Small opportunistic study – pragmatic approach• What are the outcomes of building on existing NHS service expertisehealth based vocational • Non-randomised, underpowered = uncertaintyrehabilitation intervention? • Intervention of a single OT on TBI survivors intending to return to work• How should VRinterventions be • OT – PhD study – Known to acute services = advantage in recruitmentdescribed? – Persistent, dedicated and determined – Knowledge of local services – useful in costing care College of Occupational College of Occupational Therapists Therapists Problems The Model • No TBI Register • Early, Specialist, Health based, Community (Outreach) Rehabilitation • Follow up problematic in TBI – ‘Early’ - identifies people at point of injury to prevent job loss • Costing Usual Care - Identifying with certainty – ‘Specialist’ - TBI specialist & VR specific knowledge which services were involved – ‘Health Based’ - delivered by NHS professionals in health setting – ‘Mixed’ - work return and work retention • Limited Funding (COT) focussed on OT rather – ‘Community Rehabilitation’ - delivered in community than team input College of Occupational College of Occupational Therapists Therapists Feasibility and pilotingNEXT STEPS Next steps - Feasibility RCT to explore.....Feasibility Study to explore…. Development Evaluation Implementation • Eligible numbers • Completeness of follow up • Recruitment rate of the primary endpoint• Research objectives • Can participants be • The spectrum of• Can we develop a treatment manual, training package and randomised to the mentoring model and implement it, so that the ‘Nottingham VR disease among recruits intervention’ can be delivered in 3 NHS regional TBI referral • Reasons for non intervention ? centres? recruiting • The likely effect on drop out• Can we conduct a randomised trials comparing early specialist TBI • Compliance with VR of randomisation to the vocational rehabilitation (ESTVR) in addition to standard care with and with usual care control group standard care alone • Are the measures fit for • Can we capture economic• Can we identify Primary outcomes of an NHS based ESTVR data from TBI survivors? important to service users, NHS service providers and purpose commissioners? College of Occupational Therapists 7
  8. 8. Promoting high quality research to develop rehabilitation practices References which are effective, relevant and • Carlson, P. M., M. L. Boudreau, J. Davis, J. Johnston, C. Lemsky, M. A. McColl, P. forward thinking. Minnes and C. Smith (2006). Participate to learn: A promising practice for community ABI rehabilitation. Brain Inj 20(11): 1111-7 • van Velzen, J. M., C. A. van Bennekom, M. J. Edelaar, J. K. Sluiter and M. H. Frings- Dresen (2009). How many people return to work after acquired brain injury?: a A forum to: systematic review. Brain Inj 23(6): 473-88 • Waddell, G., A. K. Burton and N. A. Kendal (2008). Vocational Rehabilitation. What • Raise the profile of rehabilitation research works, for whom, and when? Vocational Rehabilitation Task Force Group and I. I. A. Council, TSO (The Stationery Office).• Encourage evaluation through well designed studies • Hart, T., M. Dijkers, R. Fraser, K. Cicerone, J. A. Bogner, J. Whyte, J. Malec and B. Waldron (2006). Vocational Services for Traumatic Brain Injury: Treatment Definition • Foster a climate for developing and sharing skills and Diversity Within Model Systems of Care. J Head Trauma Rehabil 21(6): 467-482. • Tyerman, A. and M. Meehan (2004). Vocational Assessment and rehabilitation after • Enable active researchers to share the results of acquired brain injury, Inter-agency guidelines,. British Society of Rehabilitation Medicine, jobcentreplus, Dept for Work and Pensions, Royal College of Physicians, their work Clinical Effectiveness and Evaluation Unit, . • Ownsworth, T. and K. McKenna (2004). Investigation of factors related to• Advance rehabilitation practice for acute and chronic employment outcome following traumatic brain injury: a critical review and conceptual model. Disabil Rehabil 26(13): 765-83. disabling conditionswww.srr.org.uk College of Occupational College of Occupational Therapists Therapists 8

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