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1.  A multidisciplinary job retention vocational rehabilitation programme for patients with chronic rheumatic diseases: patients' and occupational physicians' satisfaction 
Annals of the Rheumatic Diseases  2004;63(5):562-568.
Objective: To investigate patients' and occupational physicians' satisfaction with the quality of a vocational rehabilitation programme for maintaining work ability in chronic rheumatic diseases.
Methods: The vocational rehabilitation programme was developed for patients with rheumatic diseases and consisted of systematic assessment of the problems at work and the development of individual solutions. The programme was run by a multidisciplinary team comprising a rheumatologist, a social worker, a physical and occupational therapist, and a psychologist. Satisfaction ratings were measured using a multidimensional questionnaire involving a rating scale (0–10) and a structured telephone interview.
Results: 59 of the 65 patients who participated in the programme (91%) completed the questionnaire. Patients were most satisfied with the interpersonal approach and professional knowledge, and least satisfied with the waiting time for the final report and the practical application of the given advice. Mean satisfaction score was 7.3 (SD 1.0). Twenty eight of the occupational physicians involved were interviewed. They were satisfied with the programme overall; 21 (75%) stated that their role in the vocational rehabilitation process could be defined more clearly, and they would appreciate more contact with the team members, preferably in the early phases.
Conclusions: Patients' and occupational physicians' satisfaction with a multidisciplinary vocational rehabilitation programme was good. Areas for improvement mainly concerned the speed of the process and the communication between team members and occupational physicians.
PMCID: PMC1754975  PMID: 15082488
2.  Return to work of cancer survivors: a prospective cohort study into the quality of rehabilitation by occupational physicians 
Aims: To describe and assess the quality of rehabilitation of cancer survivors by occupational physicians and to relate the quality of the process of occupational rehabilitation to the outcome of return to work.
Methods: One hundred occupational physicians of a cohort of cancer survivors were interviewed about return to work management. Quality of rehabilitation was assessed by means of four indicators that related to performance in knowledge of cancer and treatment, continuity of care, patients complaints, and relations at work. The cohort of patients was prospectively followed for 12 months to assess time to return to work and rate of return to work. Patients' and physicians' satisfaction with care was also assessed. The relation between performance and these outcome measures was studied in a multivariate analysis, taking into account the influence of other work and disease related factors that could potentially predict return to work.
Results: For knowledge of cancer and treatment, only 3% had optimal performance because occupational physicians did not communicate with treating physicians. For continuity of care, patient complaints, and relations at work, performance was optimal for 55%, 78%, and 60% of the physicians respectively. After adjustment for other prognostic factors, overall physician's performance (hazard ratio (HR) 0.5, 95% CI 0.3 to 0.8) and continuity of care (HR 0.5, 95% CI 0.3 to 0.9) were related to the return to work of patients. Overall optimal performance was also related to a small but significant higher level of satisfaction with care, both for patients and physicians.
Conclusion: Quality of occupational rehabilitation of cancer survivors can be improved substantially, especially with regard to communication between physicians and continuity of care. There is a need for the development of more effective rehabilitation procedures which should be evaluated in a randomised controlled trial.
PMCID: PMC1740540  PMID: 12709521
3.  Dutch occupational physicians and general practitioners wish to improve cooperation 
OBJECTIVES: To investigate cooperation between occupational physicians (OPs) and general practitioners (GPs). METHODS: Literature review; structured interviews; questionnaires sent to randomised samples of OPs (n = 232) and GPs (n = 243). RESULTS: Actual cooperation is poor. However, more than 80% of both groups responded that they want to improve their cooperation, aiming at better quality of care. Obstacles identified by OPs include insufficient knowledge among GPs about occupational health services (OHSs) (57%) and their patients' working conditions (52%). OPs also consider that GPs suspect them of serving employers more than employees (44%) and of verifying reasons of absence, with information from GPs (34%). Responses from GPs confirm these two suspicions (48%, response 58%), adding obstacles like commercialisation of OHS, lack of financial incentives, etc. Both groups are unanimous about prerequisites for improvement, especially guaranteeing the professional autonomy of OPs (OPs 86%, GPs 76%). CONCLUSION: As a first step to overcome obstacles to cooperation, OPs must clarify their position to GP colleagues. Initiatives have been taken after presenting this study.
PMCID: PMC1757665  PMID: 10658552
4.  Work resumption at the price of distrust: a qualitative study on return to work legislation in the Netherlands 
BMC Public Health  2013;13:153.
Return to work (RTW) after sick leave is considered necessary to support the employees’ health. Cooperation between employees and employers may encourage employees’ RTW, but is hampered by bottlenecks that we do not completely understand. Dutch legislation means to support this cooperation and allows trying RTW during two years. The Resource Dependence Institutional Cooperation (RDIC) model has been developed for studying cooperation in public health. Study aims were to get insight into the degree of cooperation between Dutch sick-listed employees and employers, how this (lack of) cooperation can be understood, and how valid the RDIC model is for understanding this (lack of) cooperation.
This qualitative study was based on in-depth interviews with 8 employees and 8 employers. Employees reported sick for 1.5-20 months for various reasons. Interviews were analysed using an interpretative approach and pattern matching.
Cooperation was lacking early during sick leave. Later on there were regular meetings, but employers decided about RTW without consulting the employees. Particularly employers were motivated to cooperate during the first year, while employees were especially motivated during the second. This could be understood by experienced dependence; employees (first year) and employers (second year) did not consider cooperation to be important for achieving medical recovery (employees) or RTW (employers). These divergent goals may be understood by personal norms about the timing of medical recovery and RTW. Legislation was particularly effective regarding employer behaviour in year 1 and employee behaviour in year 2. Employees distrusted their employers during the first year, while employers reported to distrust the employees during the second year. Besides, employees and employers experienced a moderate ability to cooperate. This could be understood particularly by having moderate knowledge about legislation. The RDIC model appeared to be valid to understand the cases studied, but the additional factor distrust also played a role.
Legislation appeared to support cooperation, but awareness of a mutual dependence, trust, knowledge about the legislation and personal norms regarding recovery and RTW are also important. Professionals such as occupational physicians should support this to attain a degree of cooperation that is necessary for effective RTW.
PMCID: PMC3621699  PMID: 23421974
Cooperation; Employee; Employer; Legislation; RDIC model; Return-to-work; Sick leave
5.  Physicians Report Barriers to Deliver Best Practice Care for Asplenic Patients: A Cross-Sectional Survey 
PLoS ONE  2011;6(3):e17302.
Current management of asplenic patients is not in compliance with best practice standards, such as defined by the British Committee for Standards in Haematology. To improve quality of care, factors inhibiting best practice care delivery need to be identified first. With this study, we aimed to identify and quantify physicians' barriers to adhere to best practice management of asplenic patients in the Netherlands.
Methods and Principal Findings
A cross-sectional survey, preceded by multiple focus group discussions, was performed among Dutch physicians responsible for prevention of infections in asplenic patients, including specialists (of Internal medicine and Surgery) and general practitioners (GPs). Forty seven GPs and seventy three hospital specialists returned the questionnaire, yielding response rates of 47% and 36,5% respectively. Physicians reported several barriers to deliver best practice. For both GPs and specialists, the most frequently listed barriers were: poor patient knowledge (>80% of hospital specialists and GPs) and lack of clarity about which physician is responsible for the management of asplenic patients (50% of Internists, 46% of Surgeons, 55% of GPs). Both GPs and hospital specialists expressed to experience a lack of mutual trust: specialists were uncertain whether the GP would follow their advice given on patient discharge (33–59%), whereas half of GPs was not convinced that specialists' discharge letters contained the correct recommendations. Almost all physicians (>90%) indicated that availability of a national guideline would improve adherence to best practice, especially if accessible online.
This study showed that, in accordance with reports on international performance, care delivery for asplenic patients in the Netherlands is suboptimal. We identified and quantified perceived barriers by physicians that prevent adherence to post-splenectomy guidelines for the first time. Better transmural collaboration and better informed patients are likely to improve the quality of care of the asplenic patient population. A national, online-available guideline is urgently required.
PMCID: PMC3053367  PMID: 21423748
6.  Effectiveness of occupational therapy in Parkinson’s disease: study protocol for a randomized controlled trial 
Trials  2013;14:34.
Occupational therapists may have an added value in the care of patients with Parkinson’s disease whose daily functioning is compromised, as well as for their immediate caregivers. Evidence for this added value is inconclusive due to a lack of rigorous studies. The aim of this trial is to evaluate the (cost) effectiveness of occupational therapy in improving daily functioning of patients with Parkinson’s disease.
A multicenter, assessor-blinded, two-armed randomized controlled clinical trial will be conducted, with evaluations at three and six months. One hundred ninety-two home-dwelling patients with Parkinson’s disease and with an occupational therapy indication will be assigned to the experimental group or to the control group (2:1). Patients and their caregivers in the experimental group will receive ten weeks of home-based occupational therapy according to recent Dutch guidelines. The intervention will be delivered by occupational therapists who have been specifically trained to treat patients according to these guidelines. Participants in the control group will not receive occupational therapy during the study period. The primary outcome for the patient is self-perceived daily functioning at three months, assessed with the Canadian Occupational Performance Measure. Secondary patient-related outcomes include: objective performance of daily activities, self-perceived satisfaction with performance in daily activities, participation, impact of fatigue, proactive coping skills, health-related quality of life, overall quality of life, health-related costs, and effectiveness at six months. All outcomes at the caregiver level will be secondary and will include self-perceived burden of care, objective burden of care, proactive coping skills, overall quality of life, and care-related costs. Effectiveness will be evaluated using a covariance analysis of the difference in outcome at three months. An economic evaluation from a societal perspective will be conducted, as well as a process evaluation.
This is the first large-scale trial specifically evaluating occupational therapy in Parkinson’s disease. It is expected to generate important new information about the possible added value of occupational therapy on daily functioning of patients with Parkinson’s disease.
Trial registration NCT01336127.
PMCID: PMC3599260  PMID: 23374761
Parkinson disease; Occupational therapy; Guidelines; caregiver; Randomized controlled trial; Study protocol; Effectiveness; Economic evaluation
7.  Routine dipstick urinalysis in daily practice of Belgian occupational physicians 
Archives of Public Health  2012;70(1):15.
Little work has been done to assess the quality of health care and the use of evidence-based methods by occupational physicians in Belgium. Therefore, the main objective is to describe one aspect of occupational health assessments, namely the common use of dipstick urinalysis, and to compare the current practice with international guidelines.
A self-administered questionnaire was mailed to 211 members of the Scientific Association of Occupational Medicine in the Dutch speaking part of Belgium.
A total of 120 occupational physicians responded, giving a response rate of 57%. Dipstick urinalysis was a routine investigation for the vast majority of physicians (69%). All test strips screened for protein and in 90% also for blood. Occupational health services offered clinical tests to satisfy customer wants as international guidelines do not recommend screening for haematuria and proteinuria in asymptomatic adults. A lack of knowledge concerning positive testing and referral criteria was demonstrated in almost half of the study participants.
Belgian occupational physicians still routinely perform dipstick testing although there is no evidence to support this screening in healthy workers. To practice evidence-based medicine, occupational physicians need more instruction and training. Development and implementation of more guidelines is not only of use for the individual practitioner, it may also enhance professionalization and efficiency of occupational health care.
PMCID: PMC3436716  PMID: 22958323
Evidence-based practice; Occupational health; Guidelines; Health surveillance
8.  Early coordinated multidisciplinary intervention to prevent sickness absence and labour market exclusion in patients with low back pain: study protocol of a randomized controlled trial 
Musculoskeletal disorders account for one third of the long-term absenteeism in Denmark and the number of individuals sick listed for more than four weeks is increasing. Compared to other diagnoses, patients with musculoskeletal diseases, including low back pain, are less likely to return to work after a period of sick leave. It seems that a multidisciplinary intervention, including cooperation between the health sector, the social sector and in the work place, has a positive effect on days off work due to musculoskeletal disorders and particularly low back pain. It is a challenge to coordinate this type of intervention, and the implementation of a return-to-work (RTW)-coordinator is suggested as an effective strategy in this process. The purpose of this paper is to describe the study protocol and present a new type of intervention, where the physiotherapist both has the role as RTW-coordinator and treating the patient.
A randomized controlled trial (RCT) is currently on-going. The RCT includes 770 patients with low back pain of minimum four weeks who are referred to an outpatient back centre. The study population consists of patients, who are sick-listed or at risk of sick-leave due to LBP. The control group is treated with usual care in a team of a physiotherapist, a chiropractor, a rheumatologist and a social worker employed at the centre. The Intervention group is treated with usual care and in addition intervention of a psychologist, an occupational physician, an ergonomist, a case manager from the municipal sickness benefit office, who has the authority in the actual case concerning sickness benefit payment and contact to the patients employer/work place. The treating physiotherapist is the RTW-coordinator. Outcome will be reported at the end of treatment as well as 6 and 12 months follow up. The primary outcome is number of days off work. Secondary outcomes are disability, pain, and quality of life. The study will follow the recommendations in CONSORT-statement in designing and reporting RCTs.
This large RCT is testing the effectiveness of a preventive intervention targeting patients on short term sick leave or at risk being sick listed because of low back pain. We have developed a novel multidisciplinary team structure using the treating physiotherapist as the return to work coordinator, and having the case manager from the municipal sickness benefit office participating in team meetings. The study has the potential to contribute to the knowledge about how to target the challenges in the treatment of LBP. The aim is to prevent sickness absence and labour market exclusion - both on the individual level and economic costs at community level. Short term results will be available in 2014.
This study is approved by the Danish Regional Ethics Committee ( H-C-2008-112) and is registered at.
Trial registration NCT01690234
PMCID: PMC3606127  PMID: 23496897
Low back pain (LBP); Return to work (RTW); Sickness absence; Rehabilitation; Prevention; Multidisciplinary intervention; Coordination; Denmark
9.  An intervention program with the aim to improve and maintain work productivity for workers with rheumatoid arthritis: design of a randomized controlled trial and cost-effectiveness study 
BMC Public Health  2012;12:496.
Workers with rheumatoid arthritis (RA) often experience restrictions in functioning at work and participation in employment. Strategies to maintain work productivity exist, but these interventions do not involve the actual workplace. Therefore the aim of this study is to investigate the (cost)effectiveness of an intervention program at the workplace on work productivity for workers with RA.
This study is a randomized controlled trial (RCT) in specialized rheumatology treatment centers in or near Amsterdam, the Netherlands. Randomisation to either the control or the intervention group is performed at patient level. Both groups will receive care as usual by the rheumatologist, and patients in the intervention group will also take part in the intervention program. The intervention program consists of two components; integrated care, including a participatory workplace intervention. Integrated care involves a clinical occupational physician, who will act as care manager, to coordinate the care. The care manager has an intermediate role between clinical and occupational care. The participatory workplace intervention will be guided by an occupational therapist, and involves problem solving by the patient and the patients’ supervisor. The aim of the workplace intervention is to achieve consensus between patient and supervisor concerning feasible solutions for the obstacles for functioning at work. Data collection will take place at baseline and after 6 and 12 months by means of a questionnaire. The primary outcome measure is work productivity, measured by hours lost from work due to presenteeism. Secondary outcome measures include sick leave, quality of life, pain and fatigue. Cost-effectiveness of the intervention program will be evaluated from the societal perspective.
Usual care of primary and outpatient health services is not aimed at improving work productivity. Therefore it is desirable to develop interventions aimed at improving functioning at work. If the intervention program will be (cost)effective, substantial improvements in work productivity might be obtained among workers with RA at lower costs. Results are expected in 2015.
Trial registration number
PMCID: PMC3528624  PMID: 22747949
10.  Consumer satisfaction with occupational health services: should it be measured? 
OBJECTIVES—To find answers in the literature to the questions if, why, and how consumer satisfaction with occupational health services (OHSs) should be measured.
METHODS—Publications about the concept of consumer satisfaction with health care and surveys of consumer satisfaction with occupational health care were reviewed.
RESULTS—For care providers, surveys of consumer satisfaction can be useful to improve quality or as indicators of non-compliant behaviour among patients. For clients, satisfaction surveys can be helpful for choosing between healthcare providers. Satisfaction is made up of an affective component of evaluation and a cognitive component of expectations. Also, in occupational health care, patient satisfaction is measured by dimensions such as the humanness and competence of the care provider similar to health care in general. However, there are dimensions that are specific to occupational health—such as the perceived independence of the physician, unclear reasons for visiting an OHS, and the perceived extent of knowledge of OHS professionals about the patient's working conditions. Dimensions of client satisfaction are mostly similar to patient satisfaction but include more businesslike aspects. They are different for the two groups of client, employers and employees. To measure consumer satisfaction in occupational healthcare specific questionnaires must be constructed. To achieve the highest possible reader satisfaction guidelines are provided for construction of a questionnaire.
CONCLUSIONS—Consumer satisfaction is a complex theoretical concept, but it is relatively easy to measure in practice and can be a valuable tool for quality improvement. Consumers' evaluations of occupational health services will become increasingly important due to changes in the organisation of occupational health care. Occupational healthcare providers are encouraged to measure the consumer satisfaction of their services.

Keywords: consumer satisfaction; occupational health services
PMCID: PMC1740125  PMID: 11245745
11.  Design of the Balance@Work project: systematic development, evaluation and implementation of an occupational health guideline aimed at the prevention of weight gain among employees 
BMC Public Health  2009;9:461.
Occupational health professionals may play an important role in preventive health promotion activities for employees. However, due to a lack of knowledge and evidence- and practice based methods and strategies, interventions are hardly being implemented by occupational physicians to date. The aim of the Balance@Work project is to develop, evaluate, and implement an occupational health guideline aimed at the prevention of weight gain among employees.
Following the guideline development protocol of the Netherlands Society of Occupational Medicine and the Intervention Mapping protocol, the guideline was developed based on literature, interviews with relevant stakeholders, and consensus among an expert group. The guideline consists of an individual and an environmental component. The individual component includes recommendations for occupational physicians on how to promote physical activity and healthy dietary behavior based on principles of motivational interviewing. The environmental component contains an obesogenic environment assessment tool. The guideline is evaluated in a randomised controlled trial among 20 occupational physicians. Occupational physicians in the intervention group apply the guideline to eligible workers during 6 months. Occupational physicians in the control group provide care as usual. Measurements take place at baseline and 6, 12, and 18 months thereafter. Primary outcome measures include waist circumference, daily physical activity and dietary behavior. Secondary outcome measures include sedentary behavior, determinants of behavior change, body weight and body mass index, cardiovascular disease risk profile, and quality of life. Additionally, productivity, absenteeism, and cost-effectiveness are assessed.
Improving workers' daily physical activity and dietary behavior may prevent weight gain and subsequently improve workers' health, increase productivity, and reduce absenteeism. After an effect- and process evaluation the guideline will be adjusted and, after authorisation, published. Together with several implementation aids, the published guideline will be disseminated broadly by the Netherlands Society of Occupational Medicine.
Trial Registration
PMCID: PMC2799413  PMID: 20003405
12.  Variations in corticosteroid/anesthetic injections for painful shoulder conditions: comparisons among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians 
Variations in corticosteroid/anesthetic doses for injecting shoulder conditions were examined among orthopaedic surgeons, rheumatologists, and primary-care sports medicine (PCSMs) and physical medicine and rehabilitation (PMRs) physicians to provide data needed for documenting inter-group differences for establishing uniform injection guidelines.
264 surveys, sent to these physicians in our tri-state area of the western United States, addressed corticosteroid/anesthetic doses and types used for subacromial impingement, degenerative glenohumeral and acromioclavicular arthritis, biceps tendinitis, and peri-scapular trigger points. They were asked about preferences regarding: 1) fluorinated vs. non-fluorinated corticosteroids, 2) acetate vs. phosphate types, 3) patient age, and 4) adjustments for special considerations including young athletes and diabetics.
169 (64% response rate, RR) surveys were returned: 105/163 orthopaedic surgeons (64%RR), 44/77 PCSMs/PMRs (57%RR), 20/24 rheumatologists (83%RR). Although corticosteroid doses do not differ significantly between specialties (p > 0.3), anesthetic volumes show broad variations, with surgeons using larger volumes. Although 29% of PCSMs/PMRs, 44% rheumatologists, and 41% surgeons exceed "recommended" doses for the acromioclavicular joint, >98% were within recommendations for the subacromial bursa and glenohumeral joint. Depo-Medrol® (methylprednisolone acetate) and Kenalog® (triamcinolone acetonide) are most commonly used. More rheumatologists (80%) were aware that there are acetate and phosphate types of corticosteroids as compared to PCSMs/PMRs (76%) and orthopaedists (60%). However, relatively fewer rheumatologists (25%) than PCSMs/PMRs (32%) or orthopaedists (32%) knew that phosphate types are more soluble. Fluorinated corticosteroids, which can be deleterious to soft tissues, were used with these frequencies for the biceps sheath: 17% rheumatologists, 8% PCSMs/PMRs, 37% orthopaedists. Nearly 85% use the same non-fluorinated corticosteroid for all injections; <10% make adjustments for diabetic patients.
Variations between specialists in anesthetic doses suggest that surgeons (who use significantly larger volumes) emphasize determining the percentage of pain attributable to the injected region. Alternatively, this might reflect a more profound knowledge that non-surgeons specialists have of the potentially adverse cardiovascular effects of these agents. Variations between these specialists in corticosteroid/anesthetic doses and/or types, and their use in some special situations (e.g., diabetics), bespeak the need for additional investigations aimed at establishing uniform injection guidelines, and for identifying knowledge deficiencies that warrant advanced education.
PMCID: PMC1950874  PMID: 17617900
13.  Ethical problems in intensive care unit admission and discharge decisions: a qualitative study among physicians and nurses in the Netherlands 
BMC Medical Ethics  2015;16:9.
There have been few empirical studies into what non-medical factors influence physicians and nurses when deciding about admission and discharge of ICU patients. Information about the attitudes of healthcare professionals about this process can be used to improve decision-making about resource allocation in intensive care. To provide insight into ethical problems that influence the ICU admission and discharge process, we aimed to identify and explore ethical dilemmas healthcare professionals are faced with.
This was an explorative, descriptive study using qualitative methods (individual and focus group interviews). We conducted 19 individual interviews and 4 focus group interviews with nurses and physicians working in the ICU or the general ward of 10 Dutch hospitals.
The ethical problems in the context of ICU admission and discharge can be divided into problems concerning full bed occupancy and problems related to treatment decisions.
The gap between the high level of care the ICU can provide and the lower care level in the general ward sometimes leads to mutual misunderstandings. Our results indicate that when professionals of different wards feel there is a collective responsibility and effort to solve a problem, this helps to prevent or alleviate moral distress.
ICU patients’ wishes are often unknown, causing healthcare professionals to err on the side of more treatment. Additionally, the highly technological nature of intensive care appears to encourage over-treatment.
It is important for ICUs and general wards to communicate and cooperate well, since there is a mutual dependency for optimal patient flow between the different departments. Interventions that improve the understanding and cooperation between these wards may help mitigate ethical problems.
The nature of the ICU environment makes it important for healthcare professionals to be aware of the risk of over-treatment, reflect on why they do what they do, and be mindful of a possible negative impact of over-treatment on their patients. Early discussion of a patient’s wishes with regard to treatment options is important in preventing over-treatment.
PMCID: PMC4344998  PMID: 25880418
Critical Care; Ethics; Intensive Care Units; Qualitative Research; Rationing; Resource Allocation
14.  Rheumatism in industry: a review 
Anderson, J. A. D. (1971).Brit. J. industr. Med.,28, 103-121. Rheumatism in industry: a review. Information about causes, effects, and prevention of rheumatic disease among industrial workers lacks standardization, as shown by the literature in this field; one reason for this is that there are discrepancies about the range of diseases and syndromes which should be included under this heading. The Industrial Survey Unit of the Arthritis and Rheumatism Council defined a rheumatic complaint as musculo-skeletal pain not related to recent (i.e., within six weeks) trauma. A study by the Unit of the social and economic effects of rheumatism among 2 684 male employees from a range of manual occupations is considered in relation to the observations made by other investigators. Sickness absence (at present estimated to be about 29·8 million working days per annum in Britain) and premature retirement can be shown to result directly from rheumatic complaints, especially rheumatoid arthritis and disc disease; furthermore, there seems to be general agreement that sickness absence is more marked in heavy manual occupations than in light ones. However, the extent to which job changes ascribed to rheumatic complaints are in fact caused by them is more doubtful. Evidence supporting the view that occupational factors are related to the aetiology of some chronic rheumatic diseases is fairly strong. Chronic tenosynovitis, bursitis, osteoarthrosis, and, to a lesser extent, disc disease are among those in which such a relationship can be demonstrated; however, the reason why some men are more prone to develop these conditions than others working in similar jobs is still in doubt, suggesting that the aetiology is multifactorial. In other rheumatic diseases, notably rheumatoid arthritis, a fairly extensive study of the literature does not indicate any clear correlation between occupation and aetiology. A system of job analysis for individual workers based on effort, posture, and climatic conditions at work is suggested. Its use as an alternative to grouping employees under their occupational titles might help to clarify these points. Prevention of rheumatic disease (including the use of pre-employment medical examinations) seems impracticable at the present time, but some progress in tackling the problems of rheumatism among industrial workers might be possible by improving rehabilitative services. These improvements would depend on closer collaboration not only between government departments but among doctors themselves and between them and others working in this field.
PMCID: PMC1009254  PMID: 4929448
15.  Evaluation research in occupational health services: general principles and a systematic review of empirical studies 
OBJECTIVES: To study the nature and extent of evaluation research in occupational health services (OHSs). METHODS: Literature review of evaluation research in OHSs. On the basis of a conceptual model of OHS evaluation, empirical studies are categorised into aspects of input, process, output, outcome, and OHS core activities. RESULTS: Many methods to evaluate OHSs or OHS activities exist, depending on the objective and object of evaluation. The amount of empirical studies on evaluation of OHSs or OHS activities that met the non-restrictive inclusion criteria, was remarkably limited. Most of the 52 studies were more descriptive than evaluative. The methodological quality of most studies was not high. A differentiated picture of the evidence of effectiveness of OHSs arises. Occupational health consultations and occupational rehabilitation are hardly studied despite much time spent on the consultation by occupational physicians in most countries. The lack of effectiveness and efficiency of the pre-employment examination should lead to its abandonment as a means of selection of personnel by OHSs. Periodic health monitoring or surveillance, and education on occupational health hazards can be carried out with reasonable process quality. Identification and evaluation of occupational health hazards by a workplace survey can be done with a high output quality, which, however, does not guarantee a favourable outcome. CONCLUSIONS: Although rigorous study designs are not always applicable or feasible in daily practice, much more effort should be directed at the scientific evaluation of OHSs and OHS instruments. To develop evidence-based occupational health care the quality of evaluation studies should be improved. In particular, process and outcome of consultation and rehabilitation activities of occupational physicians need to be studied more.
PMCID: PMC1757745  PMID: 10474531
16.  Workers’ experiences with compensated sick leave due to musculoskeletal disorder: a qualitative study 
The most common occupational disease that is compensated by Industrial Accident Compensation Insurance (IACI) in Korea is musculoskeletal disease (MSD). Although complaints about the workers’ compensation system have been raised by injured workers with MSD, studies that examine workers’ experiences with the Korean system are rare. This paper is a qualitative study designed to examine injured workers’ experiences with the workers’ compensation system in Korea. The aim of this study is to explore the drawbacks of the workers’ compensation system and to suggest ways to improve this system.
All workers from an automobile parts factory in Anseong, GyeongGi province who were compensated for MSD by IACI from January 2003 to August 2013 were invited to participate. Among these 153 workers, 142 workers completed the study. Semi-structured open-ended interviews and questionnaires were administered by occupational physicians. The responses of 131 workers were analyzed after excluding 11 workers, 7 of whom provided incomplete answers and 4 of whom were compensated by accidental injury. Based on their age, disease, department of employment, and compensation time, 16 of these 131 workers were invited to participate in an individual in-depth interview. In-depth interviews were conducted by one of 3 occupational physicians until the interview contents were saturated.
Injured workers with MSD reported that the workers’ compensation system was intimidating. These workers suffered more emotional distress than physical illness due to the workers’ compensation system. Injured workers reported that they were treated inadequately and remained isolated for most of the recuperation period. The compensation period was terminated without ample guidance or a plan for an appropriate rehabilitation process.
Interventions to alleviate the negative experiences of injured workers, including quality control of the medical care institutions and provisions for mental and psychological care for injured workers, are needed to help injured workers return to work earlier and more healthy.
PMCID: PMC4387791  PMID: 25852943
Musculoskeletal disease; Workers’ compensation; Occupational injuries; Qualitative research
17.  Do 360-degree Feedback Survey Results Relate to Patient Satisfaction Measures? 
There is evidence that feedback from 360-degree surveys—combined with coaching—can improve physician team performance and quality of patient care. The Physicians Universal Leadership-Teamwork Skills Education (PULSE) 360 is one such survey tool that is used to assess work colleagues’ and coworkers’ perceptions of a physician’s leadership, teamwork, and clinical practice style. The Clinician & Group-Consumer Assessment of Healthcare Providers and System (CG-CAHPS), developed by the US Department of Health and Human Services to serve as the benchmark for quality health care, is a survey tool for patients to provide feedback that is based on their recent experiences with staff and clinicians and soon will be tied to Medicare-based compensation of participating physicians. Prior research has indicated that patients and coworkers often agree in their assessment of physicians’ behavioral patterns. The goal of the current study was to determine whether 360-degree, also called multisource, feedback provided by coworkers could predict patient satisfaction/experience ratings. A significant relationship between these two forms of feedback could enable physicians to take a more proactive approach to reinforce their strengths and identify any improvement opportunities in their patient interactions by reviewing feedback from team members. An automated 360-degree software process may be a faster, simpler, and less resource-intensive approach than telephoning and interviewing patients for survey responses, and it potentially could facilitate a more rapid credentialing or quality improvement process leading to greater fiscal and professional development gains for physicians.
Our primary research question was to determine if PULSE 360 coworkers’ ratings correlate with CG-CAHPS patients’ ratings of overall satisfaction, recommendation of the physician, surgeon respect, and clarity of the surgeon’s explanation. Our secondary research questions were to determine whether CG-CAHPS scores correlate with additional composite scores from the Quality PULSE 360 (eg, insight impact score, focus concerns score, leadership-teamwork index score, etc).
We retrospectively analyzed existing quality improvement data from CG-CAHPS patient surveys as well as from a department quality improvement initiative using 360-degree survey feedback questionnaires (Quality PULSE 360 with coworkers). Bivariate analyses were conducted to identify significant relationships for inclusion of research variables in multivariate linear analyses (eg, stepwise regression to determine the best fitting predictive model for CG-CAHPS ratings). In all higher order analyses, CG-CAHPS ratings were treated as the dependent variables, whereas PULSE 360 scores served as independent variables. This approach led to the identification of the most predictive linear model for each CG-CAHPS’ performance rating (eg, [1] overall satisfaction; [2] recommendation of the physician; [3] surgeon respect; and [4] clarity of the surgeon’s explanation) regressed on all PULSE scores with which there was a significant bivariate relationship. Backward stepwise regression was then used to remove unnecessary predictors from the linear model based on changes in the variance explained by the model with or without inclusion of the predictor.
The Quality PULSE 360 insight impact score correlated with patient satisfaction (0.50, p = 0.01), patient recommendation (0.58, p = 0.002), patient rating of surgeon respect (0.74, p < 0.001), and patient impression of clarity of the physician explanation (0.69, p < 0.001). Additionally, leadership-teamwork index also correlated with patient rating of surgeon respect (0.46, p = 0.019) and patient impression of clarity of the surgeon’s explanation (0.39, p = 0.05). Multivariate analyses supported retention of insight impact as a predictor of patient overall satisfaction, patient recommendation of the surgeon, and patient rating of surgeon respect. Both insight impact and leadership-teamwork index were retained as predictors of patient impression of explanation. Several other PULSE 360 variables were correlated with CG-CAHPS ratings, but none were retained in the linear models post stepwise regression.
The relationship between Quality PULSE 360 feedback scores and measures of patient satisfaction reaffirm that feedback from work team members may provide helpful information into how patients may be perceiving their physicians’ behavior and vice versa. Furthermore, the findings provide tentative support for the use of team-based feedback to improve the quality of relationships with both coworkers and patients. The 360-degree survey process may offer an effective tool for physicians to obtain feedback about behavior that could directly impact practice reimbursement and reputation or potentially be used for bonuses to incentivize better team professionalism and patient satisfaction, ie, “pay-for-professionalism.” Further research is needed to expand on this line of inquiry, determine which interventions can improve 360-degree and patient satisfaction scores, and explain the shared variance in physician performance that is captured in the perceptions of patients and coworkers.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-014-3981-3) contains supplementary material, which is available to authorized users.
PMCID: PMC4385380  PMID: 25287521
18.  Patient participation in decisions about disease modifying anti-rheumatic drugs: a cross-sectional survey 
Involvement of patients in decision-making about medication is currently being advocated. This study examined (the concordance between) inflammatory arthritis patients’ preferred and perceived involvement in decision-making in general, and in four specific decisions about Disease-Modifying Anti-Rheumatic Drugs (DMARDs). Furthermore, this study examined how patients’ involvement is related to satisfaction about decision-making and which factors are related to preferred roles, perceived roles and concordance.
Using a cross-sectional survey, 894 patients diagnosed with Rheumatoid Arthritis, Psoriatic Arthritis or Ankylosing Spondylitis were sent a questionnaire which focused on medical decisions in general and on four specific decisions: (a) starting with a traditional DMARD; (b) starting to inject methotrexate; (c) starting a biological DMARD; and (d) decreasing or stopping a DMARD. For each decision preferred and perceived involvement in decision-making was assessed using the Control Preference Scale. Concordance was calculated by subtracting the scores for perceived role from scores for the preferred role. Furthermore, satisfaction with the decision process and socio-demographic, health-related, patient-related and physician-related variables were assessed.
The response rate was 58%. For all decisions, most patients (59%-63%) preferred Shared Decision-Making (SDM). SDM was perceived frequently (26%-55%) and patients’ preferences were met in 54% of the respondents. Yet, in some specific decisions, 26% to 54% of patients would have liked more participation. Perceiving less participation then preferred was associated with less satisfaction with the decision-process, but perceiving more participation than preferred was not. Our results did not reveal any meaningful models to predict preferred or perceived participation in decision-making in general or with reference to specific decisions about DMARDs.
Most arthritis patients prefer to be involved in decisions about their medication and SDM is perceived frequently. Yet, in some specific decisions patient participation can be further improved. Patients especially prefer more participation in decision-making regarding starting a first traditional DMARD, which occurs most commonly in newly diagnosed patients. Whereas perceiving too little participation was associated with decreased satisfaction, perceiving too much participation was not. Therefore, rheumatologists should urge patients to participate in every medical decision.
PMCID: PMC4192293  PMID: 25281209
Shared decision-making; Patient involvement; Patient participation; Arthritis; Disease modifying anti-rheumatic drugs
19.  Survey of physician experiences and perceptions about the diagnosis and treatment of fibromyalgia 
Fibromyalgia (FM) is a condition characterized by widespread pain and is estimated to affect 0.5-5% of the general population. Historically, it has been classified as a rheumatologic disorder, but patients consult physicians from a variety of specialties in seeking diagnosis and ultimately treatment. Patients report considerable delay in receiving a diagnosis after initial presentation, suggesting diagnosis and management of FM might be a challenge to physicians.
A questionnaire survey of 1622 physicians in six European countries, Mexico and South Korea was conducted. Specialties surveyed included primary care physicians (PCPs; n=809) and equal numbers of rheumatologists, neurologists, psychiatrists and pain specialists.
The sample included experienced doctors, with an expected clinical caseload for their specialty. Most (>80%) had seen a patient with FM in the last 2 years. Overall, 53% of physicians reported difficulty with diagnosing FM, 54% reported their training in FM was inadequate, and 32% considered themselves not knowledgeable about FM. Awareness of American College of Rheumatology classification criteria ranged from 32% for psychiatrists to 83% for rheumatologists. Sixty-four percent agreed patients found it difficult to communicate FM symptoms, and 79% said they needed to spend more time to identify FM. Thirty-eight percent were not confident in recognizing the symptoms of FM, and 48% were not confident in differentiating FM from conditions with similar symptoms. Thirty-seven percent were not confident developing an FM treatment plan, and 37% were not confident managing FM patients long-term. In general, rheumatologists reported least difficulties/greatest confidence, and PCPs and psychiatrists reported greatest difficulties/least confidence.
Diagnosis and managing FM is challenging for physicians, especially PCPs and psychiatrists, but other specialties, including rheumatologists, also express difficulties. Improved training in FM and initiatives to improve patient-doctor communication are needed and may help the management of this condition.
PMCID: PMC3502453  PMID: 23051101
20.  Rheumatoid arthritis patients and rheumatologists approach the decision to escalate care differently: Results of a maximum difference scaling experiment 
Arthritis care & research  2011;63(10):1407-1414.
Anti-rheumatic drugs are frequently not appropriately modified, according to ACR Guidelines, in patients with active rheumatoid arthritis (RA) as defined by a DAS28 score greater than 3.2. The objective was to determine which factors most strongly influence patients’ and rheumatologists’ decisions to escalate care.
We administered a Maximum Difference Scaling survey to 106 rheumatologists and 213 RA patients. The survey included 58 factors related to the decision to escalate care in RA. Participants answered 24 choice tasks. In each task, participants were asked to choose the most important factor from a set of five. We used Hierarchical Bayes modeling to generate the mean relative importance score (RIS) for each factor.
For rheumatologists, the five most influential factors were: number of swollen joints (RIS: 5.2; sd: 0.4), DAS28 score (RIS 5.2; sd 0.5), physician global assessment of disease activity (RIS 5.2. sd 0.6), worsening erosions over the last year (RIS: 5.2; sd: 0.6) and RA disease activity now compared to three months ago (RIS 5.1; sd: 0.6). For patients, the 5 most important factors were: current level of physical functioning (RIS: 4.3; sd: 1.1), motivation to get better (RIS: 3.5; sd: 1.4), trust in their rheumatologist (RIS: 3.5; sd: 1.6), satisfaction with current DMARDs (RIS: 3.4; sd: 1.4) and current number of painful joints (RIS 3.4; sd: 1.4).
Factors influencing the decision to escalate care differ between rheumatologists and patients. Better communication between patients and their physicians may improve treatment planning in RA patients with active disease.
PMCID: PMC3698485  PMID: 21748861
Rheumatoid Arthritis; Quality of Care; Decision Making; Patient Participation
21.  Relation between indicators for quality of occupational rehabilitation of employees with low back pain 
OBJECTIVES: To assess if the implementation of guidelines for occupational rehabilitation of patients with low back pain by means of process variables--a set of objective criteria for technical performance and continuity of care--led to a better outcome in clinical and return to work variables. METHODS: The study group consisted of 59 patients with at least 10 days of sick leave because of low back pain. Univariate analyses as well as multiple logistic regression and Cox's regression analyses were performed to assess the relation between quality of care and outcome. RESULTS: Process indicators for technical competence, continuity of care, and total performance were all significantly related to satisfaction of employees. Continuity of care and total performance were significantly related to working status at 3 months, and time to return to work. None of the process indicators was related to pain or disability after 3 months follow up. Satisfaction was not related to any of the other outcome variables. This indicates that if guidelines for occupational rehabilitation are met, outcome is better. CONCLUSION: Quality of the process of care was related to outcome. Interventions of occupational physicians need improvement in the areas of continuity of care and communication with treating physicians. The effectiveness of an improved intervention should be studied in a subsequent randomised clinical trial.
PMCID: PMC1757763  PMID: 10472321
22.  WHEDA study: Effectiveness of occupational therapy at home for older people with dementia and their caregivers - the design of a pragmatic randomised controlled trial evaluating a Dutch programme in seven German centres 
BMC Geriatrics  2009;9:44.
A recent Dutch mono-centre randomised controlled trial has shown that occupational therapy improves daily functioning in dementia. The aim of this present study is to compare the effects of the Dutch community occupational therapy programme with a community occupational therapy consultation on daily functioning in older people with mild or moderate dementia and their primary caregivers in a German multi-centre context.
A multi-centre single blind randomised controlled trial design is being used in seven health care centres (neurological, psychiatric and for older people) in urban regions. Patients are 1:1 randomised to treatment or control group. Assessors are blind to group assignment and perform measurements on both groups at baseline, directly after intervention at 6 weeks and at 16, 26 and 52 weeks follow-up. A sample of 140 community dwelling older people (aged >65 years) with mild or moderate dementia and their primary caregivers is planned. The experimental intervention consists of an evidence-based community occupational therapy programme including 10 sessions occupational therapy at home. The control intervention consists of one community occupational therapy consultation based on information material of the Alzheimer Society. Providers of both interventions are occupational therapists experienced in treatment of cognitively impaired older people and trained in both programmes. 'Community' indicates that occupational therapy intervention occurs in the person's own home. The primary outcome is patients' daily functioning assessed with the performance scale of the Interview for Deterioration in Daily Living Activities in Dementia and video tapes of daily activities rated by external raters blind to group assignment using the Perceive, Recall, Plan and Perform System of Task Analysis. Secondary outcomes are patients' and caregivers' quality of life, mood and satisfaction with treatment; the caregiver's sense of competence, caregiver's diary (medication, resource utilisation, time of informal care); and the incidence of long-term institutionalisation. Process evaluation is performed by questionnaires and focus group discussion.
The transfer from the Dutch mono-centre design to the pragmatic multi-site trial in a German context implicates several changes in design issues including differences in recruitment time, training of interventionists and active control group treatment.
The study is registered under DRKS00000053 at the German register of clinical trials, which is connected to the International Clinical Trials Registry Platform.
PMCID: PMC2761388  PMID: 19799779
23.  Enhancing return-to-work in cancer patients, development of an intervention and design of a randomised controlled trial 
BMC Cancer  2010;10:345.
Compared to healthy controls, cancer patients have a higher risk of unemployment, which has negative social and economic impacts on the patients and on society at large. Therefore, return-to-work of cancer patients needs to be improved by way of an intervention. The objective is to describe the development and content of a work-directed intervention to enhance return-to-work in cancer patients and to explain the study design used for evaluating the effectiveness of the intervention.
Development and content of the intervention
The work-directed intervention has been developed based on a systematic literature review of work-directed interventions for cancer patients, factors reported by cancer survivors as helping or hindering their return-to-work, focus group and interview data for cancer patients, health care professionals, and supervisors, and vocational rehabilitation literature. The work-directed intervention consists of: 1) 4 meetings with a nurse at the treating hospital department to start early vocational rehabilitation, 2) 1 meeting with the participant, occupational physician, and supervisor to make a return-to-work plan, and 3) letters from the treating physician to the occupational physician to enhance communication.
Study design to evaluate the intervention
The treating physician or nurse recruits patients before the start of initial treatment. Patients are eligible when they have a primary diagnosis of cancer, will be treated with curative intent, are employed at the time of diagnosis, are on sick leave, and are between 18 and 60 years old. After the patients have given informed consent and have filled out a baseline questionnaire, they are randomised to either the control group or to the intervention group and receive either care as usual or the work-directed intervention, respectively. Primary outcomes are return-to-work and quality of life. The feasibility of the intervention and direct and indirect costs will be determined. Outcomes will be assessed by a questionnaire at baseline and at 6, 12, 18, and 24 months after baseline.
This study will provide information about the effectiveness of a work-directed intervention for cancer patients. The intention is to implement the intervention in normal care if it has been shown effective.
Trial registration
PMCID: PMC2907345  PMID: 20594347
24.  Why are Dutch rheumatologists reluctant to use the COBRA treatment strategy in early rheumatoid arthritis? 
Annals of the Rheumatic Diseases  2007;66(7):974-976.
The Combinatietherapie Bij Reumatoide Artritis (COBRA) trial has proved that combination therapy with prednisolone, methotrexate and sulphasalazine is superior to sulphasalazine monotherapy in suppressing disease activity and radiological progression of early rheumatoid arthritis (RA). In addition, 5 years of follow‐up proved that COBRA therapy results in sustained reduction of the rate of radiological progression. Despite this evidence, Dutch rheumatologists seem reluctant to prescribe COBRA therapy.
To explore the reasons for the reluctance in Dutch rheumatologists to prescribe COBRA therapy.
A short structured questionnaire based on social–psychological theories of behaviour was sent to all Dutch rheumatologists (n = 230).
The response rate was 50%. COBRA therapy was perceived as both effective and safe, but complex to administer. Furthermore, rheumatologists expressed their concern about the large number of pills that had to be taken, the side effects of high‐dose prednisolone and the low dose of methotrexate. Although the average attitude towards the COBRA therapy was slightly positive (above the neutral point), the majority of responding rheumatologists had a negative intention (below the neutral point) to prescribe COBRA therapy in the near future.
The reluctance of Dutch rheumatologists to prescribe effective COBRA therapy may be due to perceptions of complexity of the treatment schedule and negative patient‐related consequences of the therapy.
PMCID: PMC1955117  PMID: 17392349
25.  Kawasaki syndrome: an intriguing disease with numerous unsolved dilemmas 
More than 40 years have passed since Kawasaki syndrome (KS) was first described. Yet KS still remains an enigmatic illness which damages the coronary arteries in a quarter of untreated patients and is the most common cause of childhood-acquired heart disease in developed countries. Many gaps exist in our knowledge of the etiology and pathogenesis of KS, making improvements in therapy difficult. In addition, many KS features and issues still demand further efforts to achieve a much better understanding of the disease. Some of these problem areas include coronary artery injuries in children not fulfilling the classic diagnostic criteria, genetic predisposition to KS, unpredictable ineffectiveness of current therapy in some cases, vascular dysfunction in patients not showing echocardiographic evidence of coronary artery abnormalities in the acute phase of KS, and risk of potential premature atherosclerosis. Also, the lack of specific laboratory tests for early identification of the atypical and incomplete cases, especially in infants, is one of the main obstacles to beginning treatment early and thereby decreasing the incidence of cardiovascular involvement. Transthoracic echocardiography remains the gold-standard for evaluation of coronary arteries in the acute phase and follow-up. In KS patients with severe vascular complications, more costly and potentially invasive investigations such as coronary CT angiography and MRI may be necessary. As children with KS with or without heart involvement become adolescents and adults, the recognition and treatment of the potential long term sequelae become crucial, requiring that rheumatologists, infectious disease specialists, and cardiologists cooperate to develop specific guidelines for a proper evaluation and management of these patients. More education is needed for physicians and other professionals about how to recognize the long-term impact of systemic problems related to KS.
PMCID: PMC3163180  PMID: 21774801

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