Return to Work Coordination Programmes for Work Disability: A Meta-Analysis of Randomised Controlled Trials

BackgroundThe dramatic rise in chronically ill patients on permanent disability benefits threatens the sustainability of social security in high-income countries. Social insurance organizations have started to invest in promising, but costly return to work (RTW) coordination programmes. The benefit, however, remains uncertain. We conducted a systematic review to determine the long-term effectiveness of RTW coordination compared to usual practice in patients at risk for long-term disability. Methods and FindingsEligible trials enrolled employees on work absence for at least 4 weeks and randomly assigned them to RTW coordination or to usual practice. We searched 5 databases (to April 2, 2012). Two investigators performed standardised eligibility assessment, study appraisal and data extraction independently and in duplicate. The GRADE framework guided our assessment of confidence in the meta-analytic estimates. We identified 9 trials from 7 countries, 8 focusing on musculoskeletal, and 1 on mental complaints. Most trials followed participants for 12 months or less. No trial assessed permanent disability. Moderate quality evidence suggests a benefit of RTW coordination on proportion at work at end of follow-up (risk ratio = 1.08, 95% CI = 1.03 to 1.13; absolute effect = 5 in 100 additional individuals returning to work, 95% CI = 2 to 8), overall function (mean difference [MD] on a 0 to 100 scale = 5.2, 95% CI = 2.4 to 8.0; minimal important difference [MID] = 10), physical function (MD = 5.3, 95% CI = 1.4 to 9.1; MID = 8.4), mental function (MD = 3.1, 95% CI = 0.7 to 5.6; MID = 7.3) and pain (MD = 6.1, 95% CI = 3.1 to 9.2; MID = 10). ConclusionsModerate quality evidence suggests that RTW coordination results in small relative, but likely important absolute benefits in the likelihood of disabled or sick-listed patients returning to work, and associated small improvements in function and pain. Future research should explore whether the limited effects persist, and whether the programmes are cost effective in the long term.背景：长期领取残疾津贴的慢性病患者数量急剧攀升，正威胁高收入国家社会保障体系的可持续性。社会保险机构已开始投入前景可观但成本高昂的重返工作岗位（Return to Work, RTW）协调项目，但其实际获益效果仍不明确。本研究开展了一项系统综述，旨在对比重返工作岗位协调项目与常规诊疗方案，评估其针对存在长期残疾风险患者的长期有效性。 研究方法与结果：符合纳入标准的试验纳入了缺勤时长至少4周的雇员，并将其随机分配至重返工作岗位协调组或常规诊疗组。本研究检索了截至2012年4月2日的5个学术数据库。由2名研究者独立、重复开展标准化的纳入资格评估、研究质量评价与数据提取工作，并采用GRADE（推荐分级、评估、制定与评价，Grading of Recommendations Assessment, Development and Evaluation）框架对荟萃分析结果的置信度进行评级。 本研究共纳入来自7个国家的9项临床试验，其中8项聚焦于肌肉骨骼疾病，1项针对精神类病症。多数试验的随访时长不超过12个月，且无试验评估永久性残疾结局。 中等质量证据表明，重返工作岗位协调可提升随访结束时的在职比例（风险比=1.08，95%置信区间[CI]：1.03~1.13；绝对效应为每100名患者中额外5人成功重返工作岗位，95%CI：2~8），同时可改善整体功能（0~100量表的平均差[Mean Difference, MD]=5.2，95%置信区间[CI]：2.4~8.0；最小临床重要差异[Minimal Important Difference, MID]=10）、躯体功能（MD=5.3，95%CI：1.4~9.1；MID=8.4）、心理功能（MD=3.1，95%CI：0.7~5.6；MID=7.3）及疼痛程度（MD=6.1，95%CI：3.1~9.2；MID=10）。 结论：中等质量证据显示，重返工作岗位协调项目可使残疾或病假患者的重返工作可能性产生小幅相对获益，且绝对获益具有临床意义，同时可小幅改善患者的功能状态与疼痛水平。未来研究应探讨此类项目的有限效应是否可持续，以及其长期成本效益情况。