General discussion
IMPLICATIONS FOR RESEARCH
The problem analysis in the Gatekeeper Improvement Act
As stated before, the OHP has to write a problem analysis in the 6th week of sick leave. In this problem analysis, components of the ICF may be recognised. The OHP has to give an indication of the cause for sick leave being a health condition, and/or working conditions, conflict on the job, physical and mental job demands, personal and social factors. Apart from the cause for sick leave, the OHP has to assess impairments of the employee with regard to work functioning and the ability to work with adaptations, the relationship between employer and employee and the assessment of the risk of a disability pension.
No recent studies exist regarding the quality of the problem analysis, although an earlier panel study in OHPs and insurance physicians suggested a lack of quality.61 This calls for studies regarding the quality of problem analysis, and the relation of the various components of the ICF model with respect to RTW outcomes.
Furthermore, it is questionable if a problem analysis at 6 weeks is useful in all cases of sick leave > 6 weeks of duration. In case of a possible mental disorder, an earlier problem analysis could be preferable; in case of an uncomplicated physical disorder, a problem analysis may be useless. The results of the first study in this thesis (chapter 2) indicate that
a questionnaire at 7 days of sick leave provides useful information on the risk of long sick leave spells. Research should be directed towards the possibility to write a problem analysis only in case of an expected unsuccessful RTW outcome, based on the employee questionnaire and the OHP judgment.
Self-rated health and RTW outcomes
Self-rated health is strongly associated with work functioning. Because of the growing need for employees to continue working with a chronic disease or until higher age, the association has to be examined in future longitudinal studies. The longitudinal studies might indicate that occupational health practice should shift the focus from mainly RTW management to improving employee health, for example by offering preventive health programmes.
Job loss during sick leave
Given the lack of studies on job loss during sick leave, there is a need for larger, longitudinal studies replicating the results of this study and elucidating risk factors. The type of contract and possible causes of resignation should be taken into account, as well as severity and treatment of the disorder.
Quality of OHP diagnosis
It is not known in how many of the sick leave cases in this study or in general OHP practice the OHP diagnosis changes during the sick leave spell.58 More longitudinal, prospective research is needed to investigate the quality of the first diagnosis and the extent to which this first diagnosis has to be changed during the sick leave spell. Moreover, the severity of symptoms and co-morbidity, including substance abuse, should be taken into account in longitudinal studies.
Work functioning after RTW
Longitudinal research is needed to identify predictors of work functioning after RTW and to get information about the improvement of work functioning following RTW over time.
A specific point of interest should be the responsiveness for change over time of the work functioning instruments used in the studies. Moreover, there is a need for studies on interventions specifically designed to improve health-related work functioning after initial (full) RTW.
Sustainable RTW
More and longitudinal research is needed to identify factors involved in RTW sustainability, including psychosocial work hazards and type of contract. Employees with temporary contracts showed some level of presenteeism, i.e. working while sick. In future studies, presenteeism should be assessed structurally, for example by measurement of
among employees with temporary contracts and preferably over a longer time period after RTW.
Phase specificity of RTW
Of special interest was, whether associations between health, environmental en personal determinants and different RTW outcomes vary in different phases of the RTW process.
The studies suggest phase-specificity. However, differences are not always significant and because of the cross sectional nature of the study no conclusions with regard to causality can be inferred. Longitudinal studies, specifically aimed at phase-specificity are needed to clarify the associations. This is important for a better understanding of the influence of factors on RTW outcomes, and may thereby support the choice and timing of interventions.
CONCLUSION
The data on factors used as determinants in this thesis are either collected by OHPs in the course of RTW management or accessible in personnel files of the employer. These factors are not only associated with (time to) RTW but also with other RTW outcomes, such as job loss, RTW sustainability and work functioning after RTW. Longitudinal research is needed to confirm these associations, and to make sure that these factors are important to direct preventive measures to improve RTW outcomes as studied in this thesis. With an ageing work force in which more and more employees will suffer from chronic disease, OHPs should redirect their focus from mere RTW management to improving sustainable employability of the work force. Important information to guide OHPs is at their fingertips in OHP files.
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Summary
Sick leave has great consequences for employers, employees and society. In the last decades of the 20th century, sick leave rates were relatively high in the Netherlands, and return to work (RTW) management became an important issue for policy makers and occupational health services. Instead of financially compensating for lost work ability, facilitating work participation became the most important goal of RTW management.
Legislation to prevent the award of disability pension directed the attention of occupational health physicians and other stakeholders to improving RTW outcomes. RTW and time to RTW became a topic of scientific research.
RTW as such however is only one possible outcome of RTW management. Other outcomes, such as job loss during sick leave, sustainability of RTW and work functioning after RTW, are yet scarcely studied. The International Classification of Functioning, Disability and Health (ICF) provides a framework to study the influence of health factors, personal factors and environmental factors, and their interactions, on societal (including work) participation. This thesis aims to identify the factors associated with (time to) RTW and other RTW outcomes mentioned above.
Chapter 1 provides a general introduction on the subject of RTW outcomes and the