Background
Chronic low back pain (CLBP) is an important cause of work disability and sickness absence [
1,
2]. In European countries, up to 35% of work disability is caused by CLBP [
2]. In the Netherlands, the total costs of disability because of back pain were estimated at 1361 million Euros in 2007, which comprises a proportion of 38.5% of the total costs of back pain [
3]. An effective return to work (RTW) process is essential to prevent applications for disability benefits due to chronic disability [
4,
5]. With the high number of disabled workers, the outcome and content of this RTW process are important issues [
5‐
8]. Although the assessment of the RTW process is part of the application of disability benefits in several countries (i.e. Denmark, Germany, the Netherlands, Norway) [
8], few studies focus on this assessment or on the factors relevant to the quality assessment of the RTW process [
4,
5].
The RTW process can be assessed by means of the assessment of RTW Effort Sufficiency (RTW-ES), as part of the evaluation of the RTW process in relation to the application for disability benefits [
8]. RTW efforts made in the RTW process include all activities undertaken by employee, employer or health professionals involved in the RTW process to improve the work ability of the sick-listed employee in the period between onset of sickness absence and the application for disability benefits [
9]. The perspective of this assessment is that if the RTW process is designed effectively and the RTW efforts are sufficient, the chances of RTW have been tested in an optimal way, and RTW should be achieved in accordance with health status and work ability of the sick-listed employee [
10]. The assessment of RTW-ES investigates the quality of the RTW process. Assessing RTW-ES is of importance when considering the remaining functional possibilities of the employee and determining future RTW opportunities.
In the Netherlands, this assessment takes place prior to the assessment of functional and earning capacity (i.e. the income that would be generated if the individual would be employed to full functional capacity) as part of the disability evaluation, after two years of sickness absence [
9]. The RTW-ES assessment is performed only when the Dutch employee has not fully returned to work after two years of sickness absence, but does have remaining work ability and is applying for disability benefits. If the RTW efforts are not considered sufficient, the application for disability benefits can be delayed to make sure that the necessary efforts can still be undertaken. This is similar to the consequences in other countries, where the rehabilitation period is extended (i.e. Denmark) or a rehabilitation subsidy is applied for (i.e. Finland, Germany) [
8]. The assessment is based on a reintegration report, which is written by both employer and employee. The reintegration report includes a problem analysis, i.e. a mandatory description of the (dis)abilities of the employee made by an Occupational Physician (OP) of the Occupational Health Service (OHS) hired by the employer, an action plan, i.e. the plan designed to achieve work resumption, and the employee's opinion regarding the RTW process. Records of all interventions, intermittent RTW process advice by independent professionals, and agreements between employer and employee are also required in the reintegration report [
8,
9,
11].
The assessment of RTW-ES in the Netherlands is performed by Labor Experts (LE's) of the Dutch Social Insurance Institute (SII). LE's are specialized in the field of vocational rehabilitation and after graduating, have followed a one to two year intensive post academic in company training. LE's assess whether all opportunities for RTW have been examined and undertaken by the employee or employer, if applicable. The LE's also focus on the context of the RTW process, i.e. factors which might influence the RTW process and its quality, like the relationship between employer and employee, and the employee's attitude. The LE's consider only the non-medical aspects of the RTW process, but they can consult a Social Insurance Physician (SIP) about the medical aspects of the RTW process, e.g. medical interventions and medical prospects. If necessary, the LE's can consult the employee, employer or OP to gather or verify information.
If the efforts made during the RTW process are considered insufficient by the LE, the direct and indirect consequences can be serious [
8]. A direct consequence of insufficient efforts is that the application for disability benefits is delayed for a maximum of one year, or until the employer and/or employee have undertaken the necessary actions. A more indirect consequence is that insufficient efforts are an indication that the time to RTW of the employee has been unnecessarily prolonged. In 2010, LE's of the Dutch SII's were responsible for over 27,000 RTW-ES assessments [
12].
Over the last years protocols and guidelines have been developed for professionals to improve the quality and standardize their decision-making process [
13‐
15]. These protocols are systematically developed and contain recommendations based on evidence from published literature. In current practice, for LE's, only a protocol is available which focus mainly on procedural matters [
8], and its contents have not been gathered by means of scientific evidence. Moreover, it does not provide a set of factors relevant in the RTW-ES assessment based on scientific evidence. Gathering information about the relevant factors in the assessment of RTW-ES by means of research and including this kind of evidence-based information in the existing protocol will optimize not only the transparency and reliability but also the validity of the assessment [
13].
The quality and effect of the RTW process on RTW outcome is influenced by a large number of factors [
1,
7,
16], which makes the operationalization of 'sufficiency of RTW efforts' and the quality assessment of the RTW process a unique challenge. The assessment of RTW-ES is a complex decision making process, in which relevant factors are regarded implicitly [
8]. Knowing which factors are related to RTW-ES is essential, but no guidelines as to which factors are relevant to the decision are available in the Netherlands or in other countries. Literature concerning factors relevant to the assessment of RTW-ES is scarce [
8]. Also, it is of interest to know whether factors relevant to the assessment of RTW-ES can be fitted within the model of Functioning, Disability and Health (ICF) model [
17]. By analyzing our results within the ICF model we aim to use a comprehensive framework. Using this well-known categorization system also facilitates the connection to existing and future literature. This way, our approach could help to improve comparability.
A possible source of information about factors relevant to the assessment of RTW-ES is the implicit knowledge of the professionals performing the assessment. Focus group research is a suitable method to gather information on a decision process which is otherwise performed implicitly by professionals [
18,
19]. The focus group process aims to explore and clarify individual and shared perspectives [
18,
20,
21]. This is particularly effective in complex processes [
21], such as the assessment of RTW-ES. The method to unravel the assessment is to gather arguments for the assessment outcome in a standardized setting, and to identify the underlying grounds, thereby making the knowledge and experience of the professionals more explicit [
18,
19,
22]. These underlying grounds are necessary to understand the translation of gathered information into arguments used for the decision, a different conclusion of professionals may arise in identical cases because different grounds are being referred to [
19,
23].
The main aim of this study was to identify the factors relevant to RTW-ES by means of focus groups, by investigating arguments and underlying grounds relevant to the assessment of RTW-ES in cases of sick-listed employees with CLBP, and to categorize these factors within the ICF model.
Discussion
Nineteen factors related to RTW-ES were identified after analyzing arguments and grounds of LE's derived from two CLBP cases. Twelve of these 19 factors can be fitted within a single domain of the ICF model. The factor functional capacity is related to 'activities'. Factors in the personal domain related to RTW-ES include age, educational level, competencies, tenure, attitude, self-efficacy and illness perception. Factors in the environmental domain related to RTW-ES are work-relatedness of the sickness absence, job availability, the relation between employer and employee, and employer's attitude. The remaining seven factors can not be fitted within the ICF model. These factors are categorized under intervention (i.e. training/education, job offerings, professional advice), job accommodation (i.e. temporary/modified duty, change of employer), and measures (i.e. assessment, monitoring).
To compare our results with other studies with regard to generalization, no literature about the relation between factors found in research on RTW and factors related to the assessment of RTW-ES was available [
4]. We decided to compare the factors found in this study to the existing literature on factors related to RTW to investigate consistencies and differences between the factors related to these outcomes.
The 19 factors found to be relevant to RTW-ES in CLBP patients in this study are mostly consistent with literature on RTW. For example, the relation between a higher age, educational level and attitude of the employee and RTW has also been found in literature [
26,
27], however, the interpretation and direction of the relevant factor can be different when considering RTW-ES. Literature concerning RTW in patients with CLBP states that the remaining functional capacity is strongly related to RTW after sickness absence [
27]. It can be assumed that this is also a reason to take functional capacity into account when assessing RTW-ES. Fewer efforts can be undertaken when an employee with limited capacity is involved. If the employee has limited remaining capacity, efforts to RTW could be considered less useful. Nevertheless, it can also be assumed that more efforts should be undertaken to promote RTW of employees with limited functional capacity, as it will be harder for them to RTW. Another example is the effort of offering temporary or modified work. Research on RTW in CLBP has found that RTW increases the well-being of the sick-listed employee [
16], and that temporary work shortens the time to RTW [
28,
29]. Literature has also shown that the lack of modified work is related to the transition from acute to chronic LBP [
30], and the availability of modified work might therefore be relevant when the effort sufficiency during the RTW process is assessed after two years.
According to LE's, investigating and offering temporary or modified work is related to RTW-ES, but they state that non-temporary work is preferred over temporary work.
When considering RTW-related outcomes, both RTW and RTW-ES can be of interest to the RTW process [
4,
15], but the literature of RTW can not simply be transcribed to RTW-ES. For example, undertaking an effort (e.g. offering training or education) can be considered essential to RTW-ES because it influences factors relevant to RTW-ES (positive attitude of the employer, self-efficacy of the employee), regardless of whether the training has proven to be effective to RTW. In our previous research we have examined the strength and relevance of factors related to RTW-ES and RTW among employees applying for disability benefits after 2 years of sickness absence [
4], and have investigated the comparability of the factors related to these two outcomes. We have concluded that different factors are relevant to RTW-ES and RTW, but the relationship between employer and employee is relevant to both. The lack of similarity between these outcomes can be explained by the relative independence of the outcomes. For example, RTW-ES can be sufficient or insufficient, regardless of RTW outcome. For example, when the RTW outcome is sufficient, the RTW efforts are assumed to be sufficient as well. However, RTW outcome can be sufficient despite lack of RTW-ES, and in cases where RTW efforts are sufficient the RTW outcome can be negative.
A strength of this study is that this is the first study that explores the implicit knowledge used by professionals to assess RTW-ES. Using a focus group method has proven to be an intensive but effective method to collect the implicit knowledge of LE's. In order to gather a wide range of arguments, grounds and factors, two focus groups have been assembled, each using a different case. Moreover, to ensure the quality of the results, we have used a method to collect arguments which was as close as possible to being a natural situation while maintaining standardization. This way, the arguments collected by each LE could be used for group-wise discussion.
Another strength lies in the universal phrasing of the grounds mentioned by the LE's and the factors derived from these grounds. Discussions focused mostly on the applicability of the ground, i.e. if the ground could apply to all imaginable cases. For example, reorganization might not in all cases limit job availability for the sick-listed employee. Of course, some grounds (e.g. regarding the responsibilities of the employer) can be viewed in context: Dutch legislation requires the employer to undertake all efforts necessary to promote the RTW of the employee. However, these efforts are not specified, and mostly the procedural aspects and the relation between RTW efforts and RTW results are described in detail. Moreover, efforts to promote RTW are beneficial to RTW regardless of the legislatory consequences (financial or otherwise). A good employer-employee relationship is beneficial to RTW [
7] and is important to RTW-ES regardless of whether the employer will experience financial consequences.
Also of interest when considering efforts relevant to RTW-ES are the assessability (possibilities for discussion) and modifiability (possibilities of alteration) of factors. For example, no assessment is necessary for the factor age, which is also not modifiable. Self-efficacy, however, is a factor which is open to discussion and should be assessed by a professional, and is also modifiable.
A limitation might be that only two cases concerning CLBP were used. Using more cases or different cases might have yielded more factors. However, we feel that by selecting two cases which each concerned CLBP, but with different backgrounds and RTW processes, we have enhanced the opportunity to gather different arguments and discuss factors in an effective way. Furthermore, LE's from two Dutch SII's were included in the study. We do not know whether these LE's are representative of their occupational group. Future studies are necessary to reproduce and expand our findings. Another limitation related to the focus group method might be our use of actors for the roles of several stakeholders. However, our priority was to provide a standardized but realistic situation, which we feel we have achieved by training these actors to portray each stakeholder.
A further point of discussion might be that no factors related to 'disease', 'functions', and participation were mentioned by the LE's. The lack of factors fitted within these categories can be attributed to the Dutch context, where disease and functions are investigated by the Social Insurance Physician (SIP) and other medical specialists. LE's mainly consider the participation as an outcome, and investigate aspects related to activities, taking personal and environmental factors into consideration when assessing RTW-ES. Also, some factors that are relevant to RTW have not been mentioned by LE's (e.g. gender, work requirements, family support), and have not been discussed.
Furthermore, by categorizing the factors derived from the focus group study in the ICF model an attempt was made to provide a clear overview and improve comparability. The categorization of the factors related to actions (e.g. measures, intervention or accommodation) was subject of debate. The ICF model is used to classify components of functioning and disability, while the actions are focused on changing one or more of these components. Moreover, using the ICF model for actions is a complicated process, and requires reduction of actions into a series of observations which could be categorized in the ICF model. [
14]. The availability of training would be a factor related to the environmental domain, but the offering of the training and the effect of the training has an effect on several components (e.g. educational level, competencies, attitude and job availability).
The relevance of this study lies in that it is one of the first studies to investigate factors relevant to RTW-ES [
4]. The results found in this focus group study will provide an overview of factors relevant to the assessment of RTW-ES. The assessment of RTW-ES will remain a unique and multifactorial decision making process performed by a professional (i.e. the LE) based on the information which is available and the context it is placed in (e.g. legislation). However, providing factors relevant to the assessment of RTW-ES to the professionals who perform this assessment might make the assessment more evidence-based and could contribute to a more systematic approach of the assessment of RTW-ES.
Further research is required to investigate whether the results of this study can be replicated within a different context (e.g. another country, different focus group members), and whether they are relevant in cases where the patient has a disease other than CLBP (e.g. depression), or in cases where the patient has diagnosed comorbidity. In this study, the relevance of factors has been investigated, but no distinction has been made on the association itself, e.g. whether older or younger age is relevant to RTW-ES, and in what way. Further research could elaborate on the direction of the association. Also of interest to further research is whether the professionals all consider these factors during a similar assessment, and whether the interpretation (e.g. the importance of a factor in a specific case) is comparable. It should be investigated whether the introduction of the results found in this study (i.e. an evidence-based protocol) will contribute to a more systematic approach by the professionals assessing RTW-ES. Also, if professionals have access to similar information for the assessment of RTW-ES, this could benefit the reliability of the assessment and the argumentation used in the decision-making process.
Competing interests
This study was funded by a SIG grant (Stichting Instituut Gak), the Netherlands. The authors declare no competing interests.
Authors' contributions
AM carried out the study and has drafted the manuscript. JHBG participated in the design of the study and helped to draft the manuscript. WELDB participated in the design of the study and helped to draft the manuscript. JWG participated in the design of the study and helped to draft the manuscript. SB helped carry out the study, participated in its design and coordination, and helped to draft the manuscript. All authors read and approved the final manuscript.