kate radford return to work

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College of Occupational

Therapists

Return to work after

Traumatic Brain Injury (TBI):

A cohort comparison

Kate Radford PhD Associate Professor in Rehabilitation Research

University of Nottingham

Phillips J1, Drummond A1, Walker MF1, Sach T2, Tyerman A3,

Haboubi N4, Jones T5

1University of Nottingham, 2University of East Anglia, 3Cambourne Centre, Aylesbury, 4Nottingham University Hospitals, 5Service User, Nottingham


Therapists

Background

• Evidence-based practice is intrinsic to modern healthcare delivery and in recognition of this building research evidence

• Development of Occupational Therapy interventions has been identified as a major research priority for the profession (COT 2007).

• Occupational Therapy is a complex intervention (Creek 2003) and evaluating it is not straight forward.


Therapists

MRC guidelines 2000

Sequential phases of developing randomised controlled

trials of complex interventions.

Campbell M et al. BMJ 2000;321:694-696

©2000 by British Medical Journal Publishing Group


Therapists

MRC guidance 2008

Key elements of the development and evaluation process

Craig P et al. BMJ 2008;337:bmj.a1655

©2008 by British Medical Journal Publishing Group


Therapists

Feasibility Studies answer the question “Can this study be done?”

• Standard deviation of primary outcome measure to estimate sample size;

• willingness of participants to be randomised

• willingness of clinicians to recruit participants

• number of eligible patients;

• characteristics of the proposed outcome measure and in some cases feasibility studies might involve designing a suitable outcome measure;

• follow-up rates, response rates to questionnaires, adherence/compliance rates

Feasibility and piloting

Development Evaluation

Implementation


Therapists

Pilot Studies

• version of the main study run in miniature -tests whether components of the main study can all work together

• focus on the processes of the main study, e.g. ensure recruitment, randomisation, treatment, and follow-up assessments all run smoothly.

• resemble main study in many respects, including an assessment of the primary outcome.

• Sometimes the first phase of the substantive study (internal pilot) Or data analysed separately (external pilot).

http://www.cot.org.uk/






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Therapists

Background

Return to work after traumatic brain injury (TBI)

• Primary goal (Carlson et al. 2006)

• Low rates of post injury employment:

41% (range 0-85%) in work at 1 and 2 years (Van Velzen

et al. 2009)

• Failing Rehabilitation?

• Economic Impact -2.8 Billion Euros (Rickels et al. 2010)

• Patchy UK provision (Deshpande and Turner Stokes, 2004, Playford et al .2011)


Therapists

Aims:

• Is TBI specialist VR delivered by an OT part of a specialist TBI team more effective at supporting work return and retention 12 months after injury in people with TBI than usual care?

• What is the feasibility of collecting and evaluating economic data?



Implementation


Therapists

TBI survivors all severities

Recruitment ≤ 4 weeks post discharge

Specialist Service =

Nottingham Traumatic Brain Injury Service

Minor TBI = OT Only

Postal follow up, 3, 6 and 12 months

Routine Care =

Patients outside the catchment area

Method


Therapists


Therapists


Therapists







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Therapists

382 potential people identified

36 (27.4%)

declined

94 in study

40 Intervention group

32 Men (80%)

33 Mean 34 years (18-66)

Mean GCS 9.4

54 Non-intervention group

45 men (83%)

Mean 34 years (16-68)

Mean GCS 10.3

130 eligible

252 Non-

eligible people

Recruitment (22 months)


Therapists

Baseline difference

Intervention group in hospital for 11 days less

Intervention group = mean12 days (sd 20)*

Non intervention group = mean 23 days (sd 21)* (Mann Whitney U p=0.004)


Therapists

Return to work – all participants

0%

20%

40%

60%

80%

100%

Pre-injury 4 weeks 3 months 6 months 12 months

Time since injury

Percen

tag

e in

wo

rk

Interventon group Non intervention

15% difference

12%

more in

work


Therapists

Return to work – moderate/severe TBI

0%

20%

40%

60%

80%

100%

Pre-injury 4 weeks 3 months 6 months 12 months

Time since injury

Percen

tag

e a

t w

ork

Interventon group Non intervention

27%

difference OR 3.05 (0.9,10.6)

χ2= p= 0.07 8%

difference


Therapists

Return to Work – minor TBI

0%

20%

40%

60%

80%

100%

120%

Pre-injury 4 w eeks 3 months 6 months 12 months

Time since injury

Percen

tag

e in

wo

rk

Intervention group Non intervention

37%

difference Fischer's p=0.03

10%

difference


Therapists

Pilot 12 month - cost effectiveness analysis

Mean

costs

per

person

Intervention

group

Non-

intervention

group

Mean

difference

per person

Health

costs

£2107 £2032 +£75

Society

costs

£8786 £10648 -£1862







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Therapists

Incremental Cost Effectiveness Ratio


Therapists

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


Therapists

What did the

OT do?


Therapists

E.g. Confidence, Experience etc.

The International Classification of Functioning (WHO)


Therapists

Some key points

• Recognises the importance of both health and social factors in influencing success of vocational rehabilitation programmes

• Programmes need to address impairment, activity, personal and social / environmental factors to be effective


Therapists

Aim + Method

Aim

• To determine the content of OT intervention

Method

• Designed a proforma

• Had 15 sections

• Recorded OT treatment in 10 min units after

every session







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Therapists

Sections on the proforma

• Where seen

• Assessment

• Current issues

• Goals

• Personal ADL

• Education about TBI

• Instrumental ADL

• Physical issues

• Psychological issues

• Cognitive/Executive

skills

• Work preparation

• Return to work process

• Miscellaneous

• Liaison

• General issues


Therapists

Work Preparation 10

min RTW process 10

min

Routines/time keeping RTW planning meeting

Discuss work options Work assessment meeting

Patient contact with work

place

Monitoring and grading

meetings

Detailed job analysis Maintenance meetings

Identify potential

problems/solutions

Written information to

employers

Pacing/fatigue Statutory issues

Other Other


Therapists

Results


Therapists

Participants = 29 Glasgow

Coma Score

Severe 14 (48%), Minor 8 (28%)

Moderate 7 (24%)

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%),

Semi-skilled 10 (34%), Unskilled 9 (31%)


Therapists

Outcome of Intervention

• At discharge 25/29 (86%) = work/study

– 22/29 (76%) returned to previous

employer/college in some capacity

– 3/29 (10%) had started a new job

– 4/29 (14%) were not working (2 disengaged)

• Everyone remained in work for 18

months


Therapists

Style of Intervention

2

14

8

5

0

2

4

6

8

10

12

14

16

Advice only 7% Treatment only

- no direct

employer

involvement

48%

Treatment and

employer

involvement

28%

Treatment and

involvement of

others* 17%

Num

ber

of part

icip

ants

*DEA’s, Occ health doctor, pathway providers







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Therapists

Intervention content

• 66% of the OT intervention directly focused on RTW:

– Work preparation (23%)

– Assessment (15%)

– RTW process (13%)

– Current issues (15%)

• No intervention on PADL


Therapists

Top 5 work concessions

• Flexible extra breaks (18%)

• Decreased hours (18%)

• Reduced duties (15%)

• Reduced days (15%)

• Flexible start/finish times (13%)

• Graded return to work = 88% participants


Therapists

OT travel21%

OT admin11%

OT face to face with participant31%

OT non participant face to face liasion

36%

Summary of OT

time

1/3 = face to face

intervention

1/3 = Liaison

1/3 = Admin and

travel

Distribution of OT time per participant


Therapists

Amount of Treatment

• 65% of treatment in people’s homes

• 17% of treatment in the work place

• Average session approx 1 hour

• Mean no. OT sessions –

– mod/severe TBI 7 (1-23)

– minor TBI 4 (2-7)

• Mean length of intervention

– mod/severe TBI = 9 ½ months (21-838 days)

– minor TBI = 4 ½ months (23-188 days)


Therapists

Use of the proforma

Positive

• Quick to use

• Captured main

treatment focus

Negative

• Some interventions difficult to categorise

• Redundant categories

Conclusion

Proforma has potential for development


Therapists

Clinical Implications

Key messages

• Job Brokerage and re-training is hard - more likely to return to previous employer

• Advise patients to keep options open

Intervention

• Important to be work focused

• Clinicians need liaison and travel time

Work site visits: Need flexibility







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Therapists

Measuring outcomes

• What is work?

• What counts as success?

• What are the outcomes of

health based vocational

rehabilitation intervention?

• How should VR

interventions be

described?

Lack of consensus


Therapists

Limitations and lessons

• Small opportunistic study – pragmatic approach building on existing NHS service expertise

• Non-randomised, underpowered = uncertainty

• Intervention of a single OT on TBI survivors intending to return to work

• OT – PhD study – Known to acute services = advantage in recruitment

– Persistent, dedicated and determined

– Knowledge of local services – useful in costing care


Therapists

Problems

• No TBI Register

• Follow up problematic in TBI

• Costing Usual Care - Identifying with certainty which services were involved

• Limited Funding (COT) focussed on OT rather than team input


Therapists

The Model

• Early, Specialist, Health based, Community (Outreach) Rehabilitation

– ‘Early’ - identifies people at point of injury to prevent job loss

– ‘Specialist’ - TBI specialist & VR specific knowledge

– ‘Health Based’ - delivered by NHS professionals in health setting

– ‘Mixed’ - work return and work retention

– ‘Community Rehabilitation’ - delivered in community


Therapists

NEXT STEPS Feasibility Study to explore….

• Research objectives

• Can we develop a treatment manual, training package and mentoring model and implement it, so that the ‘Nottingham VR intervention’ can be delivered in 3 NHS regional TBI referral centres?

• Can we conduct a randomised trials comparing early specialist TBI vocational rehabilitation (ESTVR) in addition to standard care with standard care alone

• Can we identify Primary outcomes of an NHS based ESTVR important to service users, NHS service providers and commissioners?



Implementation

Next steps - Feasibility RCT to explore.....

• Eligible numbers

• Recruitment rate

• The spectrum of disease among recruits

• Reasons for non recruiting

• Compliance with VR and with usual care

• Are the measures fit for purpose

• Completeness of follow up of the primary endpoint

• Can participants be randomised to the intervention ?

• The likely effect on drop out of randomisation to the control group

• Can we capture economic data from TBI survivors?







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Therapists

Promoting high quality research to

develop rehabilitation practices

which are effective, relevant and

forward thinking.

A forum to:

• Raise the profile of rehabilitation research

• Encourage evaluation through well designed studies

• Foster a climate for developing and sharing skills

• Enable active researchers to share the results of

their work

• Advance rehabilitation practice for acute and chronic

disabling conditions

www.srr.org.uk


Therapists

References • Carlson, P. M., M. L. Boudreau, J. Davis, J. Johnston, C. Lemsky, M. A. McColl, P.

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 systematic review. Brain Inj 23(6): 473-88

• Waddell, G., A. K. Burton and N. A. Kendal (2008). Vocational Rehabilitation. What works, for whom, and when? Vocational Rehabilitation Task Force Group and I. I. A. Council, TSO (The Stationery Office).

• 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 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 acquired brain injury, Inter-agency guidelines,. British Society of Rehabilitation Medicine, jobcentreplus, Dept for Work and Pensions, Royal College of Physicians, Clinical Effectiveness and Evaluation Unit, .

• Ownsworth, T. and K. McKenna (2004). Investigation of factors related to employment outcome following traumatic brain injury: a critical review and conceptual model. Disabil Rehabil 26(13): 765-83.


http://www.srr.org.uk/


kate radford return to work

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