How to make a national priority into a clinical reality

Prof Juan A. Jover,

Rheumatology Service Hospital Clnico San Carlos, Spain

How to make a national priority

into a clinical reality

Juan A. Jover, Rheumatology Service Hospital Clnico San Carlos, Madrid. Spain

A (long) journey from data to results

The reservoir of knowledge

Research

Dissemination

Applications

The reservoir of knowledge

Musculoskeletal, Rheumatic, Osteoarticular, Diseases, Disorders

Joints Connective Tissue Spine Soft tissue Bone Generalized pain

Characteristics

High incidence and prevalence

Chronic course High impact in quality of life: Pain and Disability

Burden of diseases in Canada, 2000

http://www.phac-aspc.gc.ca/ph-sp/preveco-01-eng.php#fig1 Adapted from IHE, 2008; data from the Public Health Agency of Canada

The complexity of Work Disability

Occupational Process
- Economic Activity - Employers - Unions - Occupational Health

Sanitary Process
- Individual factors - Collective - Public Health - Health System
- Primary Care - Specialized care

Administrative Process
- Compensation - Laws - Control - Fraud TWD

What if?
PWD

MSD-TWD Program (98-01)

Inclusion: 12 months

Follow-up: 12 months

Control

TWD initiation due to MSDs (13.000 nonselected patients)

Intervention

Results Days of TWD Patients with PWD Direct Costs Indirect Costs Cost/efficacy Cost/benefit

Three health districts in Madrid Randomized study Voluntary program Patients maintained their group Intention to treat analysis

Early Intervention Protocolized clinical management Patient Education Self-management Administrative Duties

Research: a clinical approach to MSD-WD

39 % reduction of TWD duration (days)

% of patients back to work

100

50% reduction of PWD (cases)

Increased patient satisfaction Positive Economic evaluation 40% Decreased direct costs Control Intervention 50% Decreased indirect costs 1.110 % benefit at two years Positive Extension of the Program > 38.000 processes >1 million days off-work saved

0 0

25

50

75

30

60

90

120 150 180 210 240 270 300 330 360

Days

What to do with patients not doing well?

Early Cognitive Behavioural Intervention Psycho MSD-TWD 04

% of patients back to work

75

100

MSD-TWD program
50 0 0 25

30

60

90

120

150

180

210

240

270

300

330

360

Days

Early Psychological intervention

181 patients of the MSD-TWD program, off-work at 3 - 6 weeks Randomization
MSD-TWD Program
MSD-TWD Program + CBT Intervention
1.00

1.00

0.75

0.75

0.50

0.50

0.25 0.00
40 60 80 100 120 140 160 180 200 220 240 260

0.25

0.00
0 40 80 120 160 200 240 280 320 360

First TWD episode

TWD relapses

System Dynamics Model of TWD

(1) d SWDE(t) EST WD(t)- EFSWD(t)- ES2LWD(t) dt SWDE(t) MDSWDE (2) EFSWD(t)

(Valve 0)

if t MDSWDE 0 (3) ES2LWD(t) PES2L SWDE(t) if t MDSWDE 100

(Valve 2)

(Valve 1)
(4) d LWDE(t) ES2LWD(t)- EFLWD(t)- EAPD(t) dt LWDE(t) MDLWD

(5) EFLWD(t)

(Valve 4)

(Valve 3)

(6) EAPD(t)

PEAPD LWDE(t) 100

(7 )

d EWPD(t) EAPD(t) - EGPD(t) - UERW(t) dt (100 - PUPD) EWPD(t) 100 MWT PD PUPD EWPD(t) 100 MWT PD

(Valve 6) (Valve 5)
(8) EGPD(t)

(9) UERW(t)

(10)

d ERW(t) EFSWD(t) EFLWD(t) UERW(t) dt d EPD(t) EGPD(t) dt

(11)

(12) EFT WD(t) EFSWD(t) EFLWD(t) (13) ET WD(t) SWDE(t) LWDE(t)

System Dynamics Model of TWD: An hydraulic analogy

Active Workers

Valve 0 Valve 1 Valve 2

ST-TWD

MSD-TWD program (40%)

Psycho-TWD program (20%)

Valve 4

Valve 3

LT-TWD
Valve 6 Valve 5

PWD EVAL

PWD Concession

Return to Work

Dissemination
Labour environment

Secondary Outputs

Occupational Process Funding of Programs Support of Programs Administrative Process

National Institute of Social Security

Sanitary Process Employers, Unions, Occupational Health

Policy Makers
Senate Ministry of Health Autonomous Communities

Proposal for a MSD National Strategy National Rheumatic Diseases Strategy Regional Plans in Rheumatic Diseases

Health Professional Body

Primary care
Rheumatology clinical leaders

WD as a clinical problem

Recommendations for clinicians

Disability is the major Health problem in Clinical Rheumatology Include Work Disability as one of your major Clinical Objectives TWD and PWD are Health indicators, that could help you to improve your Service Organization, regarding:
Access
Process Health Outcomes

An early, clinical approach to TWD is highly efficient

Patients with serious, autoimmune conditions Patients with banal diseases and recent-onset TWD

Applications
TWD programs in (3) different Autonomous Communities
Inspection Services Primary care

Rheumatology Services

Procedures
TWD episodes are a fixed phenomenon, in a given population Access in the first week of TWD Close follow up until return to work Specific Clinical Protocols

Funding
NHS National Institute of Social Security Public-Private Partnership

Routine access of new patients (HCSC)

N
% Inflammatory

QoL Poor or Very Poor

4.000 General
WL 30-40 days

9%

Disability
WL < 7 days

1.700

7,5%

x5

Urgent
LE < 72 h

1.700

13%

x 10

Health Service Research

Access

Care Process

Health Results

ICT-EHR

Thanks
MSD-TWD Team
Lydia Absolo Gloria Candelas Margarita Blanco Cristina Lajas Petisco Csar Hernndez-Garca Benjamn Fernndez-Gutirrez Leticia Len
Javier Bachiller Paz Collado Marcelino Revenga Patricia Ricci Pablo Lzaro Maria Dolores Aguilar Emilio Vargas Loreto Carmona

Fundacin ABBOTT Espaa

Antonio Baares Sara Pascual