Kate Radford return to work

Return to work after Background
Traumatic Brain Injury (TBI):
• Evidence-based practice is intrinsic to modern healthcare
A cohort comparison delivery and in recognition of this building research evidence

Kate Radford PhD • Development of Occupational Therapy interventions has been
Associate Professor in Rehabilitation Research identified as a major research priority for the profession (COT
University of Nottingham 2007).

Phillips J1, Drummond A1, Walker MF1, Sach T 2, Tyerman A3, • Occupational Therapy is a complex intervention (Creek 2003)
Haboubi N4, Jones T 5 and evaluating it is not straight forward.
1University of Nottingham, 2University of East Anglia, 3Cambourne Centre, Aylesbury, 4Nottingham
University Hospitals, 5Service User, Nottingham

College of Occupational College of Occupational
Therapists Therapists

MRC guidelines 2000 MRC guidance 2008
Sequential phases of developing randomised controlled Key elements of the development and evaluation process
trials of complex interventions.

Campbell M et al. BMJ 2000;321:694-696 Craig P et al. BMJ 2008;337:bmj.a1655
©2000 by British Medical Journal Publishing Group ©2008 by British Medical Journal Publishing Group

Feasibility and
Feasibility Studies answer the piloting

question Development Evaluation
Pilot Studies
“Can this study be done?”
Implementation
• version of the main study run in miniature -tests whether
components of the main study can all work together
• Standard deviation of primary outcome measure to estimate • focus on the processes of the main study, e.g. ensure
sample size; recruitment, randomisation, treatment, and follow-up
• willingness of participants to be randomised assessments all run smoothly.
• willingness of clinicians to recruit participants • resemble main study in many respects, including an
• number of eligible patients; assessment of the primary outcome.
• characteristics of the proposed outcome measure and in some • Sometimes the first phase of the substantive study (internal
cases feasibility studies might involve designing a suitable outcome pilot) Or data analysed separately (external pilot).
measure;
• follow-up rates, response rates to questionnaires,
adherence/compliance rates College of Occupational College of Occupational

1

Feasibility and
piloting
Background
Aims: Development Evaluation

Return to work after traumatic brain injury (TBI) Implementation

• Primary goal (Carlson et al. 2006) • Is TBI specialist VR delivered by an OT part
• Low rates of post injury employment: of a specialist TBI team more effective at
41% (range 0-85%) in work at 1 and 2 years (Van Velzen
supporting work return and retention 12
et al. 2009)

• Failing Rehabilitation? months after injury in people with TBI
• Economic Impact -2.8 Billion Euros (Rickels et al. 2010) than usual care?
• Patchy UK provision (Deshpande and Turner Stokes, 2004, Playford et al .2011) • What is the feasibility of collecting and
evaluating economic data?

Method
TBI survivors all severities
Recruitment ≤ 4 weeks post discharge

Specialist Service = Routine Care =
Nottingham Traumatic Brain Injury Service Patients outside the
Minor TBI = OT Only catchment area

Postal follow up, 3, 6 and 12 months



2

Recruitment (22 months) Baseline difference
252 Non- Intervention group in hospital for 11 days less
382 potential people identified eligible people Intervention group = mean12 days (sd 20)*
Non intervention group = mean 23 days (sd 21)*
130 eligible 36 (27.4%) (Mann Whitney U p=0.004)
declined

94 in study

40 Intervention group 54 Non-intervention group
32 Men (80%) 45 men (83%)
33 Mean 34 years (18-66) Mean 34 years (16-68)
Mean GCS 9.4 Mean GCS 10.3

Return to work – all participants Return to work – moderate/severe TBI
27%
100% difference
Percentage at work

100% 15% OR 3.05 (0.9,10.6)
80%
Percentage in work

80% difference 8% χ2= p= 0.07

60%
12% difference
60% 40%
more in
40% work 20%
20% 0%
0% Pre-injury 4 weeks 3 months 6 months 12 months
Pre-injury 4 weeks 3 months 6 months 12 months
Time since injury
Time since injury
Interventon group Non intervention Interventon group Non intervention

Return to Work – minor TBI Pilot 12 month - cost effectiveness analysis
37%
120% difference 10%
Fischer's p=0.03 difference Mean Intervention Non- Mean
100%
costs group intervention difference
Percentage in work

80%
per group per person
60%
person
40%

20%
Health £2107 £2032 +£75
0%
costs
Pre-injury 4 w eeks 3 months 6 months 12 months
Time since injury
Society £8786 £10648 -£1862
costs
Intervention group Non intervention College of Occupational
Therapists
College of Occupational
Therapists

3

Incremental Cost Effectiveness Ratio 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
Therapists

The International Classification of
Functioning (WHO)

What did the
OT do?

E.g. Confidence,
Experience etc.


Some key points Aim + Method

• Recognises the importance of both health and social Aim
factors in influencing success of vocational • To determine the content of OT intervention
rehabilitation programmes
Method
• Programmes need to address impairment, activity, • Designed a proforma
personal and social / environmental factors to be • Had 15 sections
effective
• Recorded OT treatment in 10 min units after
every session


4

Sections on the proforma Work Preparation 10 RTW process 10
min min
• Where seen • Cognitive/Executive Routines/time keeping RTW planning meeting
• Assessment skills Discuss work options Work assessment meeting
• Current issues • Work preparation Patient contact with work Monitoring and grading
• Goals • Return to work process place meetings
• Personal ADL
• Miscellaneous Detailed job analysis Maintenance meetings
• Education about TBI
• Liaison Identify potential Written information to
• Instrumental ADL problems/solutions employers
• General issues
• Physical issues Pacing/fatigue Statutory issues
• Psychological issues Other Other

Participants = 29
Results Glasgow
Coma Score
Severe 14 (48%),
Moderate 7 (24%)
Minor 8 (28%)

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
Therapists

Outcome of Intervention Style of Intervention
• At discharge 25/29 (86%) = work/study 16
14
Number of participants

14
12
10
– 22/29 (76%) returned to previous 8
8

employer/college in some capacity 6
4
5

2
– 3/29 (10%) had started a new job 2
0
– 4/29 (14%) were not working (2 disengaged) Advice only 7% Treatment only Treatment and Treatment and
- no direct employer involvement of
employer involvement others* 17%
involvement 28%
• Everyone remained in work for 18 48%
months *DEA’s, Occ health doctor, pathway providers

5

Intervention content Top 5 work concessions
• 66% of the OT intervention directly • Flexible extra breaks (18%)
focused on RTW: • Decreased hours (18%)
– Work preparation (23%) • Reduced duties (15%)
– Assessment (15%) • Reduced days (15%)
– RTW process (13%) • Flexible start/finish times (13%)
– Current issues (15%)
• Graded return to work = 88% participants

• No intervention on PADL

Distribution of OT time per participant Amount of Treatment
Summary of OT • 65% of treatment in people’s homes
time • 17% of treatment in the work place
OT travel

OT non
21%
• Average session approx 1 hour
participant 1/3 = face to face
face to
face intervention • Mean no. OT sessions –
OT admin
liasion
36% 11%
– mod/severe TBI 7 (1-23)
1/3 = Liaison – minor TBI 4 (2-7)
1/3 = Admin and • Mean length of intervention
OT face to
face with
travel – mod/severe TBI = 9 ½ months (21-838 days)
participant
31% – minor TBI = 4 ½ months (23-188 days)


Clinical Implications
Use of the proforma
Key messages Intervention
Positive Negative • Job Brokerage and re- • Important to be work
• Quick to use training is hard - more focused
• Some interventions
• Captured main difficult to categorise likely to return to • Clinicians need liaison
treatment focus previous employer and travel time
• Redundant categories • Advise patients to
keep options open
Conclusion
Proforma has potential for development Work site visits: Need flexibility


6

Lack of consensus
Limitations and lessons
• What is outcomes
Measuring work?
• What counts as success? • Small opportunistic study – pragmatic approach
• What are the outcomes of building on existing NHS service expertise
health based vocational • Non-randomised, underpowered = uncertainty
rehabilitation intervention?
• Intervention of a single OT on TBI survivors intending
to return to work
• How should VR
interventions be • OT – PhD study
– Known to acute services = advantage in recruitment
described?
– Persistent, dedicated and determined
– Knowledge of local services – useful in costing care


Problems The Model
• No TBI Register • Early, Specialist, Health based, Community (Outreach)
Rehabilitation
• Follow up problematic in TBI – ‘Early’ - identifies people at point of injury to prevent job loss
• Costing Usual Care - Identifying with certainty – ‘Specialist’ - TBI specialist & VR specific knowledge
which services were involved – ‘Health Based’ - delivered by NHS professionals in health setting
– ‘Mixed’ - work return and work retention
• Limited Funding (COT) focussed on OT rather
– ‘Community Rehabilitation’ - delivered in community
than team input


Feasibility and
piloting
NEXT STEPS
Next steps - Feasibility RCT to explore.....
Feasibility Study to explore…. Development Evaluation

Implementation
• Eligible numbers • Completeness of follow up
• Recruitment rate of the primary endpoint
• Research objectives • Can participants be
• The spectrum of
• Can we develop a treatment manual, training package and randomised to the
mentoring model and implement it, so that the ‘Nottingham VR
disease among recruits
intervention’ can be delivered in 3 NHS regional TBI referral • Reasons for non intervention ?
centres? recruiting • The likely effect on drop out
• Can we conduct a randomised trials comparing early specialist TBI • Compliance with VR of randomisation to the
vocational rehabilitation (ESTVR) in addition to standard care with
and with usual care control group
standard care alone
• Are the measures fit for • Can we capture economic
• Can we identify Primary outcomes of an NHS based ESTVR data from TBI survivors?
important to service users, NHS service providers and purpose
commissioners? College of Occupational
Therapists

7

Promoting high quality research to
develop rehabilitation practices References
which are effective, relevant and
• Carlson, P. M., M. L. Boudreau, J. Davis, J. Johnston, C. Lemsky, M. A. McColl, P.
forward thinking. 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
A forum to: systematic review. Brain Inj 23(6): 473-88
• Waddell, G., A. K. Burton and N. A. Kendal (2008). Vocational Rehabilitation. What
• Raise the profile of rehabilitation research works, for whom, and when? Vocational Rehabilitation Task Force Group and I. I. A.
Council, TSO (The Stationery Office).
• Encourage evaluation through well designed studies • 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
• Foster a climate for developing and sharing skills 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
• Enable active researchers to share the results of acquired brain injury, Inter-agency guidelines,. British Society of Rehabilitation
Medicine, jobcentreplus, Dept for Work and Pensions, Royal College of Physicians,
their work Clinical Effectiveness and Evaluation Unit, .
• Ownsworth, T. and K. McKenna (2004). Investigation of factors related to
• Advance rehabilitation practice for acute and chronic employment outcome following traumatic brain injury: a critical review and conceptual
model. Disabil Rehabil 26(13): 765-83.
disabling conditions

www.srr.org.uk College of Occupational College of Occupational
Therapists
Therapists

8

Kate Radford return to work

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