Using occupational therapists in vocational clinics in primary care: a feasibility study

Background: GPs are under considerable pressure providing routine care. However, they may not be the most appropriate professionals to manage getting patients back to work, and keeping them there. Objective: To test the feasibility of delivering occupational therapy-led vocational clinics (OTVoc) to provide return to work advice and support for people with musculoskeletal conditions and mental health problems, in primary care. Methods: Prospective mixed methods study in two primary care centres (eight GP surgeries). We collected anonymised service level data on all patients receiving OTVoc. Next, patient participants who met inclusion criteria and consented, undertook baseline and 3-month follow-up assessments. Interviews were also conducted to explore stakeholders’ views- GPs, Nurse Practitioners, Front Desk Staff, Occupational Therapists, patients and their employers about OTVoc- and included study eligibility, referral, experiences and attitudes to return to work. Data were analysed using descriptive statistics and thematic analysis. Results: The majority of standardized measures showed some improvement over the study period: the sickness absence rate dropped from 71 to 15% and use of GP ‘fit’ notes reduced from 76 to 6%. Interview data indicated positive attitudes to OTVoc, the use of the fit note and the Allied Health Professions Health and Work Reports (AHP H&WRs). GPs felt that OTVoc reduced their workload. Conclusion: Further research is feasible and warranted. OTVoc was positively received and stakeholders believed it was effective in getting patients back to work or preparing for their return. There was enthusiasm for extending service eligibility criteria, suggesting potential for further development and evaluation

Investigating the barriers and facilitators to implementing Mental Health First Aid in the workplace: a qualitative study

Purpose: There has been little research into the use and efficacy of Mental Health First Aid across UK workplaces. The present study investigated the implementation of MHFA across six UK organisations, identifying key barriers and facilitators.Design: Twenty-seven workplace representatives were recruited from six organisations through purposive sampling and took part in semi-structured interviews exploring their experiences of workplace MHFA. The data underwent thematic analysis, identifyingkey themes around implementation.Findings: Implementation varied across organisations, including different reasons for initial interest in the programme, and variable ways that MHFA-trained employees operated post-training. Key barriers to successful implementation included negative attitudes around mental health, the perception that MHFA roles were onerous, and employees’ reluctance to engage in the MHFA programme. Successful implementation was perceived to be based on individual qualities of MHFA instructors and good practice demonstrated by trained individuals in the workplace. The role of the innerorganisational setting and employee characteristics were further highlighted as barriers and facilitators to effective implementation.Research implications: MHFA is a complex intervention, presenting in different ways when implemented into complex workplace settings. As such, traditional evaluation methods may not be appropriate for gaining insights into its effectiveness. Future evaluations of workplace MHFA must consider the complexity of implementing andoperationalising this intervention in the workplace.Originality: This study is the first to highlight the factors affecting successful implementation of MHFA across a range of UK workplaces

Is stroke early supported discharge still effective in practice? A prospective comparative study

Objective: Randomised controlled trials have shown the benefits of Early Supported Discharge (ESD) of stroke survivors. Our aim was to evaluate whether ESD is still beneficial when operating in the complex context of frontline healthcare provision. Design: We conducted a cohort study with quasi experimental design. A total of 293 stroke survivors (transfer independently or with assistance of one, identified rehabilitation goals) within two naturally formed groups were recruited from two acute stroke units: ‘ESD’ n=135 and ‘Non ESD’ n=158 and 84 caregivers. The ‘ESD’ group accessed either of two ESD services operating in Nottinghamshire, UK. The ‘Non ESD’ group experienced standard practices for discharge and onward referral. Outcome measures (primary: Barthel Index) were administered at baseline, 6 weeks, 6 months and 12 months. Results: The ESD group had a significantly shorter length of hospital stay (P=0.029) and reported significantly higher levels of satisfaction with services received (P<0.001). Following adjustment for age differences at baseline, participants in the ESD group (n=71) had significantly higher odds (compared to the Non ESD group, n=85) of being in the ⩾90 Barthel Index category at 6 weeks (OR = 1.557, 95% CI 2.579 to 8.733), 6 months (OR = 1.541, 95% CI 2.617 to 8.340) and 12 months (OR 0.837, 95% CI 1.306 to 4.087) respectively in relation to baseline. Carers of patients accessing ESD services showed significant improvement in mental health scores (P<0.01). Conclusion: The health benefits of ESD are still evident when evidence based models of these services are implemented in practice

Managing post-stroke fatigue : a qualitative study to explore multifaceted clinical perspectives

IntroductionPost-stroke fatigue (PSF) is common and debilitating. However, while its effective management is a priority for clinicians and stroke survivors, there remains little evidence to provide guidance or underpin practice. Our aim, therefore, was to gain insights into the experiences of clinicians who routinely manage patients with fatigue.MethodQualitative interview study. The target was to recruit a purposeful sample of approximately 20 participants with expertise in managing PSF and fatigue arising from other conditions. Maximum variation sampling was used to ensure a balance of participants across different settings. Data were analysed using a framework approach, iteratively developed and refined by including emergent themes.ResultsWe recruited 20 participants: nine occupational therapists (OTs), five physiotherapists, three nurses and three psychologists, which included three ‘fatigue experts’ from Europe and Australia. Analysis generated core themes around management and strategies used; these were similar regardless of professional background, clinical or geographical setting or condition treated. OTs felt a particular responsibility for fatigue management, although multidisciplinary teamwork was stressed by all.ConclusionThere are clear similarities in clinicians’ experiences of managing PSF and fatigue across different conditions and also across professional groups. Clinicians rely predominantly on their own clinical knowledge for guidance

Managing employees undergoing total hip and knee replacement: experiences of workplace representatives

Joint replacement is a cost-effective and efficient method of relieving pain, and improving function and health related quality of life, for people with arthritis of the hip and knee [1]. Arthritis-related loss of physical function is associated with unemployment, reduced income and increased sickness absence [2]. In a survey investigating the impact of osteoarthritis (OA), Fautrel et al found that OA has a substantial impact on work, with 20% of patients surveyed still in the workforce and two thirds of those reporting that OA was affecting their work [3]. These factors, in combination with an ageing workforce and changes to the pension age, have resulted in an increase in the number of hip and knee replacements carried out on people of working age over the past ten years. In 2015, 17,293 of 84,462 (20%) hip replacements and 16,121 of 94,437 (17%) knee replacements performed in England, Wales and Northern Ireland were in people aged under 60 years; 25,249 (30%) hip replacements and 32,321 (34%) knee replacements were performed on inpatients aged between 60-69 years [4]. Projections from 2005 suggest that by 2030, the demand for primary total hip (THR) and knee (TKR) replacements will increase by 174% and 673% respectively [5].Consequently return to work (RTW) will be a priority for an increasing proportion of the population following surgery

Return-to-work outcomes and usefulness of actual fit notes received by employers

Background: GPs can use the fit note to advise that a patient ‘may be fit’ or is ‘not fit’ for work. Previous employer-based research on the fit note is largely qualitative and based on general perceptions and past experience. Knowledge of the return-to-work outcomes and usefulness of actual fit notes is needed to strengthen the evidence-base and inform practice. Objective: To investigate the return-to-work outcomes of fit notes issued to employed patients, and their employers’ opinions as to the usefulness of each note. Methods: Participating organizations collecting fit notes were asked to rate the outcome and usefulness of each fit note via postal questionnaires. Quantitative data were analysed descriptively; qualitative data were analysed using thematic content analysis. Results: Five hundred and sixteen questionnaires were posted, with a 97% return rate (n = 498). More than 80% of employees (n = 44) returned to work after the expiry date of a ‘may be fit’ note compared with 43% (n = 167) of those issued with a ‘not fit’ note. Fit notes were considered more useful if they provided information on the condition and its effect on the employee’s ability to work, if they stated whether or not the employee needed reassessment and if clear advice regarding return-to-work had been provided. Conclusions: ‘May be fit’ notes are useful in helping employees return to work. However, this option is infrequently used, and the completion and content of many fit notes does not meet employers’ needs. These factors need to be urgently addressed if the fit note is to reach its full potential

Recommendations to facilitate the ideal fit note: are they achievable in practice?

Background: Although the UK fit note has been broadly welcomed as a tool to facilitate return to work, difficulties and uncertainties have resulted in wide variation in its use. Agreement on what constitutes the ‘ideal’ fit note from the perspective of all stakeholders is needed to inform best practice. A recent Delphi study conducted by the authors reached consensus on 67 recommendations for best practice in fit note use for employed patients. However, such recommendations are not necessarily followed in practice. The purpose of this study was therefore to investigate the perceived achievability of implementing these Delphi recommendations with a further reference panel of stakeholders. Methods: Potential participants were identified by the research team and study steering group. These included representatives of employers, government departments, trades unions, patient organisations, general and medical practitioners and occupational health organisations who were believed to have the knowledge and experience to comment on the recommendations. The consensus Delphi statements were presented to the participants on-line. Participants were invited to comment on whether the recommendations were achievable, and what might hinder or facilitate their use in practice. Free text comments were combined with comments made in the Delphi study that referred to issues of feasibility or practicality. These were synthesised and analysed thematically. Results: Twelve individuals representing a range of stakeholder groups participated. Many of the recommendations were considered achievable, such as improved format and use of the electronic fit note, completion of all fields, better application and revision of guidance and education in fit note use. However a number of obstacles to implementation were identified. These included: legislation governing the fit note and GP contracts; the costs and complexity of IT systems and software; the limitations of the GP consultation; unclear roles and responsibilities for the funding and delivery of education, guidance and training for all stakeholders, and the evaluation of practice. Conclusions: This study demonstrated that although many recommendations for the ideal fit note are considered achievable, there are considerable financial, legal, organisational and professional obstacles to be overcome in order for the recommendations to be implemented successfully

Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.

The Global Burden of Diseases, Injuries and Risk Factors 2017 includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data. METHODS: We estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting

Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.

How long one lives, how many years of life are spent in good and poor health, and how the population's state of health and leading causes of disability change over time all have implications for policy, planning, and provision of services. We comparatively assessed the patterns and trends of healthy life expectancy (HALE), which quantifies the number of years of life expected to be lived in good health, and the complementary measure of disability-adjusted life-years (DALYs), a composite measure of disease burden capturing both premature mortality and prevalence and severity of ill health, for 359 diseases and injuries for 195 countries and territories over the past 28 years. Methods We used data for age-specific mortality rates, years of life lost (YLLs) due to premature mortality, and years lived with disability (YLDs) from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to calculate HALE and DALYs from 1990 to 2017. We calculated HALE using age-specific mortality rates and YLDs per capita for each location, age, sex, and year. We calculated DALYs for 359 causes as the sum of YLLs and YLDs. We assessed how observed HALE and DALYs differed by country and sex from expected trends based on Socio-demographic Index (SDI). We also analysed HALE by decomposing years of life gained into years spent in good health and in poor health, between 1990 and 2017, and extra years lived by females compared with males. Findings Globally, from 1990 to 2017, life expectancy at birth increased by 7·4 years (95% uncertainty interval 7·1-7·8), from 65·6 years (65·3-65·8) in 1990 to 73·0 years (72·7-73·3) in 2017. The increase in years of life varied from 5·1 years (5·0-5·3) in high SDI countries to 12·0 years (11·3-12·8) in low SDI countries. Of the additional years of life expected at birth, 26·3% (20·1-33·1) were expected to be spent in poor health in high SDI countries compared with 11·7% (8·8-15·1) in low-middle SDI countries. HALE at birth increased by 6·3 years (5·9-6·7), from 57·0 years (54·6-59·1) in 1990 to 63·3 years (60·5-65·7) in 2017. The increase varied from 3·8 years (3·4-4·1) in high SDI countries to 10·5 years (9·8-11·2) in low SDI countries. Even larger variations in HALE than these were observed between countries, ranging from 1·0 year (0·4-1·7) in Saint Vincent and the Grenadines (62·4 years [59·9-64·7] in 1990 to 63·5 years [60·9-65·8] in 2017) to 23·7 years (21·9-25·6) in Eritrea (30·7 years [28·9-32·2] in 1990 to 54·4 years [51·5-57·1] in 2017). In most countries, the increase in HALE was smaller than the increase in overall life expectancy, indicating more years lived in poor health. In 180 of 195 countries and territories, females were expected to live longer than males in 2017, with extra years lived varying from 1·4 years (0·6-2·3) in Algeria to 11·9 years (10·9-12·9) in Ukraine. Of the extra years gained, the proportion spent in poor health varied largely across countries, with less than 20% of additional years spent in poor health in Bosnia and Herzegovina, Burundi, and Slovakia, whereas in Bahrain all the extra years were spent in poor health. In 2017, the highest estimate of HALE at birth was in Singapore for both females (75·8 years [72·4-78·7]) and males (72·6 years [69·8-75·0]) and the lowest estimates were in Central African Republic (47·0 years [43·7-50·2] for females and 42·8 years [40·1-45·6] for males). Globally, in 2017, the five leading causes of DALYs were neonatal disorders, ischaemic heart disease, stroke, lower respiratory infections, and chronic obstructive pulmonary disease. Between 1990 and 2017, age-standardised DALY rates decreased by 41·3% (38·8-43·5) for communicable diseases and by 49·8% (47·9-51·6) for neonatal disorders. For non-communicable diseases, global DALYs increased by 40·1% (36·8-43·0), although age-standardised DALY rates decreased by 18·1% (16·0-20·2)