Persons on long term sick leave (defined as longer than 3 months) may benefit from interventions facilitating return to work.
The aim of this systematic review was to evaluate effects of interventions that may be initiated within the health care system. The primary outcome of interest was return to work. Secondary outcomes included intervention's effects on health and functioning. The aim was also to examine the cost-effectiveness of the evaluated interventions, highlight ethical aspects and identify scientific evidence gaps to guide future research.
A systematic review was conducted in accordance with the PRISMA statement. The protocol is registered in Prospero (CRD42022315330). The certainty of evidence was assessed with the GRADE framework. Studies considered for inclusion were targeting populations on sick leave due to the most common diagnoses for long term sick leave based on Swedish statistics. All types of interventions were considered and were characterized as unimodal (one treatment), multimodal (several treatment modalities), intervention including workplace contact or workplace coordination, and interventions aiming at health care personnel /organizations.
Results were summarized for short time (≤12 months) and long-time (>12 months) effects on return to work. Effects on health and/or function were assessed regardless of follow-up time.
Effects on costs and cost effectiveness were assessed based on results in included studies.
Ethical analysis was performed by the project group, which included an academic scholar in ethics. The method was mainly based on discussion, aimed at identifying conflicts of interest between different agents involved, and potential ethical dilemmas.
Persons on sick leave for a condition that is common when on long term sick leave according to Swedish statistics.
Any intervention that could be initiated within health care practice with the overall aim of facilitating return to work. Interventions could be unimodal or multimodal. Furthermore, it could be collaborative with other organisations, such as employer, occupational health care, or social insurance agency.
Any control, which could be no treatment, treatment as usual, wait list or other active treatment.
Primary: measures of sick leave, work participation and/or return to work.
Secondary: measures on health and or functioning.
Health economic outcomes: effects on cost and cost effectiveness
Randomized controlled studies, including cluster randomized studies.
At least 6 months follow-up.
We performed risk of bias assessments and included studies with low or moderate risk of bias in the analysis.
Due to extensive heterogeneity, we performed a synthesis without meta-analysis investigating effects for each intervention category (unimodal, multimodal, workplace contact or coordination, and interventions targeting heath care staff) and study populations on sick leave for mental disorder, musculoskeletal disorders, or both.
Language: English, Swedish, Norwegian or Danish.
Search period: From 2000 to 2022. Final search May, 2022.
Databases searched: Cochrane Library, EMBASE, PsycINFO (EBSCO) and Medline.
Client/patient involvement: No
We included 95 articles based on 68 unique studies. A total of 40 000 persons were evaluated for the return-to-work outcome. We included 10 studies that evaluated effects on costs and cost effectiveness.
Most of the studies included did not report significant findings on return to work.
We found low certainty evidence that unimodal, multimodal and workplace/coordination interventions may improve return to work.
| RTW = return to work; short = short period, 12 months or shorter; long = long period, longer than 12 months; HoF = Health or functioning. ⊕◯◯◯ = very low certainty, the effect is uncleart; ⊕⊕◯◯ = low certainty, the intervention may have a positive effect; Green colour = Positiv effect of the intervention; Orange colour = Unclear effect of the intervention |
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| Population | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Mental or muskuloskeletal disorder | Mental disorder | Muskuloskeletal disorder | ||||||||
| Outcome | RTW short |
RTW long |
HoF | RTW short | RTW long |
HoF | RTW short | RTW long |
HoF | |
| Type of intervention | Unimodal intervention | ⊕⊕◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕⊕◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ |
| Multimodal intervention |
⊕⊕◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕⊕◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | |
| Coordination/ Workplace intervention |
⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕⊕◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | |
| Interventions targeting health care personnel |
⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | ⊕◯◯◯ | |
Ten studies evaluating intervention effects on costs or cost effectiveness were included. It was not possible to assess overall effects based on categories of intervention types, due to the low number of studies in each category. It was concluded that also a small positive effect on return to work (> 5 days relative reduction in one year per person), would result in positive effects on a societal level.
The practice of sick leave and return to work is a complex ethical situation where patients may be vulnerable in terms of reduced autonomy and integrity.
Despite lots of well conducted research, few studies presented robust support of the relative effectiveness of the investigated intervention. Our results are in line with other systematic reviews in the area. We advise that well conducted research studies with positive findings is replicated in future research. There is a need present outcomes and results in a way that makes it possible to perform meta analyses.
In accordance with SBU’s requirements, the experts and scientific reviewers participating in this project have submitted statements about conflicts of interest. These documents are available at SBU’s secretariat. SBU has determined that the conditions described in the submissions are compatible with SBU’s requirements for objectivity and impartiality.
The full report in Swedish, Insatser i vården vid långtidssjukskrivning
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