Australian Perspectives on the GPs Role in Return To Work: Results of Recent Research

Transcription

1 Australian Perspectives on the GPs Role in Return To Work: Results of Recent Research Danielle Mazza 1, Bianca Brijnath 1, Agnieszka Kosny 2, Nabita Singh 1, Rasa Ruseckaite 3 and Alex Collie 2,3, 1 Department of General Practice, 2 Department of Epidemiology and Preventive Medicine, 3 Institute for Safety Compensation and Recovery Research

2 Background Meaningful, safe and sustainable work is good for health Work is the best medicine the AFOEM Statement (>150 signatories) With almost 96% of injured worker claims originating in the general practice setting, GP s are the key gatekeeper Few available studies on the role of healthcare providers in facilitating RTW and no Australian studies explicitly focusing on the role of GPs in facilitating RTW. International data shows GPs encounter a number of barriers to facilitating RTW.

3 Aim To provide an understanding of the GPs role in facilitating RTW and the barriers encountered in this process. Study was funded by WorkSafe Victoria and the Transport Accident Commission.

4 Mixed methods Qualitative Quantitative Sept-Dec 12 Compensation Research Database WorkSafe Victoria 93 interviews: 25 GPs, 17 injured persons, 25 employers and 26 Compensation agents GP claims certificates (~125,000 injured persons; ~10,000 GPs) Data thematically analysed Jan 03 - Dec 10 4

5 Qualitative sample Group (n) Mean age (SD) Gender (n) Mean years of experience in current job role (SD) GPs (25) 52 yrs (10.2) Male = 72% (18) Female = 28% (7) Employers (EMP) (25) 45 yrs (11.8) Male = 36% (9) Female = 64% (16) Compensation agents (CS) (26) 34 yrs (9.4) Male = 15% (4) Female = 85% (22) Injured persons (17) Mean Age (SD) 48yrs (13.7) Gender (n) Men = 71% (12) Women = 29% (5) Primary injury type (n) Musculoskeletal = 71% (12) MHC = 18% (3) Both = 12% (2) Development of secondary Yes = 67% (8) MHC in 12 MSK claims (n) No = 33% (4) Clients back at work (n) Yes = 47% (8) No = 53% (9) Time since injury (n) 3-6months = 29% (5) 6-9months = 0 > 9months = 71% (12) 24 yrs (11.8) 9 yrs (6.5) 7 yrs (5.7)

6 Quantitative sample Condition Injured persons Total certificates Unfit for work certificates Gender (M/F) Mean (SD) age in years at onset Numb er (%) Rate, 95%CI Number (%) Rate, 95%CI Alternate duties certificates Numb er (%) Rate, 95%CI Numbe r (%) Fit for work certificates Rate, 95%CI Fractures MSK injuries and diseases Back pain and strain Other traumatic injuries Mental health conditions Other diseases 8,668/3,434 (71.6/28.4) 31,490/18,5 62 (62.9/37.1) 14,835/4,63 2 (76.2/23.8) 12,831/7,55 7 (62.9/37.1) 5,416/7,247 (42.8/57.2) 7,730/2,022 (79.3/20.7) Total 80,970/43,4 54 (65.1/34.9) 40.9 (13.1) 42.8 (11.5) 38.3 (13.2) 40.8 (11.6) 43.4 (10.3) 44.2 (11.5) 41.8 (11.9) 12,102 (100) 50,052 (100) 19,467 (100) 20,388 (100) 12,663 (100) 9,752 (100) 124,42 4 (100) 0.83 [ ] 3.45 [ ] 1.34 [ ] 1.40 [ ] 0.87 [ ] 0.67 [ ] 8.57 [ ] 9,838 (81.3) 34,055 (68.0) 15,401 (79.1) 15,816 (77.6) 11,911 (94.1) 5,172 (53.0) 92,193 (74.1) 0.68 [ ] 2.35 [ ] 1.06 [ ] 1.09 [ ] 0.82 [ ] 0.36 [ ] 6.35 [ ] 2,051 (16.9) 14,134 (28.2) 3,414 (17.5) 4,218 (20.7) 610 (4.8) 3,889 (39.9) 28,316 (22.8) 0.14 [ ] 0.97 [ ] 0.24 [ ] 0.29 [ ] 0.04 [ ] 0.27 [ ] 1.95 [ ] 213 (1.8) 1,863 (3.7) 652 (3.3) 354 (1.7) 142 (1.1) 691 (7.1) 3,915 (3.1) 0.01 [ ] 0.13 [ ] 0.04 [ ] 0.02 [ ] 0.01 [ ] 0.05 [ ] 0.27 [ ]

7 Key themes from the qualitative and quantitative research 1. Differing views about the role of the GP 2. GP certification practices: what is actually happening? 3. The added complexity and burden of mental health claims 4. Key barriers and enablers for GPs to facilitate RTW 5. Issues with the certificate of capacity

8 Differing views about the role of the GP GPs are considered the key gatekeeper for facilitating injured worker RTW by all four stakeholder groups. However there is a dissonance between the various groups understanding of the GP role: I see that I m an advocate for the patient and I m also basically mostly trying to concentrate on treating their actual medical problem or the injury (GP#20, f, 47yo, 21 ye). I would like to see them [GPs] empowered to have a bit more confidence to actually have some stronger conversations with their clients around RTW (CS17,f,26yo,2ye). 8

9 GPs certification practices: What is actually happening?

10 GPs certification practices: What is actually happening? 124,424 initial medical certificates issued by GPs: 74.1% unfit for work 22.8% alternative duties UFW certificates issued to: 94.1% with mental health conditions 81.3% with fractures 79.1% with other traumatic injuries 77.6% with back pain and strains 68.0% with musculoskeletal conditions 53.0% with other diseases. Alternative-duties certificates were significantly longer in duration than UFW certificates.

11 GPs certification practices: What is actually happening? Dissonance about the GP s role in certification between the stakeholder groups. The heart-sink patients are patients the WorkCover ones that make us all shudder there s all this conflict between the insurance company itself, the employer, the patient [and] we are stuck in the middle. (GP#19, f, 37yo, 13ye). Poor communication between stakeholders Allegations of patient malingering and provider over-servicing. The patient s social circumstances Relationship between the employer and the injured person Age (older workers less likely to RTW) Availability of sick leave Childcare responsibilities at home Mazza et al. In prep. Br J. Gen Prac

12 The added complexity and burden of mental health claims Mental Health Claims Management and Return to Work: Qualitative Insights from Melbourne, Australia Bianca Brijnath 1*, Danielle Mazza 1, Nabita Singh 1, Agnieszka Kosny 2, Rasa Ruseckaite 3 and Alex Collie 2,3 J Occup Rehab doi: /s Accepted 5 March 2014

13 The added complexity and burden of mental health claims GP certification behaviour has changed over time: Increase in Unfit for Work (UFW) certificates mainly for mental health condition claims. Women are the main recipients of UFW certificates for mental health condition claims. Certified duration of time off work for female claimants increasing over time

14 The added complexity and burden of mental health claims Assessment & Diagnostic difficulties: The most difficult part of a stress claim is working out the validity of it to start with, whether work is a contributing or significant factor (EMP5, f,53 yo,7ye). Conflicting medical opinions:...the doctors being the advocate for the worker, you got the other side of the coin with independent medical examiners being branded insurance doctors saying the other thing (CS#18, m, 61yo, 4ye). Stigma: I felt guilty. I felt as if, I was questioning myself whether I was putting it all on, whether it was for real, whether you know maybe I should be back at work (IP#10, f, 61yo). MH as a secondary illness: If you ve got injury where pain lasts for a long [time], after a while the brain does all sorts of funny things to that and some of the psychological stuff comes in (GP#25, m, 50yo, 25ye). Complex management: Whilst a fractured leg might heal in six weeks, some sort of PTSD or depression could take years and years to heal so it s very, very, very slow (CS#14, f, 29yo, 3ye).

15 Key barriers for GPs to facilitate RTW Health system barriers Finding specialists for referral Clinician refusal to treat Conflicting medical opinions Doctor shopping Compensation system barriers GP s lack understanding of how the system operates High turnover of compensation agents Delay in approving payment for treatment = delay in RTW GP s feel they are not adequately renumerated for time and effort Kosny et al. In prep. Policy and Practice in Health & Safety Singh et al. submitted. JOEM. Brijnath et al. submitted. BMJ.

16 Key enablers for GPs to facilitate RTW GP education and training: Mental health claims assessment and management Clinical management of chronic pain GP registrars to be educated about Work Cover and the health benefits of return to work It wouldn t hurt us to occasionally go to a meeting bringing us up to speed on work cover legislation. I think the more confident you are in handling the whole system, the more confident you are ringing up an employer and talking about it if you know where you stand. (GP1, m,62yo, 40ye) Injured person motivation and preparedness to RTW Employer-employee relations Ongoing communication Provision of alternative/modified duties Show of empathy and support

17 Issues with the Certificate of Capacity Primary method of communication GPs unclear about what precisely the form wanted from them Compensation agents and employers complained that the certificate of capacity needed to promote a stronger RTW focus Electronically completed and integrated into online and realtime systems to enable consistent and coordinated communication

18 Discussion The role of the GP in facilitating RTW is recognised as critical by all parties. Need to change current certification practice because: Increasing number of certificates being issued and for longer durations of time. Most certificates issued are UFW and workers with mental health claims are most likely to be certified as unfit. Main barriers include: Lack of a common definition on the GP s role in RTW GPs reliance only on injured workers feedback on capacity to work Lack of availability of alternative/modified duties Age and social circumstances of the injured worker and their family Poor communication between GPs, employers and compensation agents High administrative burden on GPs from compensation system and low remuneration of time and effort Delayed payments, difficulty in referrals and conflicting medical opinions.

19 Discussion Overcoming the barriers: Specific and targeted education and training for GPs on how the compensation system works, the health benefits of RTW, pain management and MHC claims assessment and management. Development of a consensus on GPs role in RTW Guideline development on diagnosis and management of mental health claims Further research: Implementation research to put in place guideline recommendations Longitudinal cohort analysis to better understand the relationship between GPs recommendations and patient outcomes.

20 Conclusions First study of its type and size in Australia and internationally. Built capacity and collaboration in general practice-compensation injury. WSV and TAC have been highly responsive to study findings: Redesign of certificate of capacity Health Benefits of Safe Work Program GP education and training Our team has forged linked with other state and national compensation authorities and key stakeholders (e.g. ComCare; Queensland MAIC; RACGP) Looking to build on the research: we ve now established the baseline, the next step is to develop the interventions in particular areas (e.g. guideline development and evaluation for mental health claims).