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How to make a national priority

into a clinical reality

Prof Juan A. Jover,Rheumatology Service

Hospital Clnico San Carlos, Spain

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How to make a national priority

into a clinical reality

Juan A. Jover, Rheumatology Service

Hospital Clnico San Carlos, Madrid. Spain

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The reservoir of knowledge

Research

Dissemination

Applications

A (long) journey from data to results

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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

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Burden of diseases in Canada, 2000

http://www.phac-aspc.gc.ca/ph-sp/preveco-01-eng.php#fig1Adapted from IHE, 2008; data from the Public Health Agency of Canada

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Sanitary Process

- Individual factors- Collective- Public Health- Health System

- Primary Care- Specialized care

Occupational Process

- Economic Activity- Employers- Unions- Occupational Health

Administrative Process- Compensation- Laws- Control- Fraud

TWD

PWD

What if?

The complexity of Work Disability

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Control

Intervention

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

Inclusion: 12 months Follow-up: 12 months

Three health districts in Madrid Randomized study Voluntary program Patients maintained their group

Intention to treat analysis

MSD-TWD Program (98-01)

TWD initiation dueto MSDs

(13.000 non-selected patients)

Early Intervention Protocolized clinical management Patient Education Self-management

Administrative Duties

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Control Intervention

Days

0

25

50

75

100

0 30 60 90 120 150 180 210 240 270 300 330 360

%of

patientsback

towork

Research:a clinical approach to MSD-WD

39 % reduction of TWD duration (days)

50% reduction of PWD (cases)

Increased patient satisfaction

Positive Economic evaluation

40% Decreased direct costs

50% Decreased indirect costs

1.110 % benefit at two years

Positive Extension of the Program

> 38.000 processes >1 million days off-work saved

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MSD-TWD program

Days

0

25

50

75

100

0 30 60 90 120 150 180 210 240 270 300 330 360

What to do with patients not doing well?

Early Cognitive Behavioural InterventionPsycho MSD-TWD 04

%of

patientsback

towork

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

0.75

1.00

0.50

0.25

0.00

First TWD episode

0.00

0.25

0.50

0.75

1.00

0 40 80 120 160 200 240 280 320 360

TWD relapses

Early Psychological intervention

181 patients of the MSD-TWD program, off-work at 3 - 6 weeks

MSD-TWD Program

Randomization

MSD-TWD Program+

CBT Intervention

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System Dynamics Model of TWD

(Valve 1)(Valve2)

(Valve 3)(Valve 4)

(Valve 0)

(Valve5)

(Valve 6)

LWDE(t)SWDE(t)ETWD(t))13(

EFLWD(t)EFSWD(t)EFTWD(t))12(

EGPD(t)dt

EPD(t)d)11(

UERW(t)EFLWD(t)EFSWD(t)dt

ERW(t)d)10(

MWTPD

EWPD(t)100

PUPDUERW(t))9(

MWTPD

EWPD(t)

100

PUPD)-(100EGPD(t))8(

UERW(t)-EGPD(t)-EAPD(t)dt

EWPD(t)d)7(

LWDE(t)100

PEAPDEAPD(t))6(

MDLWD

LWDE(t)EFLWD(t))5(

EAPD(t)-EFLWD(t)-ES2LWD(t)dt

LWDE(t)d)4(

MDSWDEtifSWDE(t)100

PES2L

MDSWDEtif0

ES2LWD(t))3(

MDSWDE

SWDE(t)EFSWD(t))2(

ES2LWD(t)-EFSWD(t)-ESTWD(t)dt

SWDE(t)d)1(

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System Dynamics Model of TWD:An hydraulic analogy

Valve 3

Valve 5

Active Workers

ST-TWDValve 2

LT-TWD

Valve 4

PWD EVAL

Valve 6

PWDConcession

Valve 1

Return toWork

Valve 0

MSD-TWDprogram

(40%)

Psycho-TWDprogram(20%)

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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

Recommendations for clinicians

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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

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Routine access of new patients (HCSC)

13%

7,5%

9%

% Inflammatory QoL

Poor or Very Poor

1

x 5

x 10

GeneralWL 30-40 days

1.700

1.700

4.000

UrgentLE < 72 h

N

Disability

WL < 7 days

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HealthService

Research

AccessHealthResults

Care Process

ICT-EHR

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Thanks

MSD-TWD Team

Lydia Absolo

Gloria Candelas

Margarita Blanco

Cristina Lajas Petisco

Csar Hernndez-GarcaBenjamn Fernndez-Gutirrez

Leticia Len

Javier BachillerPaz Collado

Marcelino RevengaPatricia Ricci

Pablo LzaroMaria Dolores AguilarEmilio VargasLoreto Carmona

Fundacin ABBOTT Espaa

Antonio BaaresSara Pascual