Cost benefit and cost effectiveness of a bio-psychosocial approach for the management of musculoskeletal disorders within an occupational health physiotherapy service.

by Paul Baker, Clinical Director at goPhysio

Published in Occupational Health Physiotherapy, The Journal of the Association of Chartered Physiotherapists in Occupational Health & Ergonomics 15.3 pages 14-16, November 2011

Abstract:

Musculoskeletal disorders (MSDs) are one of the biggest causes of sickness absence in the U.K. and costs British employers £7.4 billion a year. Unfortunately, this figure is an understatement as within occupational health (OH) the tradition of calculating the direct costs of MSD absence, without considering the indirect costs, exists. Calculating only the direct costs, represents a missed opportunity to accurately measure the extensive cost effectiveness and cost benefits of the management of MSDs within OH.

Introduction:

The Health and Safety Executive (2009) state that MSDs  are one of the biggest causes of sickness absence and account for nearly a third of the total time taken off sick from work, in Great Britain. The work foundation (2007) estimated that the direct cost of this absence (sickness benefits and reduced turnover) to British employers was £7.4 billion a year.

Unfortunately, these costings fail to consider the substantial indirect costs of absenteeism (lowered productivity, overtime, product damage, reduced staff morale and low retention). Oxenburgh et al (2004) explained that indirect costs are the greater costs.

Bevan et al (2007) highlights that the full costs of MSDs cost employers and society approximately £15 billion a year through reduced productivity, sickness benefits, reduced turnover and temporary staff. This highlights the importance of gaining a deeper economical understanding of the issues to illustrate accurately the full costs, savings and benefits of an OHS, thus facilitating more widespread service uptake and development.

Cost benefits and effectiveness

Cost benefit analysis aims to measure and directly compare all of the benefits of a service in monetary terms. It is based on assumptions that all service benefits and factors can be measured in monetary terms. In reality it is not feasible for all costs and benefits to be known (Oxenburgh et al, 2004).

When solely considering cost-benefit analysis, a wide range of other OHS benefits are ignored, such as, staff wellbeing and health, staff morale, improvements in quality of life, productivity and staff retention, which contribute greatly to productivity and the economic success of a company (Escorpizo, 2008).

Cost effectiveness analysis is concerned with the efficient use of resources in achieving specific OH outcomes. It is useful when not all benefits can be measured directly in monetary terms and when relating the benefits of a service to an individuals’ perspective i.e. health benefits, morale, improvements in quality of life, productivity and staff retention (D’Auria, 1998).

Service evaluation

Throughout all stages of service development, contract negotiation and service provision, both cost-effectiveness and cost benefit analysis should be employed. Thorough analysis of MSD data is crucial to establish the needs of the company and facilitate a more accurate assessment of service evaluation. Mrs N. Hunter, manager of Rehabworks, who states that “winning and maintaining occupational health contracts is about the quality of data gathered during the service development, provision and evaluation stages”.

A key document within OH MSD by Hanson (2006) investigated the evidence on cost-effective case management and rehabilitation principles of MSDs in an attempt to identify key components of successful case management and rehabilitation programmes. They developed an evidence-based model for managing OH MSDs.

Most of the companies implementing these programmes had little or no cost benefit data. Nevertheless, Hanson et al (2006) identified a trend; employers experienced an average return of £3 for every £1 they invested, in terms of reduced absence rates and a return to normal duties. Unfortunately, the extent to which we can use that information to accurately predict the cost benefit is negligible. There is a need for the development of standardised analytical methods, in-order to ensure a larger more reliable evidence base in this domain.

Key features of an OHS

Despite, these limitations within the research and literature, an evidence based BPS approach has evolved (Hanson 2006, Kendall 2010). Hanson identified three key components to consider when managing an OHS; creating the right culture, managing those with MSDs and managing the return to work.

BPS stepped care approach.

This approach has evolved further (Burton, 2009) and more recently by Kendall (2010). During an international think tank over 3 days, Kendall (2010) refined an evidence-based 3 phase stepped care approach along a timeline from injury.

Acute, Early Stage

During the acute stage (injury<2 weeks), within the BPS stepped care approach, it is paramount to provide early access to evidence based advice and early stage rehabilitation (Hanson 2006, Kendall  2010).

There is a wealth of evidence to support MSD self-referral to physiotherapy within primary care (Holdsworth et al, 2008). Webster (2008) studying qualitative and quantitative outcomes in 3010 patients, found that 83% were very satisfied with the self referral process and that 90% of all respondents reported strong support for the effectiveness of physiotherapy. Holdsworth (2008) found that self referral in 26 GP practices in Scotland saved 25% of the average cost of an episode of care, compared with routine GP referrals. Although, this study was undertaken within the NHS, OH is also considered within the primary care domain. These findings outline significant cost benefit savings implications for self referral and direct access to a primary care OH physiotherapy service.

Hanson (2006) identified widespread evidence that a cost effective format for providing access to evidence based advice is via a telephone triage service.  The survey indicates that approximately 50-60% of staff recover fully with telephone triage and self management advice, with no need for further physiotherapy. Although, these reports measured the simple direct cost-benefit measures of sick pay and absence, they indicate that for every £1 spent on the service they saved up to £6.52 in direct sickness wage costs. This offers a streamlined, cost effective service and enables OH practitioners to focus other resources on the small number of cases at risk of prolonged absence.

Mc Cluskey (2006) investigated the effectiveness of an early intervention programme for 2800 workers, addressing psychosocial obstacles to recovery. The programme consisted of trained OH nurses tackling patients’ psychosocial barriers to recovery and offering evidence-based advice regarding early activity and return-to-work (RTW). The study concluded that an early intervention addressing psychosocial obstacles to recovery is significantly effective at reducing MSD absence. The author concludes that any member of the OH team can provide the evidence based advice

It has been extensively researched and documented (Daltroy et al, 1997, Pinnington et al, 2004, Sullivan et al, 2005, Bernacki et al, 2000, Linton and Andersson, 2000, Loisel et al, 2005, Burton et al, 2009, Shaw et al, 2009, Waddell and Burton, 2001, Waddell and Burton, 2004) that clinically proven BPS approaches to MSD management, including physiotherapy can prevent absence, facilitate early RTW on normal duties and are overall cost effective.  Unfortunately, these studies rarely take into account the indirect costs of absenteeism and cost the benefits mainly on direct sickness benefits.

Sub-acute, Intermediate Stage:

Within the sub-acute stage (2weeks>injury<12 weeks) of the BPS stepped care approach, work retention or early RTW is the primary focus.

Arnetz et al (2003) investigated early workplace intervention involving case management, physiotherapy and RTW planning. Compared to the reference group, they found that the total mean number of sickness days for the intervention group was 25% less, significantly more employees in the intervention group recovered fully (84% versus 27%) and the time for doing this was reduced by half, with a direct cost-to-benefit ratio of 6.8. Thus, indicating that access to evidence based RTW interventions, reduce chronicity and the spiralling costs of MSD absenteeism.

Kendall (2010) explains that in cases where the injury persists beyond 2 weeks, the physiotherapist should identify psychosocial obstacles and introduce psychosocial “flag” screening. Individual and work related psychosocial factors play an important role in persisting symptoms, disability and influence the response to treatment (Burton et al, 2009). Hence screening for these “psychosocial flags” as one component within a BPS approach to MSD management is extremely cost effective regarding reduced absence, reduced chronicity and disability.

Chronic, Persistent Stage:

It is well documented that 80% of the costs associated with MSD absence is generated by 20% of the cases; these are the chronic disability cases (Injury >12 weeks) (Higginson 1994). Hence the prevention of chronicity is one of the principle objectives of the stepped care BPS approach to MSDs (Kendall, 1999) to reduce the economic burden on society, employers, individual MSD suffers and their families. Within this critical and costly stage of the BPS stepped care approach, if the individual is not improving as expected it is important to explore and resolve the issues acting as obstacles to a RTW.

Schakenraad (2004) investigated the effect of a multidisciplinary treatment programme on well-being, disability and RTW in 41 patients on long term sickness absence (> 5 months) with upper limb MSDs. They found that MDT treatment programmes involving a psychologist, physiotherapist and occupational therapist improved general well being, reduce disability and facilitated 100% of patients to RTW (63% on full duties).

At this stage refining and maximising the RTW plan, through communication with all team members including the individual and GP’s is vital (Kendall et al, 2010). Unfortunately, lack of communication between team members can become barriers to return to work. Beaumont (2003) investigated the interaction between general practitioners and OHP’s in relation to rehabilitation. His research identified that the communication channels between OH professionals and GP’s is “often very poor”. By improving communication channels and developing a team approach, it helps maximise a patients’ vocational rehabilitation and RTW outcomes, improving the cost-effectiveness and benefits of an OHS.

There is a wealth of evidence illustrating that cognitive behavioural therapy reduces chronicity. For example in a study of 243 patients who perceived that they were at risk for developing a chronic problem, Linton and Andersson (2000) concluded that the risk of a long-term MSD absence developing was lowered nine-fold by cognitive-behaviour intervention. Hence, an optimum, cost effective, evidence based service would involve cognitive behavioural therapy approaches, to reduce chronicity and disability.

Conclusion:

The literature is conclusive in that providing a fast track, direct access, and evidence based OH BPS approach in the management of MSDs is cost effective and financially beneficial. It significantly improves work retention, reduces absenteeism, chronicity and disability and their associated costs to employees, their families, companies and society as a whole.

For future practice, an accurate, standardised method to economically measure and directly compare the costs and benefits of different OHS programmes and identify successful components, is required.

Considering the high costs associated with chronic MSD absence, further research of the cost-benefit and cost-effectiveness of OHS programmes regarding RTW and chronicity prevention, would help to facilitate an optimal evidence based BPS approach for the management of MSDs within OH. This would help drive service development and reduce the financial burden of MSDs.

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Paul Baker is the founder & Clinical Director of goPhysio. goPhysio offer a range of occupational health managment solutions to businesses in the local area. If you would like to discuss how we may help your business, please give us a call on 023 8025 3317.