Impact of a non-return-to-work prognostic model (WORRK) on allocation to rehabilitation clinical pathways: A single centre parallel group randomised trial

Abstract

Introduction: Stratified medicine might allow improvement of patient outcomes while keeping costs stable or even diminishing them. Our objective was to measure if a prediction model, developed to predict non-return to work (nRTW) after orthopaedic trauma, improves the allocation to various vocational pathways for use in clinical practice.

Material and methods: Randomised-controlled trial on vocational inpatients after orthopaedic trauma (n = 280). In the intervention group, nRTW risk (estimated using the WORRK tool) was given to the clinician team before allocation of vocational pathways, while in the control group it was not. Three pathways were available: simple, coaching and evaluation (EP). Accompanying indications for interpretation of the nRTW risk were given. The primary outcome was the proportion of patients allocated to the EP. The secondary outcome was patients' and clinicians' satisfaction.

Results: 450 patients were assessed for eligibility, 280 included, 139 randomized to the control group (mean age 42.3years) and 141 to the intervention group (43.2years). The two groups had a similar risk profile. The patients in the intervention group were more often referred to the EP compared to the control group, but not statistically significantly more (risk ratio 1.31 [95% CI 0.70-2.46]). The number needed to treat was 30. When considering patients transferred to different pathways during rehabilitation, more patients from the intervention group were transferred to the EP over the course of the rehabilitation, increasing the risk ratio to 1.57 [95% CI 0.89 to 2.74].

Discussion: The knowledge of the risk of nRTW has an influence, that is not however statistically significant and is without clinical importance as previously defined by our own power calculations (based on a 15% increase in referral to EP in the intervention group compared to the control group), on clinical decision making with regards to the allocation of patients to different physical and vocational rehabilitation programs after orthopaedic trauma. This influence is less than what was expected, possibly due to insufficient directive guidelines accompanying the WORRK model, or because clinicians associate less hours of therapy (as with certain rehabilitation programs) to disadvantaging the patient. These findings do, however, support the multi-factorial aspect of clinician decision-making.

Trial registration: ClinicalTrials.gov NCT02396173.

Conflict of interest statement

The authors have declared that no competing interest exist.

Figures

Fig 1. CONSORT flow diagram of the study.

Fig 2. Point estimate and 95% confidence interval for the risk ratio for the referral to the “Evaluation Pathway” in the intervention group compared to the control group.

The upper part shows the risk ratio for the primary analysis; the lower part shows the analysis taking into account the patients who were transferred into the “Evaluation Pathway over the course of the stay.

Fig 3. Point estimate and 95% confidence interval for the risk ratio for the patients being satisfied with the rehabilitation in the intervention group compared to the control group.