Evidence Based Disability Evaluation in the Netherlands Haije Wind, MD, PhD Research Center for Insurance Medicine Coronel Institute of Occupational Health Academic Medical Center/ University of Amsterdam

2 System of disability assessment * System focuses on assessing functional abilities and selecting jobs in the Dutch labour market that match these abilities. Then computing the loss in earning capability  Is part of Social Security Legislation  Assessment is about the loss of earning capacity  Risque Social  Condition: two years waiting period  Only on request

Who is considered to be work disabled? He/she who due to direct and objective medical consequence of sickness and disablement cannot earn as much as a sound-alike

Two disciplines Insurance physician: direct and objective medical consequence Labour expert: cannot earn as much as a sound-alike

Two disciplines Insurance physician The IP examines the patient and writes a medical report and fills out a list of constraints Four aspects: Evaluation of the medical history Assessment of the actual functional abilities Assessment of the actual and indicated treatment Assessment of the prognosis Labour expert The labour expert determines the degree to which a person is incapacitated for work on the basis of this information, plus information on: Job history Training Skills

Summary Sickness or disablement? Loss of functioning as a direct and objective medical consequence of sickness of disablement? What are the functional abilities? What functions can be performed? What is the difference between the wage of the functions that can be performed and the wage of the own work? LOSS OF FUNCTIONINGLOSS OF EARNING INSURANCE PHYSICIAN Labour expert Percentage disability < 35% 35-80% %

How high is the benefit? Related to the last earned wage Threshold 35% Full disability: % WGA: Benefits Act for the partly disabled and fully not- durable disabled: 70% IVA: Benefits Act for the fully and durable Disabled: 75%

Model of disability assessment* assemble interpret document Source of information Patient Treating Physician Employer, Spouse Medical knowledge Information Judgment Documented judgment Sources of variation Instruments Questionnaires Functional tests Medical examination Instruments: Guidelines More assessors Peer consultation Instruments: AMA, ICF, FAL Communication – interaction with patient Experience, training, norms, values, culture Skills, experience *Ref: Spanjer J. et al Sources of variation in work disability assessment (2010) Work 37(4):405-11

Evidence Based Disability Evaluation ? Validity and reliability Lack of golden standard Influence of many factors on return to work

Reliability of disability assessments Different interview protocols*: - based on experience interviewers - not validated Reliability and validity Disability Assessment Structured Interview (DASI)**: - inter-rater reliability: reasonable - content validity Inter-doctor variations in assessment of functional incapacities by insurance physicians*** - small-moderate systematic variation at IP level (ICC: 6-12%) - equal to those between physicians in primary and secondary care References: * De Boer WEL et al. Interview protocols in social insurance medicine. Quality of evaluation of work disability. PhD thesis ** Spanjer J et al. Reliability and validity of the Disability Assessment Structured Interview (DASI): a tool for assessing functional limitations in claimants. J Occup Rehabil 2010 Mar;20(1): *** Schellart AJ et al. Inter-doctor variations in the assessment of functional incapacities by insurance physicians. BMC Public Health 2011; Nov 14;11:864

Evidence Based Disability Evaluation PhD thesis: Rob Kok (2014) Training Insurance Physicians in EBM skills Increase in skills and knowledge Resulted in higher % evidence-based disability evaluations EBM increased job satisfaction

Guidelines, Protocols and Medical Case Law Development of protocols in insurance medicine Development of Medical Case Law (like Case Law) Development of 3-B guidelines: treating, coaching and assessing

Overview of guidelines for IP’s Protocols (1)Protocols (2)3- B guidelines depressive disorder, adjustment disorder, anxiety disorder, mamma carcinoma, myocardial infarction, chron fatigue syndrome, chron non-specific LBP lumboradicular syndrome, whiplash syndrome, stroke chron shoulder complaints, schizophrenia, decompensatio cordis, cancer of the bowel, borderline personality disorder, chronic kidney failure, osteoarthritis of hip and knee, rheumatoid arthritis, COPD, diabetes mellitus, participation behaviour Acquired Brain Injury Rheumatic arthritis Diabetes Mellitus HIV and work In development: Depression Chronic illness and labour participation

Summary Comprehensive system aimed at assessing loss of earning capacity Important role for Insurance Physicians (IP) In social insurance: personal contact between IP and client Coming years further steps in Evidence Based Insurance Medicine Development and update of guidelines