Development, Implementation and Evaluation of Evidence-Based Practice Guidelines in Occupational Health

Introduction

Professionals in Occupational Health (OH) are involved in assessing risks for health and safety at work and provide recommendations or actions for risk prevention and management, prevention of occupational diseases, work-related diseases and work disability, promotion of work ability, and health promotion. In this role, OH professionals have to make many decisions [1]. In this decision-making process, OH professionals should strive to integrate the best available scientific evidence with their own expertise and the values and preferences of their clients. This integration is known as evidence-based practice (EBP). An important and promising instrument in the enhancement of EBP in OH is the development and implementation of evidence-based practice guidelines.

Development of evidence-based practice guidelines

Based on recent definitions of clinical practice guidelines by the US Institute of Medicine [2] and the Dutch Council for Quality of Healthcare [3], evidence-based practice guidelines in OH can be defined as ‘documents with recommendations to assist OH practitioners and OH users, intended to optimize quality of care, based on a systematic review of evidence and an assessment of the benefits and harms of the various care options, supplemented with expertise and experiences of OH practitioners and OH users’.

Why practice guidelines?

Although the development of specialized occupational healthcare in many countries can be considered a sign of substantial progress, the quality of the care provided did not, and does not always meet professional standards, partly as a result of the commercial approach that many Occupational Health Services (OHS) have adopted to survive in a rapidly changing market. Moreover, the direct influence of ‘third parties’ (for example, insurance companies or commercial providers of certain aspects of care) on the content of the work of OH professionals is growing. At the same time, major changes in work and characteristics of the working population and a crisis in OHS in several European countries is identified [4]. At many workplaces, increasing competition, work pressure, aggression, violence at work, and a growing informal economy with (very) small enterprises, more vulnerable for occupational hazards, is seen. Aging of the workforce and a growing proportion of the working population  having one or more chronic diseases, is giving rise to (partly new) occupational risks. There is a shortage of occupational physicians and other professionals, a scarcity of resources and training, and in some countries a too strong emphasis on sickness absence management, neglecting preventive tasks. To counteract this development, a clear need exists for enhancement of the scientific base of OH practice and to improve the professional quality and professional independence of professionals in OH. One of the tools for this improvement has been the development, implementation, and evaluation of practice guidelines.

Guidelines, when and for what?

Practice guidelines are not a panacea for all problems. They are particularly useful when there is evidence of (too) large inter-professional variation in practice which affects management or relevant outcomes of care; a strong research base providing evidence of effective practice; and sufficient potential benefit to employees/employers to justify the resources invested in the development and implementation of the guidelines [5]. In 1997, the Netherlands Society of Occupational Medicine (NVAB), the professional association of occupational physicians, started a programme for the development and implementation of evidence-based practice guidelines [6]. The NVAB guidelines are based on scientific evidence, with the level of evidence presented for each important recommendation in the guideline, peer-group consensus, professional or ethical principles, and best practice. So far, 12 mono-disciplinary guidelines have been published: low back pain; mental health; visual acuity; sheltered workshops; complaints related to the arms, neck, or shoulders; asthma/COPD; contact dermatitis; noise-induced hearing loss; ischaemic heart disorders; influenza prevention; pregnancy and work; and cancer and work. Four others are in development. In the United Kingdom, the NHS Plus has been developing occupational health practice guidelines on similar topics [7], as does the American College of Occupational and Environmental Medicine in the United States [8].

Attention for work-related aspects in multidisciplinary guidelines in healthcare

Work in itself is an important determinant of health and research demonstrates a growing body of evidence that having work in general may contribute positively to one’s health. Randomized controlled studies show that work-related interventions, often based on evidence-based practice guidelines, were (cost-)effective in reducing long-term sickness absence in case of depression, burnout, and back pain. Therefore, in the Netherlands, the Ministry of Health has included in its program for funding of multidisciplinary clinical guidelines the introduction of work-related aspects as an obligatory requirement [9]. In the United Kingdom, a similar initiative was launched to include occupational health aspects in the British National Institute for Health and Clinical Excellence guidelines [10].

Implementation  

Developing guidelines is one thing, making them work is another challenge. Guidelines don’t implement themselves. Therefore, in addition to the publication of the guidelines, additional tools like educational courses, employer or employee versions of the guideline, checklists, indicators, and audit instruments are developed by guideline developers, often in collaboration with different stakeholders. From recent inquiries among the members of the NVAB, we know that 90% of the occupational physicians state that they “know” most of the guidelines issued by the NVAB. The (first developed and revised) guidelines on low back pain and common mental health disorders are the best known. Adherence to the guidelines in daily practice may vary considerably. In a recent study, a process evaluation with performance indicators on adherence to the guideline on common mental health disorders, showed that the mean score of guideline adherence was 10 in a range of 0 to 20 [11]. From this and earlier studies, we know that better guideline adherence showed a statistically significant association with a shorter time to return to work after sickness absence. Still, a lot of effort has to be done in implementing guidelines.

Evaluation

The rapid proliferation of guidelines in health care has lead to some concern about the quality. For this, a validated generic instrument, the Appraisal of Guidelines and Research and Evaluation (AGREE) instrument was constructed. The recently updated AGREE II instrument exists of 24 items in 6 quality domains such as stakeholder involvement, rigor of development, clarity and presentation, and applicability [12]. AGREE has been proven a relevant and easy-to-use instrument to assess quality aspects of OH practice guidelines [13,14]. Evaluation on process level of the use of guidelines in daily practice can be done by auditing OH professionals and comparing provided care against recommendations of guidelines. Even more important and the proof of the pudding is the evaluation of the outcome of the use of guidelines. So far, in the field of OH only limited evidence is available. Scientific evaluation of one of the NVAB guidelines in a randomized controlled trial confirmed its cost-effectiveness with regard to sick leave and disability prevention [15].

Conclusions

The development and implementation of evidence-based practice guidelines in OH in the past few years has showed good potential to improve the quality of OH-related care. A guideline is not only of use for the individual OH professional, it may also enhance professionalization, accountability, and efficiency of care. As such, it is an important tool in bridging the gap between research and practice.

References

1. Van Dijk FJH, Verbeek JH, Hoving JL, Hulshof CTJ. A knowledge infrastructure for Occupational Safety and Health J Occup Environ Med 2010;52(12):1262-8.
2. Institute of Medicine. Clinical practice guidelines we can trust. Washington, DC: The National Academies Press; 2011.
3. Kremer LC, Burgers JS, ed. Guideline for Guidelines (in Dutch). Den Haag, the Netherlands: Dutch Council for Quality of Healthcare; 2011.
4. Vogel L. Preventive services in Europe: expanding amid a crisis of confidence. Policy and Practice in Health and Safety 2007:151-168.
5. Madan I, Harling K. The NHS Plus evidence-based guideline project. Occup Med 2007;57(5):307-310.
6. NVAB-Richtlijnen. Practice Guidelines in Occupational Health. Netherlands Society of Occupational Medicine. Available at: http://nvab.artsennet.nl/Artikel-3/Guidelines-1.htm#6
7. NHS Plus. Programme of evidence based guideline development relevant to occupational health practice in UK. Available at: http://www.nhsplus.nhs.uk/providers/clinicaleffectiveness-guidelines.asp
8. American College of Occupational and Environmental Medicine. Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. 3rd ed. Available at: http://www.acoem.org/practiceguidelines.aspx
9. Hulshof CTJ. Working for a healthier tomorrow. Occup Environ Med 2009;66:1-2.
10. Hashtroudi A, Paterson H. Occupational health advice in NICE guidelines. Occup Med 2009;59:353–356.
11. Rebergen DS, Bruinvels DJ, Bos CM, van der Beek AJ, van Mechelen W. Return to work and occupational physicians’ management of common mental health problems, process evaluation of a randomized controlled trial. Scand J Work Environ Health 2010;36:488–498.
12. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: Advancing guideline development, reporting and evaluation in health care. CMAJ 2010;182:E839-E842.
13. Hulshof C, Hoenen J. Evidence-based practice guidelines in OHS: Are they AGREE-able? Ind Health 2007;45:26-31.
14. Cates JR, Young DN, Bowerman DS, Porter RC. An independent AGREE evaluation of the Occupational Medicine Practice Guidelines. Spine J 2006;6:72-77.
15. Rebergen DS, Bruinvels DJ et al. Cost-effectiveness of guideline-based care for workers with mental health problems. J Occup Environ Med 2009;51:313-322.