Intervention mapping for the development of a strategy to implement the insurance medicine ...

12 Pages·2011·0.41 MB·English

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RESEARCH ARTICLE Open Access
Intervention mapping for the development of a
strategy to implement the insurance medicine
guidelines for depression
Feico Zwerver1,2,3*, Antonius JM Schellart1,2, Johannes R Anema1,2, Kathelijne C Rammeloo3,
Allard J van der Beek1,2
Abstract
Background: This article describes the development of a strategy to implement the insurance medicine guidelines
for depression. Use of the guidelines is intended to result in more transparent and uniform assessment of
claimants with depressive symptoms.
Methods: The implementation strategy was developed using the Intervention Mapping (IM) method for alignment
with insurance-medical practice. The ASE behavioural explanation model (Attitude, Social Influence and Self-
Efficacy) was used as theoretical basis for the development work. A literature study of implementation strategies
and interviews with insurance physicians were performed to develop instruments for use with the guideline. These
instruments were designed to match the needs and the working circumstances of insurance physicians.
Performance indicators to measure the quality of the assessment and the adherence to the guidelines were
defined with input from insurance physicians.
Results: This study resulted in the development of a training course to teach insurance physicians how to apply
the guidelines for depression, using the aforementioned instruments. The efficacy of this training course will be
evaluated in a Randomized Controlled Trial.
Conclusions: The use of IM made it possible to develop guideline support instruments tailored to insurance
medical practice.
Background insurance physicians (IPs) who work for the Dutch Insti-
Depression is an enormous health problem, which is tute for Employee Benefit Schemes (Institute). The con-
responsible for 11% of disability worldwide [1]. The text of insurance medicine in the Netherlands is
WHO predicts that by 2020, depression will be second presented in Figure 1[4]. Worldwide, physicians are
only to heart disease as a cause of lost disability-adjusted involved in similar assessments, even though national
life-years and untimely death [2]. Through social insur- practices, social systems and, disability legislation, may
ance, employees can claim compensation when they lose vary considerably [5].
(part of) their income due to disability. To determine In the Netherlands, 19 diagnosis specific guidelines,
these disability benefit claims, disability assessments are including depression, have recently been developed for
carried out by specialized physicians, who have to evalu- use in insurance-medical practice [6,7]. These guidelines
ate the claimants’ medical status and functional capaci- are intended to serve as a reference framework that can
ties with regard to vocational rehabilitation [3]. In the help IPs to make their disability assessments more evi-
Netherlands, these assessments are performed by dence-based and more standardized [8,9]. IPs have to
know all 19 guidelines and apply them in practice
*Correspondence:[email protected] because they are generalists. The guidelines were subse-
1VUUniversityMedicalCenter,DepartmentofPublicandOccupational quently implemented top-down by the Institute in the
Health,EMGOInstituteforHealthandCareResearch,Amsterdam,The
period between 2007 and 2009. This tight schedule of
Netherlands
Fulllistofauthorinformationisavailableattheendofthearticle
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Step 1: Needs assessment
The Dutch National Institute for Employee Benefit Schemes (the Institute) administers
the eligibility of sick employees for a benefit under the Work and Income (Capacity for The key purpose of the needs assessment was to assess
Work) Act (WIA). 750 Insurance physicians are employed at the Institute, approx. 450 the needs of the IPs with regard to the guidelines for
of who perform disability assessments under the WIA. On average, these insurance
physicians are 50 years old, they are generalists, have approx. 16 years experience as depression, as well as their opinions about the imple-
insurance physician, approx. 85% is specialized in insurance medicine, 15% also has
another extra medical speciality, and approx. 60% works full-time. They perform an mentation of the guidelines at their place of work within
average of 10 disability assessments per week, assessing patients with all types of
diseases. the Institute. Interviews were held with 10 IPs working
Figure 1 Insurance physicians in the Netherlands; source: R. in practice (see Figure 3). They were asked to provide
Steenbeek[4]. their opinions on: the content of the guidelines for
depression, the possible obstacles, and the support,
needed when using the guidelines in daily practice.
guideline implementation did not leave much time for
the IPs to really apply all these guidelines. During this Step 2: Program objectives
period, two guidelines were sometimes implemented in The program objectives were based upon the needs
one single afternoon session. Unfortunately, little atten- assessment mentioned in the first step. The expected
tion was paid to the needs of the IPs. Except for lack of outcome of the implementation strategy was defined.
time, the implementation of evidence-based guidelines What should be changed in the behaviour of the pro-
in health care practice has proven to be difficult anyway gram participants (IPs) and what should be changed in
[10]. Implementing guidelines requires the planning of their environment (the Institute)? Learning objectives
complex changes in practice. Potential barriers at var- for the IP were related to the following personal deter-
ious levels need to be overcome, such as the nature of minants: knowledge and skills, attitude, self-efficacy, and
the guidelines, the characteristics of the physicians expectations. Change objectives were related to the fol-
involved, and the social, organizational, economical and lowing environmental determinants: availability, unifor-
political context [11-14]. Using the intervention map- mity, and support. We connected the program
ping method (IM), it is possible to make provisions for objectives, the learning objectives and the change objec-
the needs of the users and those around them, and to tives. This approach enabled us to define the concrete
draw upon scientific theory and evidence, in the imple- objectives, for which implementation could be devel-
mentation of protocols and guidelines. Since 1998, IM oped. The main objective of the program was, to
has mainly been used for planning theory- and evi- develop a strategy for the implementation of the guide-
dence-based health promotion programs [15-17]. How- lines for depression that suits the needs of the IPs
ever this method has now reached the field of
occupational health medicine, where it is being used to Step 3: Selecting theory-based methods and practical
support the development of intervention programs strategies
focussing on work disability [18-20]. This article In this step, suitable theory based methods and practical
describes the use of intervention mapping for the devel- strategies were sought, in such a way that the chosen
opment of a strategy for the implementation of insur- implementation reflects the scientific literature and evi-
ance medicine guidelines for depression. The aim was to dence. These methods were subsequently translated into
answer the following core question: What approach practical intervention strategies, the effectiveness of
should be taken to implement these guidelines, in order which already had been scientifically demonstrated.
to ensure effective use by insurance physicians? A ran- Learning objectives were defined for each of the perso-
domized controlled trial (RCT) will in due course be nal determinants, and change objectives for each of the
carried out to compare the efficacy of the implementa- environmental determinants. The learning objectives, as
tion strategy described in this article with conventional laid down in the personal determinants of the IPs, can
implementation methods. be achieved if the IPs are willing to change their beha-
viour. The barriers or the support in the process of
Methods guidelines implementation at the Institute can influence
IM, developed in the nineties by Bartholomew et al. the change objectives for the environment. For this rea-
[15,21], is a planning instrument that maps out the son we looked for a theoretical model that describes
development process of an intervention from the basic behaviour, and how the environment influences beha-
needs to the potential solution. IM provides a stepwise viour. We used the Attitude, Social Influence and Self-
process for decisions, based on theory and evidence. It Efficacy (ASE) model, derived from the Theory of
consists of six steps, which are presented in Figure 2. Planned Behaviour (TPB) [22,23]. The ASE model
We used IM as basis for developing a strategy: to find a describes how a person’s attitude, social influence and
way in which to implement the guidelines for depression self-efficacy (i.e. personal effectiveness) influence beha-
that suits the needs of the IPs. viour, as is shown in Figure 4[24].
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PROGRAM PLAN for insurance physicians

INTERVENTION MAP

PRODUCTS TASKS
Step 1
Needs assessment (cid:120) Identify the target group
(cid:120) Identify stakeholders
(cid:120) Assess needs insurance physicians and
stakeholders
(cid:120) Identify key determinants (environmental
and behavioural)
Step 2
Program
objectives
(cid:120) State expected changes in behaviourand
EVALUATION environment (proximal program objective)
(cid:120) Specify performance objectives
(cid:120) Specify determinants
(cid:120) Creating matrices of stated performance
objectives and formulated learning and
change objectives
Step 3
Theory-based methods (cid:120) Selecting theory-based methods
and practical strategies (cid:120) Translating methods into practical strategies
Step 4
Program plan (cid:120) Create the program, consulting participants
(cid:120) Overall structure, themes
(cid:120) Develop program materials
(cid:120) Testing program materials
Step 5
Program
implementation (cid:120) Specify adoption and implementation
performance objectives
(cid:120) Write an implementation plan
Step 6
Evaluation plan (cid:120) Develop an evaluation model
(cid:120) Develop effect and process evaluation questions
(cid:120) Develop indicators and measures
(cid:120) Specify evaluation designs
(cid:120) Write an evaluation plan
Fig I
IMPLEMENTATION
Figure2InterventionMappingProcess,developedbyBartholomewetal[15].Note:Theterm“insurancephysician”wasaddedtothe
originalplan.
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assessment, the matrix from step 2, and the theoretical
Semi-structured interviews held with 10 insurance physicians:
model from step 3. Input for the program development
(cid:120) 44 Questions about needs with regard to the medical content of the guidelines.
process was obtained from semi-structured interviews
(cid:120) 60 Questions about obstacles and facilitators when using the guidelines in
and consultation rounds with 40 experts. These experts
practice.
Some examples of questions: were mainly regular IPs, IPs responsible for appeal
“Is the content of the guidelines for depression feasible in current practice?” cases, (regional) staff physicians, and a few psychiatrists,
“How would you like to be trained in applying the guidelines?” training experts, and members of the management of
Figure3Needsassessment. the Institute. Preparing for these interviews and consul-
tation rounds, we studied the disability assessment
reports made by IPs to find out whether or not the
As used in this research setting, the ASE model may main elements of the guidelines for depression could be
be explained as follows: the behaviour required from the found in the reports. Firstly, we had to look for the
IP consists of correct application of the guidelines for main elements of the guidelines for depression in the IP
depression when assessing clients with depressive reports. Secondly, if we succeeded in finding them,
symptoms. these main elements could generate input for the train-
The intention to behave as described is determined by: ing design. Finally, the main elements formed the basic
1) the IP’s attitude to the use of guidelines in general, assumption for the development of performance indica-
and the guidelines for depression in particular; 2) the tors (PI). In this investigation we screened IP reports on
social influence exerted by the physician’s colleagues, indicators of application of the guidelines for depression
and by the staff and managers who influence use of the according to the saturation procedure. We screened
guidelines, and who may influence availability and uni- reports until we reached the point, at which no new
formity in using the guidelines; 3) the self-efficacy of the indicators for application of the guidelines could be
IP, or his/her confidence in his/her own ability to suc- found. Knowing that we could use the IP reports in our
cessfully apply the guidelines in practice [24]. The inten- study, we designed a program plan, which incorporated
tion to use the guidelines does not necessarily result in the opinions of experts that we consulted. This program
their use in practice, i.e. the behaviour that is sought. plan covered several aspects, such as PIs, instruments,
The translation of intention into action is influenced by training, and knowledge dissemination. In this stage we
barriers and support, and by the existence of knowledge tried to match the implementation strategy with the
and skills (which can be increased by training) within needs and performance objectives of the IPs.
the process and the organization. In the following steps
we proceeded from theory to practical strategies; and Step 5: Planning the program implementation
from practical strategies to the intervention. After designing the program for the implementation
strategy, we scanned the previous steps with a focus on
Step 4: Program plan objectives, methods and strategies, to ensure adoption
The program plan for the implementation strategy was by the IPs. A study of literature on the effects of imple-
developed on the basis of the preceding steps: needs mentation strategies was used to develop a suitable
Attitude
Social influence Intention Behaviour
Self-efficacy
Knowledge Barriers and
and skills support
Figure4TheASEmodel,asdefinedbyDeVries[24].
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implementation strategy, consisting of instruments, all diagnostic criteria, and psychiatric questionnaires
training, testing and feedback [25]. Given the context of based on case histories. In conclusion, the IPs wanted to
the Institute, will the implementation strategy receive be trained in applying the guidelines in practice with the
broad support, or could there be any obstacles in the help of experts and practical instruments. The IPs’
implementation process? We consulted both users and wishes regarding the training module to support the
stakeholders at the Institute regarding the content of guidelines are summarized in Table 2.
the program and the implementation strategy. The users
we consulted were the same 10 IPs who participated in Step 2: Program objectives
the needs assessment. We then consulted six stake- In this step we defined the behavioural and environmen-
holders at the Institute, i.e. the medical adviser, two tal determinants of he program, and translated them
regional staff physicians and three regional managers. into performance objectives for the IPs and change
objectives for the Institute. The IPs should learn how to
Step 6: Evaluation use the guidelines for depression, and they should con-
The intervention map can be used as an evaluation sider themselves capable of applying the guidelines in
model for the development of the process, and for the practice. By using and applying the guideline the IPs
effect of the corresponding intervention. In a future should believe that they could improve their perfor-
study we will evaluate the efficacy of a specific training mance with regard to their work ability assessments of
in the implementation of the guidelines for depression claimants with depression. The Institute should increase
in a two- armed RCT. The primary outcomes of the the availability of the guidelines for the IPs, and should
RCT will be the quality of the IP reports of the assess- support the implementation by putting more emphasis
ment of a claimant with depression, and the adherence on quality instead of productivity. Staff physicians
of the IPs to the guidelines for depression. The out- should generate a strong influence in the use of the
comes of this RCT will be measured with performance guidelines, by monitoring the IPs’ reports on guideline
indicators (PI) and questionnaires. adherence. The expected behaviour of the IPs is, that
they will learn to apply the guidelines for depression. All
Results the determinants of this behaviour were presented in a
Step 1: Needs assessment matrix (Table 3), crossed with the program objectives,
Semi-structured interviews were held with 10 IPs. showing the specifications of the program objectives for
Almost all of these 10 IPs considered the guidelines to the IPs.
be useful as a reference, but indicated that they lacked
information that is needed for direct use in practice. Step 3: Theory-based models and practical strategies
The specific items, representing the most important Practical interventions were chosen to realize the learn-
needs mentioned by the IPs with regard to the guide- ing and change objectives mentioned in the Matrix 1.
lines, are summarised in Table 1. Subsequently, by putting the personal and environmen-
The IPs’ wishes regarding implementation of the tal determinants in another matrix with the learning
guidelines for depression were also established. They objectives, theory-based methods, and practical strate-
needed expert education. This should preferably be gies, the required conditions for the development of the
interactive training provided by experts, paying attention intervention were obtained. These methods and strate-
to practical relevance. The IPs wanted instructions on gies were incorporated in the development of an inter-
how to use the instruments, such as a desk mat listing active training with feedback. Adequate feedback on the
Table 1The needs ofthe insurance physicians withregard to guidelines fordepression
Diagnostics AlistoftheDSMIVcriteriafordepressionandtheDSMIVcriteriaforthemostrelevantdifferentialdiagnostic
psychiatricdisorders
Psychiatricexamination Alistofpsychiatricexaminationitemsonadeskmat
Seriousnessdepression Amethodwithwhichtodeterminetheseriousnessofdepressioninauniformway.TheHamiltonRatingScale
ofDepression?(HRSD)
Seriousnessanddisability Expertopiniontoclarifytherelationshipbetweentheseriousnessofthedisorderandtheassesseddisability
Prognosis Needforevidence-basedinformationaboutperiodsofrecoveryfromdepressioninrelationtotreatmentand
co-morbidity
Guidelinesfordepressionand Expertopinionontherelationshipbetweentheguidelinesfordepressionandthestandards:“Fulldisability
otherstandards entitlementonmedicalgrounds”and“reductioninworkinghours”forpartlydisabledclaimants
Copingstyles Informationaboutpersonalcharacteristicsandcopingstylesandhowtodistinguishbetweendiseaseand
behaviour
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Table 2Implementation strategy: insurance physicians’ wishesregarding educational trainingand support in theuse
ofthe guidelines
Trainingmodule Form,implementation Method
Introductiontotheguidelinesfor Expertsfromthecurativesectorand Presentationofproblemsfromcurativeandinsurance-medical
depression insurancephysicianswithknowledgeof viewpoints;mutualquestioningregardingexperienceandvision
depression
Materials,tools Summarycardlistingalldiagnosticcriteria Practiseintheuseofthematerials,andcasehistories
Case-histories Groupdiscussionandpractiseinapplying Whatconstitutesagoodassessment?Whatisunclear?Why?
theguidelines
Workabilityassessment Insurancephysicianandpsychiatrist/ Scientificinsights,experiences,focusonproblems(LFA)
psychologist-researcher
Informationontreatment Expertsfromthecurativesector Currentthinkingonappropriatetreatment.Whatquestionscan
possibilities theinsurancephysicianputtothecurativephysician?
Carryingoutandinterpreting Psychologist,psychiatrist Differentpresentationinethnicminorities(ahighproportionof
psychiatrictests theclaimants)
Detailedexplanationand Psychologist,psychiatrist Practiseintheuseofthequestionnaire
interpretationoftheHRSD
questionnaire
Feedback Insurancephysicianandguidelinesauthor/ Feedbackfromtheprofession;opportunitytoaskquestions
researcher
LFA=ListofFunctionalAbilities;HRSD=HamiltonRatingScaleofDepression
Table 3Program objectives, learning objectives andchange objectives
Program Learningobjectivesforinsurancephysician(IP)’spersonaldeterminants Changeobjectivesforenvironmental
objectivesfor determinants
insurance
physician
Knowledge Attitude Self-efficacy Expectations Availabilityand Support
andskills uniformity
IPmakes IPhassufficient IPacceptsthe IPconsidershim/ IPbelievesthatuse IPistrainedtousethe IP’squality-oriented
thorough knowledgeand guidelineasa herselfcapableof oftheguidelinescan guidelineandhasthe activitiesare
investigation skillsto practicalresource applyingthe makehis/her opportunitytopractise supportedbyNational
andrecords understandthe andauseful guidelinesinpractice. examinationsmore usingitduringthe InstituteforEmployee
findings guidelinesand sourceof thoroughand trainingand BenefitsSchemesby
transparently toimplementit information. transparent. subsequentlyin puttingtheemphasis
inthereport. inpractice. practice. onqualityinsteadof
productivity.
Accesstoevidence-
basedmedicalinfovia
Internetand/orlibrary.
Todoso,IP IPhastheskills IPsupportsthe IPconsiderhim/ IPbelievesthatthe Casehistoriesare StaffoftheInstitute
usesthe toperformthe profession’s herselfcapableof qualityand discussedamongst supportIPinuseof
guidelinesin examinationin generalobjective investigatingissues uniformityofhis/her colleaguesby theguidelinesand
orderto linewith offairassessment associatedwiththe workability referencetothe relatedactivities.
ensurequality applicable basedon assessmentand assessmentswillbe guideline,enablingIP’s Staffphysician
anduniformity requirements. thoroughness, obtainingguidance enhancedbythe toaskquestionsand encouragesuseofthe
ofthe qualityand fromtheguideline, informationinthe learnfromone guidelines,bytesting
assessment. uniformity. literatureorcolleagues guidelines. another. theIP’sreportson
guidelineadherence.
IPuses IPhassufficient IPseesthe IPbelievesthatthe Staffphysicians Netherlands
evidence- evidence-based guidelineasa informationinthe provideallIP’swith Associationof
based knowledgeto meansto guidelineswillhelp performancefeedback InsuranceMedicine
informationto recognizeand realizingthe him/hermakemore andworkwithIP’sto supportsIP’squality-
supportwork addressany objective. evidence-basedwork defineindividual orientedactivitiesand
ability lackofskills. abilityassessments. learningprogrammes encouragesuseofthe
assessment sothatallattaina guidelines.
similarlevel.
IP=insurancephysician
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Table 4Determinants oflearning andchange objectives andthe associated strategies
Determinant Learningobjectivesfortheinsurancephysician Theory-basedmethod Practicalstrategy
Knowledge Familiaritywiththecontentoftheguideline Disseminationoftraining Makingguidelineavailableincombinationwith
material practicalinstruments
Activelearningfromexperts
Skills Theabilitytoapplyknowledgeinpractice Interactivegrouptraining Interactivetraininginuseoftheguidelines
Attitude Willingnesstoaccepttheguidelinesandusethem Persuasionbyopinion Benefitshighlightedduringtrainingandbystaff
toimprovequality leaders andtheNetherlandsAssociationforInsurance
Medicine
Self-efficacy Beliefinabilitytousetheguidelinesinpractice Performance-related Positiveindividualisedfeedbackduringtraining
andfindinganswerstoquestions feedback andsubsequentlyinpractice,assistancewith
questions
Expectations Expectationthattheguidelinewillcontributeto Individualizedfeedbackand Traininginuseoftheguidelineswithexercise
moreevidence-basedassessments groupperformanceaudit case-histories,feedbackatgroupandindividual
data level
Changeobjectivesfortheenvironment
Availability Theabilitytopractise,askquestionsandworkon Feedback,personal Practiceintraining,feedbackonperformance,
personalperformance improvement,planning supportwithquestions
Uniformity Allinsurancephysicianscoveredbysimilar Quality-monitoringand Staffphysicianappraisesallinsurancephysicians
requirements quality-management usingthesameindicators
Support Supportfromcolleagues,staff,managementand In-builtprocessreminders, Qualityevaluationbymanagement,staffquality-
professionalassociation,facilitationand,where qualitymanagement, orienteddirection,promotionbythe
necessary,amendmentoftheworkprocess supportfromopinion NetherlandsAssociationforInsuranceMedicine
leaders
performances of the IPs in the training should confirm implementation strategy was prepared and involved the
their expectations that i.e. using the guidelines will con- following steps (see a, b and c below).
tribute to more evidence-based assessments. IPs first a) Development of prototype instruments
must be aware of the guidelines, then become familiar The results of the interviews with the IPs were used in
with the guidelines, and finally believe that they are cap- the development of the prototype instruments. With a
able of working with the guidelines. IPs should be facili- view to aligning the instruments with the objectives of
tated and stimulated by their environment in applying the guidelines, we consulted the adviser and secretary of
the guidelines, offering them training that suits to their the Health Council’s Subcommittee on Depression. To
needs. The Institute and the Netherlands Association supplement the guidelines for depression, a study was
for Insurance Medicine should support and involve the made of the literature on co-morbidity, prognostic risk
IPs in the development and implementation of guide- factors, and the work capacity of individuals with
lines. Determinants of learning and change objectives, depression. The result was a toolbox: a collection of
and the associated strategies matched with theory-based instruments intended to facilitate application of the
methods are presented in Table 4. guidelines (see Table 5).
The desk mat showed on the front summarised infor-
Step 4: Program plan mation on the most essential points of the guidelines for
Research on the reports made by IPs when they assessed depression. The back of the desk mat showed the rela-
a claimant with depression, showed that these reports, tionship between the various relevant risk factors in a
indeed, did include the main elements of the guidelines diagram based on the International Classification of
for depression. Saturation was achieved after 30 reports. Functioning, Disability and Health model (ICF model)
Even without training IPs in the use of the guidelines, [26], which was also used in the development of the
elements of the guidelines appeared in the IPs’ reports. insurance medicine guidelines. The ICF model is the
That made it possible to develop PIs for testing the framework within which the insurance physician oper-
reports for elements of the guidelines in the baseline ates when assessing the work ability of a disabled
situation. After this saturation procedure, we knew that employee. Furthermore, a checklist contained items
we could use the IPs’ reports to evaluate their imple- referring to the main points of the guidelines, such as
mentation of the guidelines for depression. In addition, the DSM IV criteria, seriousness of the depression,
having found the main elements of the guidelines in the co-morbidity and treatment. When assessing a claimant
IPs’ reports, we could determine the starting point for with depression, the IPs can check all the relevant items
the design of the training. The planning of the and to make sure that they have not forgotten anything.
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Table 5Content ofthe toolbox
Deskmat DiagnosisanddifferentialdiagnosisbasedontheDSM-IV
Assessmentoftheseverityofdepression
Psychiatricexamination
Psychiatricco-morbidity
Somaticco-morbidity
Effectivetreatmentmethods
Riskfactorsinrelationtotheseverityanddurationofdisabilities
TheInternationalClassificationofFunctioning,DisabilityandHealthmodel(ICFmodel)[26]
Keyfindingsoftheliteraturestudyreferredtoabove
Checklist Itemsreferringtothemainpointsoftheguidelinesfordepression
HRSD[27] Assessingtheseverityofdepression
HRSD=HamiltonRatingScaleofDepression
Finally, the Hamilton Rating Scale for Depression testbasedontheguidelinesfordepression.Apsychiatrist
(HRSD) [27] was added to the toolbox to assist the IP whoisfamiliarwiththeinsurance-medicalassessmentsys-
in the assessment of the severity of the depression at temshouldthenexplainanumberofimportantaspectsof
the time of the examination. Use of the HRSD needs to theassessmentofdepressiononthebasisofaninteresting
be included in the training for IPs in connection with andrecent case concerning an immigrantemployee with
implementation of the guidelines. an atypical presentation of depressive symptoms. Focus
b) Refinement of the prototype instruments with help of a pointsshouldincludediagnostics,thedistinctionbetween
group of IP users behaviouranddisease,symptomatology,therelationships
The toolbox was shown to a group of users, consisting between symptoms and disabilities, assessment of the
of 10 IPs. A questionnaire was used to establish their severity of the depression (including use of the HDRS),
opinions with regard to the practicability, quality, con- treatment,progressionofthecondition,andco-morbidity.
tent validity and added value of the instruments, as well Subsequently, witha videorecordingofcase study, an
as how easy they were to understand and the extent to IP trainer should describe the practical aspects of using
which they allowed room for professional assessment. theinstruments.Thegroupofparticipantsinthetraining
On the basis of the feedback from the user group, we shouldthen bedividedintosubgroups,eachfocusingon
searched for additional literature and adapted the instru- adifferentpartoftheguidelines,tomakeassessmentsof
ments where necessary. This resulted in an amended thepresentedcase.Therelationshipbetweentheexisting
and compressed desk mat and a check list. Also added medicalstandards,“fulldisabilityentitlementonmedical
to the toolbox was a consensus-based list of the main grounds”, “reduction in working hours”, and the guide-
abilities that were thought to be associated with the lines for depression should be explained by the trainer.
work ability of employees with a major depressive disor- Different coping styles and personal characteristics of
der, and that could also be associated with the items of claimantsshouldbeintegratedin the realistic casespre-
the HRSD [28]. sentedduringthetraining.Inthetraining,theIPsshould
c) Development of the training learn how to differentiate between the various types of
A separate group of experts, which included psychia- coping styles of claimants with depression. Interactivity
trists and training experts, was set up for consultations betweenthe sub-groupsand self-activationshouldalter-
regarding the design of the training. This round of con- nate frequently, while feedback should be given by the
sultations resulted in the final training design as follows. trainerinaattempttoachievethelearningobjectivesfor
The IP should be given practical instructions about all the participants. When writing down their findings
application of the guidelines for depression. This should andconclusions,theparticipantsshouldbeinstructedto
includeinstructionsonhowtoarriveatanevidence-based usetheessentialelementsofreasoning.Finally,thetrain-
assessment ofadepressive claimant’sfunctionalabilities, ing day should end with an evaluation. In this kind of
basedontheknowledgepresented intheguidelines.The training design, the number of participants for each
learningobjectivesofthetrainingappearedtobethatthe groupshouldbelimitedto20,becauseitischaracterized
participatingIPstrainedtheirskillsinmakingadiagnosis by intensive communication, withfeedbackandinterac-
ofdepression,howtoassesstheseverityofthedepression tivity between the participantsand the trainer. The pro-
andthedisabilities,andhowtoreportontherelationship gramplanissummarizedinFigure5.
between these issues. Meanwhile, they should learn how
togivetheirassessmentreportsasolidbase.Tothisend, Step 5: Program implementation
the IPs should be provided with the aforementioned We were interested in the opinions of experts, groups of
instruments. The training should start with a knowledge users, and management and staff about implementation
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featuresof the programimplementation, as identified by
Instruments
thedecision-makers,implementersandIPs,aresummar-
(cid:120) Summary of guideline on plastic desk mat
(cid:120) Checklist referring to the guidelines izedinTable6.
(cid:120) Hamilton Rating Scale for Depression (HRSD)
(cid:120) List of working abilities associated with depression
Step 6: Evaluation plan
Training The efficacy of the strategy for implementation of the
(cid:120) Interactive, feedback, based on realistic cases, experts as trainers
guidelines, described in this article, will be compared to
Figure5Programplan.
traditional implementation in a two-armed RCT. One
group of IPs will receive specific training in applying the
of the guidelines at the Institute, so that we could build guidelines for depression, while the other group will
up a picture of the context within which the IP works. continue with the traditional implementation of the
The management and staff stated that, by implementing guidelines. Hence, the specific training for the IPs will
guidelines, they meet the requirements of the Ministry be the intervention in this RCT. Outcomes will be mea-
of Social Affairs. Furthermore, by implementing guide- sured by PIs and questionnaires. The PIs measure the
lines, the Institute might obtain more public support, primary outcome, i.e. the behaviour of the IPs with
and might face fewer complaints and appeals from clai- regard to the guidelines, defined as: the quality of the
mants. Nevertheless, implementing guidelines could IPs’ reports of the assessment of a claimant with depres-
induce a loss of production. The IPs were pleased with sion. The questionnaires not only measure the IPs’
the fact that, by carrying out research on the implemen- adherence to the guidelines, but also their satisfaction
tation of insurance medicine guidelines, attention will be with the guidelines, which is a secondary outcome of
paid to the quality and the content of their work. On this study. The questionnaires were developed on
the other hand, they realized that adopting guidelines the basis of the literature and the ASE model [30,31]. In
might be a complex process for them, because they had the RCT the PIs and the questionnaires will determine
to integrate working with the guidelines in their daily the performance objectives of the IPs before and after
routine. The IPs had no previous history of working the intervention. The process of the RCT and the speci-
with guidelines. The IPs were in particular asked, to fic training of the IPs in applying the guidelines will be
identify obstacles to and support for the use of guide- evaluated in a process evaluation. The data for the pro-
lines for depression, and how the obstacles might be cess evaluation will be collected with by means of speci-
removed. One commonly identified obstacle to the use fically developed evaluation questionnaires. In order to
of a guideline was the emphasis placed on the quantity illustrate how the effects of the implementation will be
of the number of disability assessments to be made by measured, the research model is presented in Figure 6.
an IP, which was imposed by the Institute. It was sug-
gested that the Institute could facilitate the use of guide- Discussion
lines by placing more emphasis on quality, rather than The aim of this study was to develop an implementation
quantity. Applying the guidelines thoroughly takes time, strategy to improve guideline adherence and the quality
and productivity requirements limit the time that is of the assessments made by IPs of the work ability of
available. The Institute was regarded as a productivity- employees with depression. IM has its origin in public
driven organization. It was stated that staff physicians health, and in particular in health promotion programs.
could stimulate the IPs to use the guidelines by giving More recently IM has found its way into the field of
them clear instructions about how to use them. occupational health medicine, where it has been used
Fromtheliterature[29]andfromconsultationsofdeci- for Return to Work (RTW) interventions. The results of
sion-makersandimplementers,itwasfoundthat thePIs this study show that IM proved to be useful in the
for the guidelines can support the staff physicians in development of a strategy for the implementation of the
checkingtheIPs’reportsontheiradherencetotheguide- insurance medicine guidelines for depression.
line.Thatwouldbeastrongfacilitatorforusingtheguide-
linesaccordingtotheinterviewedphysicians.Furthermore Strengths and weaknesses
thePIscouldbeusedforfeedbackaftertrainingtheIPsin Strengths
the use of the guidelines, which was one of the needs of IM provides an implementation strategy framework in
theIPs.Byimplementingguidelines,thedecision-makers whichasolidtheoreticalbaseandtheparticipationofthe
meettherequirementsoftheorganizationandtheMinis- IPsisintegrated.TheIPswillbemoremotivatedtoadopt
try,buttheymightbefacedwithalossofIPproductivity. theguidelinesfordepressionifthey aregoodcompatible
TheIPsputmoreemphasisonqualitybytheimplementa- withdailypracticeandsuittotheirneeds.Byfollowingall
tion of guidelines, but wondered if they were capable stepsintheIMprocess,andwiththehelpof40expertsin
enoughofusingtheguidelines.Thepositiveandnegative the development of the instruments, performance
Zwerveretal.BMCPublicHealth2011,11:9 Page10of12
http://www.biomedcentral.com/1471-2458/11/9
Table 6Positive andnegative featuresofthe programimplementation forvarious partiesconcerned
Partiesinvolved Positivefeaturesofprogram Negativefeatures
implementation
Decision-makers
ManagementofSocio- Morepublicsupport (Initial)lossofproduction
MedicalDepartment Meetsministryrequirements Researchtakestime
Fewerappealsandcomplaints
Implementers
(Regional)managers Increasedquality Lossofproduction,possiblytemporary
Fewercomplaints Appealsarenotreduced
(Regional)staffphysicians Better-qualityassessments Guidelinesmustnotberigid
Moretransparentdecisions Legalstatusofguidelines:implicationforappeals?
Easiertestproceduretocheck
reports
Users
Insurancephysicians UsefulguidelinesandEBM Learninganewapproachtakestime;integrationinpersonalroutineisaneffort
information StricterrequirementsmaderegardingexaminationandreportingWilltheextra
Guidelineswithinstruments workloadbeappraisedandsupportedbystaffandmanagement?
tailoredtoIPsinpractice Legalstatusofguidelines:implicationforappeals?
Focusonqualityandcontent
Scopeforprofessional
assessmentmaintained
Concerned
Claimants Morethoroughanduniform Longer,morestructuredconsultations(notnecessarilyadrawback)
claimassessment
Researchers
Experts Influenceoncontent Timeinput
indicators and training, we tried to achieve the practical to other countries in which there is a central organiza-
feasibility of the guidelines for the IPs. We involved not tion for employee benefits and IPs working with guide-
onlyIPsandexpertsintheIMprocess,butalsostaffphy- lines. Another weakness is that claimants with
sicians,regionalmanagers,themedicaladviserandthetop depression were not represented in this study. Neverthe-
managementoftheInstitute. less, we think, that a justifiable, careful and transparent
Weaknesses assessment of work ability, in accordance with the
Generalization of the outcomes from IM studies might guidelines, might be more acceptable for the claimant,
be difficult, because the IM process takes the local con- than assessments without guidelines.
text into account. In our study, however the local con-
text is set by the Institute: a national organization in Comparison with other studies
which IPs assess the work abilities of claimants. There- IM studies in insurance medicine are scarce, and only
fore, the outcomes of our study can only be generalized one has been published [20]. In that study, IM was used
Knowledge/skills:
- Training and feedback
Determinants:
Behavioural IP’s behaviour: Outcomes:
intention - Quality of
- IP’s attitude to guideline regarding use of Guideline adherence assessment
guidelines - IP’s satisfaction
- Social influence on IP
Promoting factors:
- Support
- Instruments
Figure6Researchmodel,schematicallyrepresentedonthebasisoftheASEmodel.IP=InsurancePhysician