Hoving Jan L, Lacaille Diane, Urquhart Donna M, Hannu Timo J, Sluiter Judith K, Frings-Dresen Monique H W
Coronel Institute of Occupational Health and Research Center for Insurance Medicine, Academic Medical Center, University of Amsterdam, PO Box 22700, Amsterdam, Netherlands, 1100 DE.
Cochrane Database Syst Rev. 2014 Nov 6;2014(11):CD010208. doi: 10.1002/14651858.CD010208.pub2.
Work participation of patients with inflammatory arthritis (IA) is important not only economically but also for physical and psychological health. There is no Cochrane Review to date on studies of non-pharmacological interventions specifically aimed at preventing job loss in people with IA.
To assess the effects of non-pharmacological interventions that aim to prevent job loss, work absenteeism or improve work functioning for employees with IA (rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), other spondylarthritis (SpA) or IA associated with connective tissue diseases, such as Systemic Lupus Erythematosus (SLE)).
We searched the following databases from inception up to 30 April 2014; The Cochrane Library (including Cochrane Central Register of Controlled Trials, i.e. CENTRAL and DARE), MEDLINE (PubMed), EMBASE (Embase.com), CINAHL (EbSCOhost), ClinicalTrials.gov and PsycINFO (ProQuest). We did not impose language restrictions in the search.
We included randomised controlled trials (RCTs) that evaluated interventions aimed at preventing job loss in adults of working age (18 to 65 years) diagnosed with IA, including RA, AS, PsA, SpA or other types of IA. Primary outcomes were job loss and sickness absenteeism and the secondary outcome was work functioning.
Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias in the included RCTs.
We included three RCTs with a total of 414 participants at risk of job loss. The majority of participants had IA, most with RA and to a lesser degree AS. The interventions aimed to prevent job loss and improve work functioning in several ways: firstly by evaluating work changes or adaptations and secondly by providing any person-directed interventions including vocational counselling, advice or education. Interventions directly targeted at the work environment were minimal and included workplace visits (one trial) or any actions by an occupational physician (one trial). The duration or dose of the interventions varied from two 1.5-hour sessions (one RCT) over five months, two consultation and multidisciplinary treatments during three months (one RCT), to six to eight individual or group sessions over six months (also one RCT). All participants were recruited through rheumatology clinics, both in or outside hospitals. Included trials investigated job loss (n = two RCTs; 382 participants), work absenteeism and work functioning (n = one RCT; 32 participants). Overall, we evaluated the two smaller trials as having a high risk of bias and the large trial as having a low risk of bias. Trials showed marked differences in how they performed on risk of bias items, particularly on performance bias.We assessed the quality of the evidence using the GRADE approach and judged there to be very low quality evidence across the three reported outcomes. Of the two RCTs investigating job loss, the larger one (n = 242 participants) reported a large statistically significant reduction in job loss (relative risk (RR) = 0.35, 95% confidence interval (CI) 0.18 to 0.68) and the other RCT (n = 140) reported similar effects in both groups, although the CI was very wide (RR = 1.05, 95% CI 0.53 to 2.06). The latter one probably suffered from performance bias and we judged it to have a high risk of bias. The one small trial investigating sickness absenteeism found uncertain results at six months' follow-up (MD = -2.42 days, 95% CI -5.03 to 0.19). Finally, in the same small trial investigating work functioning using the Rheumatoid Arthritis-Work Instability Scale (RA-WIS), there was a moderate improvement of intermediate term work functioning (six months; scale range 0 to 23; mean improvement -4.67 points, 95% CI -8.43 to -0.91). We identified no adverse effects in the publications of the three trials.
AUTHORS' CONCLUSIONS: This Cochrane review of three RCTs found very low quality evidence overall for job loss prevention interventions having an effect on job loss, work absenteeism and work functioning in workers with inflammatory arthritis. While this review highlights that further high quality RCTs are required, the results suggest that these strategies have potential to be effective.
炎症性关节炎（IA）患者的工作参与不仅在经济方面很重要，对其身心健康也很重要。迄今为止，尚无Cochrane系统评价专门针对预防IA患者失业的非药物干预研究。
评估旨在预防IA（类风湿关节炎（RA）、强直性脊柱炎（AS）、银屑病关节炎（PsA）、其他脊柱关节炎（SpA）或与结缔组织病相关的IA，如系统性红斑狼疮（SLE））患者失业、工作缺勤或改善其工作功能的非药物干预措施的效果。
我们检索了以下数据库，检索时间从建库至2014年4月30日；Cochrane图书馆（包括Cochrane对照试验中心注册库，即CENTRAL和DARE）、MEDLINE（PubMed）、EMBASE（Embase.com）、CINAHL（EbSCOhost）、ClinicalTrials.gov和PsycINFO（ProQuest）。检索未设语言限制。
我们纳入了随机对照试验（RCT），这些试验评估了旨在预防确诊为IA（包括RA、AS、PsA、SpA或其他类型IA）的工作年龄（18至65岁）成年人失业的干预措施。主要结局为失业和病假缺勤，次要结局为工作功能。
两位综述作者独立选择纳入试验、提取数据并评估纳入的RCT中的偏倚风险。
我们纳入了3项RCT，共有414名有失业风险的参与者。大多数参与者患有IA，多数为RA，AS患者较少。干预措施旨在通过以下几种方式预防失业并改善工作功能：首先是评估工作变化或调整，其次是提供任何针对个人的干预措施，包括职业咨询、建议或教育。直接针对工作环境的干预措施很少，包括工作场所访问（1项试验）或职业医生采取的任何行动（1项试验）。干预措施的持续时间或剂量各不相同，从为期5个月的两次1.5小时课程（1项RCT）、为期3个月的两次咨询和多学科治疗（1项RCT）到为期6个月的6至8次个体或小组课程（也是1项RCT）。所有参与者均通过医院内外的风湿病诊所招募。纳入试验调查了失业情况（n = 2项RCT；38名参与者）、工作缺勤和工作功能（n = 1项RCT；32名参与者）。总体而言，我们将两项较小的试验评估为具有高偏倚风险，而大型试验为低偏倚风险。试验在偏倚风险项目上的表现存在显著差异，尤其是在执行偏倚方面。我们使用GRADE方法评估证据质量，并判断在报告的三项结局中证据质量均非常低。在两项调查失业情况的RCT中，较大的一项（n = 242名参与者）报告失业情况在统计学上有显著大幅降低（相对风险（RR）= 0.35，95%置信区间（CI）0.18至0.68），另一项RCT（n = 140）报告两组效果相似，尽管CI非常宽（RR = 1.05，95%CI 0.53至2.06）。后一项试验可能存在执行偏倚，我们判断其具有高偏倚风险。一项调查病假缺勤情况的小型试验在6个月随访时结果不确定（MD = -2.42天，95%CI -5.03至0.19）。最后，在同一项使用类风湿关节炎 - 工作不稳定性量表（RA - WIS）调查工作功能的小型试验中，中期工作功能有中度改善（6个月；量表范围0至23；平均改善 -4.67分，95%CI -8.43至 -0.91）。我们在三项试验的出版物中未发现不良反应。
这项对三项RCT的Cochrane系统评价发现，总体而言，关于预防失业干预措施对炎症性关节炎患者的失业、工作缺勤和工作功能有影响的证据质量非常低。虽然本综述强调需要进一步开展高质量的RCT，但结果表明这些策略可能有效。
