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OBJECTIVES: This study aimed to investigate the effect of a brief training intervention for occupational health services (OHS) professionals on multiprofessional resource utilization and the costs of biopsychosocial management of patients with low-back pain (LBP) compared to usual care among all participants and those in work disability-based risk groups. METHODS: OHS utilization and back-related sick leave data were collected from electronic patient records over one-year follow-up comparing 232 patients in the intervention arm and 80 control-arm patients, stratified for risk of work disability based on the Örebro Musculoskeletal Pain Screening Questionnaire. We estimated costs using linear mixed models by multiplying unit costs (in euros) by each type of OHS resource use (visits to physicians, physiotherapists, nurses, use of imaging) and the number of sick leaves. Estimated mean cost differences with confidence intervals (CI) were reported using bootstrapping to deal with skewed cost data. RESULTS: The median number of visits to physicians and physiotherapists in the intervention versus control arms was 1 [interquartile range (IQR) 0–3] and 2 (IQR 1–4) versus 2 (IQR 1–3) and 1 (IQR 0–2), respectively. The intervention arm accrued lower physician costs (€-43, 95% CI €-82– -3, P=0.034) and higher physiotherapist costs (€55, 95% CI €26–84, P<0.001) compared to the control arm. There was no statistically significant difference in average total costs between the arms (€-1908, 95% CI €-6734–2919). In the low- and medium-risk groups of work disability, physiotherapist costs were higher in the intervention than control arm, but no statistically significant differences were observed between the arms in the total resource utilization or sickness absence costs. CONCLUSIONS: Brief biopsychosocial training may support shifting OHS resources towards multiprofessional physiotherapist-driven care, instead of solely physician-driven care, for management of patients with LBP in differing risk groups of work disability with no substantial differences in total costs.

Objective This study aimed to investigate the effectiveness of brief training in the guideline-oriented biopsychosocial management of low-back pain (LBP) in occupational health services using a cluster-randomized design. A small sample of physiotherapists and physicians from the intervention units (N=12) were given three- to seven-day training focusing on the biopsychosocial management of LBP, while professionals in the control units (N=15) received no such training. Methods Eligible patients with LBP, with or without radicular pain, aged 18-65, were invited to participate. A web-based questionnaire was sent to all recruited patients at baseline, three months and one year. The primary outcome measure was disability (Oswestry Disability Index, ODI) over one year. Between-group differences were analyzed using linear and generalized linear mixed models adjusted for baseline-response delay as well as variables showing between-group imbalance at baseline. Results The final study sample comprised 234 and 81 patients in the intervention and control groups, respectively at baseline, and 137 and 47 patients, respectively, at one year. At baseline, the mean duration of pain was longer in the intervention group (P=0.017), and pain-related fear concerning physical activity was lower (P=0.012). We observed no significant difference between the groups' primary outcome measure (adjusted one-year mean difference in the ODI: 2.3; 95% confidence interval -1.0-5.7; P=0.175) or most secondary outcomes. Conclusions Brief training in guideline-oriented biopsychosocial management of LBP for occupational health professionals did not appear to be effective in reducing patients' symptom over one-year follow-up compared to treatment as usual.

In contrast to earlier studies which have used modelling to perform cost-effectiveness analysis, this study links data from a randomised controlled trial with register data from nationwide registries to reveal new evidence on costs, effectiveness, and cost-effectiveness of organised mass prostate-cancer screening based on prostate-specific antigen (PSA) testing. Cost-effectiveness analyses were conducted with individual-level data on health-care costs from comprehensive registers and register data on real-world effectiveness from the two arms of the Finnish Randomised Study of Screening for Prostate Cancer (FinRSPC), following 80,149 men from 1996 through 2015. The study examines cost-effectiveness in terms of overall mortality and, in addition, in terms of diagnosed men's mortality from prostate cancer and mortality with but not from prostate cancer. Neither arm of the FinRSPC was clearly more cost-effective in analysis in terms of overall mortality. Organised screening in the FinRSPC could be considered cost-effective in terms of deaths from prostate cancer: averting just over one death per 1000 men screened. However, even with an estimated incremental cost-effectiveness ratio of below 20,000€ per death avoided, this result should not be considered in isolation. This is because mass screening in this trial also resulted in increases in death with, but not from, prostate cancer: with over five additional deaths per 1000 men screened. Analysis of real-world data from the FinRSPC reveals new evidence of the comparative effectiveness of PSA-based screening after 20 years of follow-up, suggesting the possibility of higher mortality, as well as higher healthcare costs, for screening-arm men who have been diagnosed with prostate cancer but who do not die from it. These findings should be corroborated or contradicted by similar analyses using data from other trials, in order to reveal if more diagnosed men have also died in the screening arms of other trials of mass screening for prostate cancer.

ObjectivesProceeding from a basic concept underpinning economic evaluation, opportunity cost, this study aims to explain how different approaches to economics diverge quite dramatically in their ideas of what constitutes appropriate valuation, both in principle and practice. Because the concept of opportunity cost does not inherently specify how valuation should be undertaken or specify how appropriate any economic value framework (EVF) might be, the three main economics-based approaches to providing evidence about value for health technology assessment are described.MethodsThis paper describes how the three main EVFs—namely, the extra-welfarist, welfarist, and classical—are most typically understood, applied, and promoted. It then provides clarification and assessment of related concepts and terminology.ResultsAlthough EVFs differ, certain underlying characteristics of valuation were identified as fundamental to all approaches to economic evaluation in practice. The study also suggests that some of the rhetoric and terms employed in relation to the extra-welfarist approach are not wholly justified and, further, that only the welfarist approach ensures adherence to welfare-economic principles. Finally, deliberative analysis, especially when connected with a classical economic approach, can serve as a useful supplement to other analytical approaches.ConclusionsAll three approaches to economic evaluation have something to offer assessment processes, but they all display limitations too. Therefore, the author concludes that the language of economic evaluation should be used with sufficient humility to prevent overselling of EVFs, especially with regard to the qualities of evidence they provide for priority setting processes.

Copyright © Cambridge University Press 20192019Cambridge University PressIntroductionHealth technology assessment (HTA) processes typically combine both evidence and values in order to inform decisions about relative value. Health-economic evaluation and other economic evidence are thought by many to be important for such processes, but there is typically tension between the information offered by health-economic assessment, and the context-specific interpretation of such information. This study reviews the meaning, and interpretation, of ‘health-economic evaluation’ aimed at informing HTA processes. One central aim is to answer the question: “Can health-economic evaluation provide a representation of ‘value for money’ for HTA?”MethodsA seminal article was used as a starting point and then a variety of search techniques, including bi-directional citation searching, were used to obtain evidence relating to the study objective. A critical review is undertaken spanning the last fifty years of health-economic evaluation, which provides perspective on the balance between more context-independent assessments and the context-specific interpretation of those assessments.ResultsAlthough health-economic evaluation can legitimately be undertaken in a variety of ways, we find that processes of ‘valuation’ are fundamental to all approaches to economic evaluation in practice. Values influence how these economic value frameworks tend to be operationalized, promoted and understood. Our critical review provides those interested in prioritization with a timely reminder that health-economic evaluation should be thought of as largely context- and content -specific.ConclusionsHealth-economic evaluation can typically only offer a truncated representation of ‘value for money’ to HTA processes. In answer to the question posed above, this study finds that health-economic evaluation will typically not provide a full assessment of ‘value for money’. Therefore, it should always be accompanied by an assessment of its qualities: what is covered in the analysis, how well what is covered is measured or analysed, and what is left out. Humility about what health-economic evaluation can offer would seem useful, especially given that other elements of value exist, such as the potential harms and benefits of medical-industry profits and environmental sustainability.

Background To prevent low back pain (LBP) from developing into a prolonged disabling condition, clinical guidelines advocate early stage assessment, risk‐screening, and tailored interventions. Occupational health services recommend guideline‐oriented biopsychosocial screening and individualized assessment and management. However, it is not known whether training a limited number of health care professionals improves the management process. The primary objective of this study is to investigate whether training in the biopsychosocial practice model is effective in reducing disability. Furthermore, we aim to evaluate health‐economic impacts of the training intervention in comparison to usual medical care. Methods The occupational health service units will be allocated into a training or control arm in a two‐arm cluster randomized controlled design. The training of occupational physiotherapists and physicians will include the assessment of pain‐related psychosocial factors using the STarT Back Tool and the short version of the Örebro Musculoskeletal Pain Screening Questionnaire, the use of an evidence‐based patient education booklet as part of the management of LBP, and tailored individualized management of LBP according to risk stratification. The control units will receive no training. The study population will include patients aged 18–65 with nonspecific LBP. The primary outcome is a patient‐reported Oswestry Disability Index from baseline to 12 months. By estimating group differences over time, we aim to evaluate the effectiveness of the training intervention in comparison to usual medical care, and to undertake an economic evaluation using individual patients' health care records (participant‐level data) and the participating units' registries (cluster‐level data). In addition, through interviews and questionnaires, we will explore the health care professionals' conceptions of the adoption of, the barriers to, and the facilitators of the implementation of the practice model. Discussion The evaluation of training in the guideline‐oriented biopsychosocial management of LBP in occupational health services is justified because LBP represents an enormous burden in terms of work disability.

Background Inappropriate imaging and low-value care for low back pain (LBP) are common. A new patient-education booklet was created to overcome identified barriers to the delivery of recommended care, including the use of inappropriate imaging. Our aim was to assess the effectiveness of this booklet as part of primary care for LBP patients in comparison to usual care. Methods A cluster-randomized trial was performed. The intervention involved providing practitioners with the new patient-education booklet and a 30-min training session on its use. The booklet was provided during the clinical consult to all consenting LBP patients in the intervention group. Primary outcomes were the proportion of patients presenting with LBP who underwent imaging examinations during the first three months of follow-up and PROMIS PF-20 (Patient-Reported Outcomes Measurement Information System, 20-item physical functioning short form) change between baseline and three-month follow-up. Secondary outcomes, including sick leave and imaging examinations at 12 months, were investigated. Logistic regression using GEE-estimation was used for dichotomous outcomes, Poisson regression using GEE-estimation for count outcomes, and linear mixed models for continuous outcomes. Results Using the patient education booklet appeared to substantially reduce the proportion of LBP patients who underwent an imaging examination at three months, but the result was not statistically significant (OR 0.57, 95% confidence interval (Cl) 0.27 to 1.22). At 12 months, the effect was slightly larger and statistically significant (OR 0.50, 95%Cl 0.30 to 0.83, p = 0.008). No difference was observed in the PROMIS PF-20 T-score change between baseline and 3 months or 12 months (p = 0.365 and p = 0.923, respectively). The number of sick leave days in the intervention group was less than that in the control group at 3 months (RR 0.47, 95%Cl 0.26 to 0.83, p = 0.010) and at 12 months (RR 0.36, 95%Cl 0.18 to 0.72, p = 0.004). Conclusions The booklet appeared to be effective in reducing the proportion of LBP patients who underwent imaging examinations over 12 months. The intervention had no discernible effect on the PROMIS PF20 T-score change. The number of sick leave days was substantially lower in the intervention group. Trial registration ISRCTN, ISRCTN14389368, Registered 4 April 2019—Retrospectively registered.

Objective This study aimed to investigate the effectiveness of brief training in the guideline-oriented biopsychosocial management of low-back pain (LBP) in occupational health services using a cluster-randomized design. A small sample of physiotherapists and physicians from the intervention units (N=12) were given three- to seven-day training focusing on the biopsychosocial management of LBP, while professionals in the control units (N=15) received no such training. Methods Eligible patients with LBP, with or without radicular pain, aged 18-65, were invited to participate. A web-based questionnaire was sent to all recruited patients at baseline, three months and one year. The primary outcome measure was disability (Oswestry Disability Index, ODI) over one year. Between-group differences were analyzed using linear and generalized linear mixed models adjusted for baseline-response delay as well as variables showing between-group imbalance at baseline. Results The final study sample comprised 234 and 81 patients in the intervention and control groups, respectively at baseline, and 137 and 47 patients, respectively, at one year. At baseline, the mean duration of pain was longer in the intervention group (P=0.017), and pain-related fear concerning physical activity was lower (P=0.012). We observed no significant difference between the groups' primary outcome measure (adjusted one-year mean difference in the ODI: 2.3; 95% confidence interval -1.0-5.7; P=0.175) or most secondary outcomes. Conclusions Brief training in guideline-oriented biopsychosocial management of LBP for occupational health professionals did not appear to be effective in reducing patients' symptom over one-year follow-up compared to treatment as usual.

The proliferation of evidence synthesis methods makes it challenging for reviewers to select the ‘‘right’’ method. This study aimed to update the Right Review tool (a web-based decision support tool that guides users through a series of questions for recommending evidence synthesis methods) and establish a common set of questions for the synthesis of both quantitative and qualitative studies (https://rightreview.knowledgetranslation.net/). A 2-round modified international electronic modified Delphi was conducted (2022) with researchers, health-care providers, patients, and policy makers. Panel members rated the importance/clarity of the Right Review tool's guiding questions, evidence synthesis type definitions and tool output. High agreement was defined as at least 70% agreement. Any items not reaching high agreement after round 2 were discussed by the international Project Steering Group. Twenty-four experts from 9 countries completed round 1, with 12 completing round 2. Of the 46 items presented in round 1, 21 reached high agreement. Twenty-seven items were presented in round 2, with 8 reaching high agreement. The Project Steering Group discussed items not reaching high agreement, including 8 guiding questions, 9 review definitions (predominantly related to qualitative synthesis), and 2 output items. Three items were removed entirely and the remaining 16 revised and edited and/or combined with existing items. The final tool comprises 42 items; 9 guiding questions, 25 evidence synthesis definitions and approaches, and 8 tool outputs. The freely accessible Right Review tool supports choosing an appropriate review method. The design and clarity of this tool was enhanced by harnessing the Delphi technique to shape ongoing development. The updated tool is expected to be available in Quarter 1, 2025. •Right Review assists in identifying appropriate evidence synthesis methods.•Right Review was updated using an international Delphi process.•Right Review now has a single set of guiding questions.

This paper describes psychological theory about stress, coping, and psychological resilience, and considers how coping strategies can help develop resilience in the context of outdoor education. Outdoor education programs often aim to develop psychological resilience through structured challenging and reflective experiences. Use of coping strategies such as positive reinterpretation appears to be resilience enhancing, whereas passive acceptance and focusing on negative emotion are resilience undermining. Further research is needed to better integrate psychoeducational curricula about stress and coping into challenge-based outdoor education programs which aim to foster psychological resilience. [ABSTRACT FROM AUTHOR] [Author abstract]