Patient-centeredness in psychiatric work disability evaluations and the reproducibility of work capacity estimates.

OBJECTIVES: To evaluate the extent of patient-centeredness in psychiatric work disability evaluations and its association with the reproducibility of work capacity (WC) estimates. METHODS: In our mixed methods study, 29 video-taped interviews conducted in psychiatric work disability evaluations were coded with the Roter Interaction Analysis System (RIAS) and different measures of patient-centeredness were derived from these codings, including a summary patient-centred communication ratio. Four experts each estimated a claimant's WC on a scale from 0% to 100%. RESULTS: Patient-centred communication ratios were always >1, suggesting a preponderance of psychosocial information exchange. In contrast, utterances reflecting empathy were rare e.g., the expert did not address the claimant's emotions in 25 of 29 interviews. None of the derived patient-centeredness measures showed a significant association with WC reproducibility. CONCLUSIONS: Many of the experts' questions addressed the claimant's lifestyle and psychosocial situation. However, this likely reflected factual requirements for the expert opinion, rather than patient-centeredness. Indeed, the experts rarely showed empathy, which is a hallmark characteristic of patient-centeredness. The reproducibility of work capacity estimates was not modulated by patient-centeredness, irrespective of its quantification. PRACTICE IMPLICATIONS: Patient-centeredness in work disability evaluations should find its entry in continuing education of experts.

Functional Interviewing Was Associated With Improved Agreement Among Expert Psychiatrists in Estimating Claimant Work Capacity: A Secondary Data Analysis of Real-Life Work Disability Evaluations.

OBJECTIVE: Functional evaluations establish functional and work (in-)capacities in the context of disability assessments and are increasingly recommended as a modern technique for work disability assessments. The RELY (Reliable disability EvaLuation in psychiatrY)-studies introduced semi-structured functional interviews in real-life assessments of claimants with mental disorders for evaluating their self-perceived health-related limitations and for investigating the reproducibility of work capacity (WC) estimates. Functional interviews elicit claimants' self-perceptions about their work-related limitations and capacities in the labour market. This secondary data analysis explored the coverage of work-related key topics in these interviews and investigated whether interviews with high coverage (versus low coverage) of work-related topics resulted in better reproducibility of WC estimates among experts. METHODS: Thirty video-taped RELY-assessments underwent a content analysis along a predefined framework for functional interviewing, including the claimant's self-perceived work limitations and work-related health complaints as centrepieces of functional interviewing. Following transcription, interviews were segmented into coding units. Coding units were allocated to the five steps with 19 key topics of the framework. Enquiry into key topics was ascertained by summing the functional coding units per key topic. Median split grouped the interviews into high and low coverage of functional topics and compared them for inter-rater reliability (intraclass correlation coefficient, ICC) and inter-rater agreement (standard error of measurement, SEM). RESULTS: Interviews were broken down in 40,010 coding units, 31% of which addressed functional topics. Enquiries in self-perceived work limitations and work-related health complaints were sparse (coding units medianpsychiatrist between 0 and 1.5, medianpatients between 0 and 9.5). High coverage interviews enquired on more functional topics (68% vs. 42%, chi2(1, N = 38) = 5.32, p = 0.021) and in more depth (36% vs. 16% of functional coding units, chi2(1, N = 1,314) = 141.15, p < 0.001). Interviews with higher functional coverage reached significantly higher inter-rater agreement in WC ratings among experts (mean difference in SEM, low-high coverage, 7.5% WC, 95% CI 0.2 to 15.1%WC). Inter-rater reliability was low in both groups (ICC, 0.38 versus 0.40). CONCLUSIONS: Content analysis showed little enquiry by experts on claimants' self-perceived activity limitations and work-related capacity. The association between interviews with higher functional coverage and better expert agreement on the claimants' remaining WC requires confirmation in prospective studies.

The reproducibility of psychiatric evaluations of work disability: two reliability and agreement studies.

BACKGROUND: Expert psychiatrists conducting work disability evaluations often disagree on work capacity (WC) when assessing the same patient. More structured and standardised evaluations focusing on function could improve agreement. The RELY studies aimed to establish the inter-rater reproducibility (reliability and agreement) of 'functional evaluations' in patients with mental disorders applying for disability benefits and to compare the effect of limited versus intensive expert training on reproducibility. METHODS: We performed two multi-centre reproducibility studies on standardised functional WC evaluation (RELY 1 and 2). Trained psychiatrists interviewed 30 and 40 patients respectively and determined WC using the Instrument for Functional Assessment in Psychiatry (IFAP). Three psychiatrists per patient estimated WC from videotaped evaluations. We analysed reliability (intraclass correlation coefficients [ICC]) and agreement ('standard error of measurement' [SEM] and proportions of comparisons within prespecified limits) between expert evaluations of WC. Our primary outcome was WC in alternative work (WCalternative.work), 100-0%. Secondary outcomes were WC in last job (WClast.job), 100-0%; patients' perceived fairness of the evaluation, 10-0, higher is better; usefulness to psychiatrists. RESULTS: Inter-rater reliability for WCalternative.work was fair in RELY 1 (ICC 0.43; 95%CI 0.22-0.60) and RELY 2 (ICC 0.44; 0.25-0.59). Agreement was low in both studies, the 'standard error of measurement' for WCalternative.work was 24.6 percentage points (20.9-28.4) and 19.4 (16.9-22.0) respectively. Using a 'maximum acceptable difference' of 25 percentage points WCalternative.work between two experts, 61.6% of comparisons in RELY 1, and 73.6% of comparisons in RELY 2 fell within these limits. Post-hoc secondary analysis for RELY 2 versus RELY 1 showed a significant change in SEMalternative.work (- 5.2 percentage points WCalternative.work [95%CI - 9.7 to - 0.6]), and in the proportions on the differences ≤ 25 percentage points WCalternative.work between two experts (p = 0.008). Patients perceived the functional evaluation as fair (RELY 1: mean 8.0; RELY 2: 9.4), psychiatrists as useful. CONCLUSIONS: Evidence from non-randomised studies suggests that intensive training in functional evaluation may increase agreement on WC between experts, but fell short to reach stakeholders' expectations. It did not alter reliability. Isolated efforts in training psychiatrists may not suffice to reach the expected level of agreement. A societal discussion about achievable goals and readiness to consider procedural changes in WC evaluations may deserve considerations.

Inter-rater agreement in evaluation of disability: systematic review of reproducibility studies.

OBJECTIVES:  To explore agreement among healthcare professionals assessing eligibility for work disability benefits. DESIGN:  Systematic review and narrative synthesis of reproducibility studies. DATA SOURCES:  Medline, Embase, and PsycINFO searched up to 16 March 2016, without language restrictions, and review of bibliographies of included studies. ELIGIBILITY CRITERIA:  Observational studies investigating reproducibility among healthcare professionals performing disability evaluations using a global rating of working capacity and reporting inter-rater reliability by a statistical measure or descriptively. Studies could be conducted in insurance settings, where decisions on ability to work include normative judgments based on legal considerations, or in research settings, where decisions on ability to work disregard normative considerations. : Teams of paired reviewers identified eligible studies, appraised their methodological quality and generalisability, and abstracted results with pretested forms. As heterogeneity of research designs and findings impeded a quantitative analysis, a descriptive synthesis stratified by setting (insurance or research) was performed. RESULTS:  From 4562 references, 101 full text articles were reviewed. Of these, 16 studies conducted in an insurance setting and seven in a research setting, performed in 12 countries, met the inclusion criteria. Studies in the insurance setting were conducted with medical experts assessing claimants who were actual disability claimants or played by actors, hypothetical cases, or short written scenarios. Conditions were mental (n=6, 38%), musculoskeletal (n=4, 25%), or mixed (n=6, 38%). Applicability of findings from studies conducted in an insurance setting to real life evaluations ranged from generalisable (n=7, 44%) and probably generalisable (n=3, 19%) to probably not generalisable (n=6, 37%). Median inter-rater reliability among experts was 0.45 (range intraclass correlation coefficient 0.86 to κ-0.10). Inter-rater reliability was poor in six studies (37%) and excellent in only two (13%). This contrasts with studies conducted in the research setting, where the median inter-rater reliability was 0.76 (range 0.91-0.53), and 71% (5/7) studies achieved excellent inter-rater reliability. Reliability between assessing professionals was higher when the evaluation was guided by a standardised instrument (23 studies, P=0.006). No such association was detected for subjective or chronic health conditions or the studies' generalisability to real world evaluation of disability (P=0.46, 0.45, and 0.65, respectively). CONCLUSIONS:  Despite their common use and far reaching consequences for workers claiming disabling injury or illness, research on the reliability of medical evaluations of disability for work is limited and indicates high variation in judgments among assessing professionals. Standardising the evaluation process could improve reliability. Development and testing of instruments and structured approaches to improve reliability in evaluation of disability are urgently needed.