The Norwegian Sickness Absence Clinic (NSAC) is a publicly funded specialist outpatient
health service, which is uniquely available for the work force. The overall aim of the NSAC
is prevention of sickness absence, promote return to work (RTW) among those on sickness
absence and prevent long term disability benefit dependency. In addition to being a health
service, the NSAC has a focus on work and functional recovery, including also non-health
related factors. Patients can be referred by general practitioners for mental health problems
and musculoskeletal problems. The NSAC has a lower threshold for severity than specialist
health services generally, and in particular for mental health problems. The efficacy of this
service is unknown.
The NSAC Efficacy Study is part of a broader project, the Norwegian Sickness Absence Clinic
Study (NSACS). The NSACS currently has two sources of funding: Northern Norway Regional
Health Authority and The Norwegian Labour and Welfare Administration and involves two RCTs:
NSAC Efficacy and NSAC Nudge and fifteen work packages concerning health economics,
scalability, implementation, profiling of patient groups, and non-RCT related research
questions to improve understanding of the patient group and their challenges. To do this the
project will use patient survey data, clinician-reported procedures, opinions and outcomes,
linked to registry data for work benefits and health service use. The randomized controlled
trial NSAC Efficacy is the subject of this trial registration.
The NSAC Efficacy Study is a naturalistic randomized controlled multicentre trial, carried
out in northern Norway and involving five NSACs. The study invites 2500 patients, randomized
to either of three treatment arms:
NSAC rapid: treatment at the NSAC at- or within 4 weeks
NSAC ordinary: treatment at the NSAC after 10-14 weeks
NSAC - active control: monodisciplinary examination at the NSAC close to
diagnosis-specific deadline for examination as suggested by guidelines (8-26 weeks, the
majority at the end of this interval)
The NSACs are staffed by teams of medical doctors specializing in physical medicine and
rehabilitation, psychologists, physiotherapists, and employment counsellors with experience
from case management in the Norwegian Labor and Welfare Administration (NAV).
All patients are asked to complete an electronic survey about their mental health and
musculoskeletal pain, work conditions, motivation for work and barriers for return to work
(RTW). The control group only completes the survey on health, and only on either mental
health or musculoskeletal pain, according to referral diagnosis.
The survey tool manages the randomization algorithm.
The NSAC is a relatively new clinical service, available for the labour force, and publicly
funded with the intention to reduce sickness absence and prevent retirement from the labour
force and transitions to disability benefits. The NSAC clinic welcomes patients with the most
common diagnoses for sickness absence and is supposed to have a low threshold.
There is no single alternative clinical service for similar patients outside the labour
force, thus no single treatment as usual (TAU) alternative. Service availability will depend
on diagnosis and severity:
The majority of patients eligible for treatment in the NSAC referred with mental
disorders would not be eligible for treatment in specialist psychiatric services as
conditions in most cases would be too mild. The most common treatment alternative would
be treatment at the general practitioners.
For patients referred for musculoskeletal problems, some may be eligible for
consultations and treatment at physical medicine and rehabilitation outpatient clinics.
For those not eligible, the general practitioner is the most common alternative, and
other options such as private physiotherapists. Eligibility criteria may vary between
catchment areas.
All alternatives to the NSAC would be without employment counsellors, little cross
disciplinary assessment, and little to no focus on work and functional rehabilitation.
The active control group aims to be comparable to TAU, and differs from the NSAC in the
following respects:
Patients receive a monodisciplinary examination from either a doctor, physiotherapist of
psychologist at the NSAC. The focus of the examination is on health-related factors. The
patients will not receive further follow-up at the clinic beyond the first examination.
Upon indication, the patient is referred to other treatment or examination outside of
the NSAC.
Employment counsellors are not involved in patient consultations or in discussions about
patients.
Patients in the active control group will not be posed questions concerning work,
motivation for work or barriers for return to work. Patients will during registration in
Tivian be classified as having predominantly either musculoskeletal- or common mental
disorders, and this will dictate the type of questions posed: musculoskeletal patients
will be asked questions on musculoskeletal factors but not psychological factors, while
patients will common mental disorders will be asked questions about psychological
factors but not musculoskeletal issues. For patients being examined by a psychologist,
if issues concerning musculoskeletal health arise, the patient is asked to discuss these
with his/her GP. If issues concerning mental health arise which requires competence
beyond what the physiotherapist possesses, the physiotherapist may confer with the
medical doctor at NSAC.
The clinician is not to take initiative to discussing work-related factors with the
patient, and as far as possible avoid these becoming central topics of the consultation.
If the patient on his/her own initiative brings up such topics, the clinician is not
restricted from addressing them.
Employment counsellors are not part of patient discussions prior to examination.
Meetings or discussions about patients are kept within profession; i.e. a
physiotherapist is allowed to discuss his/her patient with other physiotherapists if
need be.
The data necessary to answer the research questions are gathered from national registries via
personal identifier, registry data on population level, questionnaires filled out by the
patient (data on health and working conditions) and questionnaires filled out by the
clinician (data on number of treatments, diagnosis, professions involved, and types of
treatment provided).
The patient questionnaire covers 9 themes, split in two sections. Section 1 covers health,
and includes musculoskeletal problems, mental health, and other health related issues (such
as alcohol consumption, medication, and physical activity). Section 2 includes working
conditions (including inter alia questions on social support, work/family conflict and
bullying), barriers for RTW, labour market affiliation, other personal aspects (such as
demography and motivation for work), questionnaires for health economic evaluation (such as
the EQ-5D) and expectations for treatment.
By and large the questionnaire consists of test batteries which have been validated for
specific topics. To reduce the number of questions posed to each patient, the baseline
questionnaire will employ index questions which have proven psychometric properties in terms
of factor loading or similar, meaning that if a problem on a specific topic such as neck pain
is not indicated, the patient will not be presented with the Neck Disability Index
questionnaire. The patient questionnaires will be filled out electronically at before first
treatment and at 6- and 12 months after first treatment. In addition, before treatments,
patients will be given shorter versions of the same questionnaire to be filled out at the
clinic. These shorter questionnaires will consist of questions to which the patient at
baseline indicated a high score, and thus includes more relevant information to the
clinician.
In the NSAC Efficacy Study, receiving treatment at NSACs presupposes consent to participate
in research, as the effect of the treatment is as of date unknown. Hence, receiving treatment
at the NSAC is not necessarily superior to other available health services. Other available
health services that may be utilized by patients serving in the control groups include
mono-disciplinary treatment by physiotherapists, psychologists, general practitioners, gyms,
electronically delivered self-help tools etc. All patients referred to NSACs will be offered
treatment, but patients that decline to participate in research are provided an examination
in line with randomization arm #3.