Economic Evaluation of Periodic Occupational Health Screening
Condition: Occupational Health; Screening; Surveys and Questionnaires
Study type: Interventional

Summary: 
      In Belgium, Periodic Health Screenings (PHS) are obliged by law for several occupations,
      including safety functions, jobs with heightened vigilance, work that involves physical,
      biological or chemical agents or tasks that are an ergonomic or mental burden. Scientifically
      it remains an open question whether these screenings guarantee the prevention of later health
      problems or problems with functioning at work.

      The objective of this study is to compare the cost-effectiveness of PHS with an online health
      screening tool with selective follow-up. In five Flemish hospitals, the employees eligible
      for PHS (exempting frequent exposure to ionizing radiation, preparation of cytostatics, or
      exposure to carcinogens, mutagens, or reprotoxic substances) are randomly assigned to a
      control group (receiving classical PHS at the occupational physician), or an intervention
      group (e-tool with selective follow-up by the physician). In the intervention group, 20% of
      the employees is seen by the occupational physician, based on their responses to the
      questionnaire. The intervention- and control group complete the questionnaire three times:
      before the study start (June 2019), in February 2020, and in September 2020. The study ends
      in March 2021.

      The survey is developed as part of the study. On the one hand it contains questions for the
      cost-effectiveness analysis: health care use, absenteeism and presenteeism, and health
      literacy. On the other hand, a validated questionnaire is developed based on a systematic
      review of existing validated and reliable instruments, a Delphi panel of occupational
      physicians, and a pilot- and field study that test the reliability and validity of the survey
      (and its referral to the occupational physician). For the latter, the employees' health,
      occupational risks, work ability, and lifestyle (alcohol abuse, drug abuse, physical
      activity, and nutrition) are surveyed. Access to the occupational physician remains
      guaranteed by means of an additional question ("Do you wish to discuss the results of your
      survey with the occupational physician?") and as spontaneous consultations with the
      occupational physicians remain possible before, during, and after the trial.

      The survey platform Qualtrics is used for data collection. Researchers have no insight in
      personal data, nor the medical files of employees, and only analyse the coded data from the
      surveys. Invitations for the survey are sent by the occupational physician. The coded
      questionnaires are saved on a KU Leuven survey, following the ISO-9001-procedure and the
      legal data storage period. The employer has no insight in the data. The study is performed by
      Jonas Steel, supervised by prof. dr. Jeroen Luyten and prof. dr. Lode Godderis, and financed
      by the Belgian Association for Occupational Physicians, and three external services for
      prevention and protection at work: IDEWE, Liantis, and Mensura.
    

Detailed description: 
      In Belgium, Periodic Health Screenings (PHS) are obliged by law for several occupations and
      allow for early detection of health problems, advice towards risk-free behaviour, timely risk
      reductions or referrals to other care personnel. This makes them one of the key preventive
      activities of the occupational physician (OP). However, there are as of yet no strong
      research indications for the optimal organisation of these occupational health screenings. A
      recent systematic review of general health screening (not only at the workplace) did not find
      studies that indicated an effect (e.g. on general mortality, cardiovascular mortality, or
      cancer mortality), but indicated they could lead to adverse effects such as overtreatment or
      misplaced reassurance. Reviews in other domains such as vision screening of older drivers,
      tuberculosis screening of healthcare workers, tomography for lung cancer, of pre-employment
      investigations frequently found too few high quality studies to draw strong conclusions.
      There is some evidence for the effectiveness of biometric screening in reducing the number of
      non-communicable diseases, especially when aimed at higher risk employees or if they are
      combined with well-designed health programmes. However, it remains an open question whether
      more focused occupational screenings with risk-selection, as is the case in Belgium and the
      Netherlands, are beneficial.

      This protocol will therefore present a study on annual periodic health screenings (PHS). In
      this sense, it will contribute to evidence-based decision-making for policy makers, who are
      currently planning to change the legislation.

      A theoretically ideal experiment would compare a group of employees undergoing periodic
      health screening with a group without an intervention. However, three factors make the
      formulation of an alternative intervention necessary. Firstly, from an ethical point of view,
      adequate medical follow-up should be provided for all participants in the study. Secondly,
      current legislation requires employees to undergo screening for "risky" occupational
      activities to assess their aptitude for those activities. Thirdly, it is important to provide
      employers with an alternative form of care or follow-up, since it would not be beneficial
      (for any party) if employers paid the same fees to the Services for Prevention and Protection
      at Work (SPPW), but got less care in return. The experiment will therefore compare
      care-as-usual (periodic health screenings by the OP - the control group) with employees that
      complete an electronic health survey with selective follow-up (the intervention group). The
      latter encompasses that the employees' answers on the health screening tool determine whether
      he/she will be seen by the OP. This allows immediate data collection for the experiment, and
      at the same time guarantees follow-up of employees with health problems by SPPW.

      The survey wants to answer to the demands (of a good PHS) of the International Labour Office
      by focusing on primary (sometimes secondary) prevention, by taking a risk analysis as a
      starting point, by allowing for both individual and collective measures, by formulating goals
      in advance, and because finding problems leads to adequate action. To fulfil these goals, the
      questionnaire will not only make use of health information (health status, early detection of
      occupational disease, accidents), but also of other signals that could point towards a higher
      risk of absence or reduced functioning: absenteeism, presenteeism, health care use, working
      conditions, job-specific factors, and lifestyle. In addition, the health literacy of
      personnel is taken into account to assess how well information about health at work (eg
      coming from the OP) is understood. Briefly summarized, health literacy contains three
      dimensions: access - how employees are able to seek and obtain health information -
      "understanding" - the expectations, perceived utility and interpretation of health
      information - and "behaviour" - the employee's intention to change behaviour as well as his
      behaviour itself. Finally, it is possible to measure the help-seeking behaviour of employees,
      to assess their tendency to seek medical care when needed. By incorporating these aspects
      into the survey and study, we will circumvent the complication that many preventive
      interventions have to face: health ameliorations and decreases in health care use,
      absenteeism and presenteeism only occur after several years.
    

Intervention name(s): Electronic survey with selective consultations
Intervention type(s): Other
Intervention description(s): Participants complete an online questionnaire, after which the 20% employees that mostly need contact with the occupational physician (based on their survey score) are invited to a consultation with the occupational physician.
Allocation: Randomized
Intervention model: Single Group Assignment
Intervention model description: Employees within the same hospital are prospectively and randomly allocated to one of two groups: an intervention group receives an electronic survey with selective follow-up by the occupational physician, and a control group where all employees undergo a periodic health screening by the occupational physician. The survey is thus used as part of the intervention, as an algorithm (based on a scoring system of the survey) which determines who should be seen by the occupational physician is evaluated. However, the survey is also used to gather data on how the selective referral affects outcomes. There are three measurement moments (each time with the same survey, and in both groups). First, baseline outcomes are measured in June 2019, after which selective follow-up in the intervention group and contact with the OP in the control group is organised in June-December 2019. Differences in outcomes between groups are then measured in February 2020, and in September 2020.
Masking: Single (Participant)
Primary purpose: Screening
Keywords: occupational medicine; survey; periodic health surveillance