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We calm advice about amusing allowance physicians and their audience from two sources. The aboriginal antecedent is a one-off assay in March 2008 to admeasurement the accomplishments variables, opinions, and considerations of allowance physicians. The questions in the assay about opinions and considerations of allowance physicians were based on the ‘Attitude – Amusing barometer – self-Efficacy’ archetypal (ASE model) [21], an addendum of the Theory of Planned Behaviour [22], which incorporates Bandura’s abstraction of self-Efficacy [23] and the concepts of Knowledge and Barriers [24]. At the end of this assay we asked the respondents for permission to articulation their answers to the assessments after-effects of their clients. Added abundant descriptions can be begin in publications abroad [9, 10]. The additional antecedent is the Claim Appraisal and Monitoring Arrangement (CAMS) of the Dutch Employee Allowance Authority, a database with appraisal after-effects of all clients. In May 2008 we extracted abstracts on affliction assessments at applicant akin from this database [25] of. The bond action – to articulation the assay abstracts of the allowance physician respondents to the assessments after-effects of their audience – was agitated out in August 2008 by a trusted third affair (an alien agency) beneath the administration of a accessible notary. All abstracts apropos clients, physicians and their bounded offices were anonymized afore they were handed over to the researchers. As this abstraction was a accessory assay of anonymized data, approval by a Medical Ethical Commission was not all-important beneath Dutch law.

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The ambition accumulation consisted of allowance physicians actively active by the Employee Allowance Authority in May 2008 who performed assessments of abiding sick-listed advisers in 2007 or in above-mentioned years, aural three commensurable approved regimes for abiding assignment disability: WAO; HERBO and WIA. Physicians who were not alive for the Dutch Employee Allowance Authority in March 2008 and physicians who performed assessments alone for added regimes (i.e. ZW: abbreviate appellation ailing leave of workers after an employer, and WAJONG: affliction alimony for adolescent disabled persons) were excluded, because these regimes awning added populations and use added appraisal belief to actuate disability. Our appraisal was that the ambition accumulation consisted of 450 allowance physicians. Two hundred and thirty-one allowance physicians (approximately 51% of the ambition group) responded to the survey, of whom 200 gave a accord to articulation their assay answers with the applicant database. For added capacity on the abstraction citizenry of allowance physicians we accredit to Steenbeek et al [9].

We created a absolute applicant accumulation from the three above-mentioned regimes so that the assessments could be analysed together. The admittance belief were: a) the applicant abstracts could be affiliated with the allowance physician data, and b) the appraisal aeon for the three regimes, i.e. from July 2003 to March 2005 for the WAO regime, from November 2004 to December 2006 for the HERBO regime, and from January 2006 to April 2008 for the WIA regime. All the audience were age-old amid 15 and 65 at the time of the appraisal and suffered from one or added of the diseases or disorders in Adaptation 10 of the International Code of Diseases [26]. The assay abstracts were affiliated for 199 allowance physicians in 27 bounded offices and 91,149 audience (linkage bootless for one physician who gave a consent). Next, we added called abstracts by applying two criteria: 1) we called physicians with 10 or added audience per appointment to be abiding of acceptable believability in the multivariate analysis, and 2) we assigned anniversary physician to the appointment area he/she had the best clients, acceptation that audience accessory the office(s) area the physician had beneath audience were afar from the analysis, this to abstain cross-classified multilevel modelling. The aboriginal archetype resulted in the abatement of three physicians and bargain the cardinal of audience to 91,139. The additional resulted in 83,755 audience adjourned by 196 allowance physicians in 27 bounded offices.

The afterward abstracts at applicant akin on the after-effects of affliction assessments by allowance physicians were extracted from the CAMS-database a) no acceptable anatomic capacities (i.e. the applicant has aught alive capacities larboard now and will not balance in the future); b) restrictions in alive hours; c) anatomic capacities per FAL item; and d) assignment affliction class. From the extracted abstracts we complete three aftereffect measures (Table

and Table

). 1) ‘No acceptable anatomic capacities, continued (NSCE)’: a aggregate of ‘no acceptable anatomic capacities’ and ‘restrictions to 30 alive hours or less’. The admeasurement ‘no acceptable anatomic capacities’ – which leads to the best assignment affliction chic 80-100% per analogue – was accumulated with ‘restrictions in alive hours’ (to a best of 30 per week) which, in practice, additionally led to no jobs. This because the arrangement that labour experts formed with did not accommodate abounding part-time jobs at that time (2003-2007). When the labour able had to specify jobs for audience who could not assignment for added than 30 hours a week, the CAMS-system generally came up with no jobs which again resulted in an appraisal of these audience in the best assignment affliction chic 80-100%. We accordingly alloyed the two outcomes into one aftereffect measure. 2) ‘Functional affliction account (FIS)’. Broersen et al. [[

], Broersen JPJ, Mulders HPG, Schellart AJM, Van der Beek AJ: The Identification of Job Opportunities for Severely Disabled Sick-listed Employees, submitted] advised the agency anatomy of the FAL-items and acclaimed four affliction scales: brainy incapacities, concrete incapacities, affliction to action apart and incapacities of the action of the hands. Because of a poor believability of the fourth calibration in our abstraction (Cronbach’s alpha

). The aftereffect admeasurement ‘functional affliction score’ (FIS) was authentic as the sum of the three absolute affliction variables. The FIS (score 0-6) reflects the severity of the affliction in altered anatomic areas (mental, physical, and autonomy) and follows about a Poisson distribution. 3) ‘Maximum assignment affliction chic (MWDC)’. This aftereffect admeasurement consists of two values: a) 80%-100% assignment affliction and b) beneath than 80% assignment disability.

Client characteristics: accessible accomplishments variables and aftereffect measures for all audience in the analysis* (n = 83755)

Gender

   (background)

Man(= 1)(ref)

44.4%

Woman (= 2)

55.6%

Age

   (background)

15-24 years

2.6%

25-34 years

19.3%

35-44 years

36.1%

45-54 years

32.4%

≥ 55 years

9.6%

Mean (sd) average age (years)

42.5 (9.1) 43.0

Statutory regime

   (background)

WAO (= 1) (ref)

26.8%

HERBO (= 2)

47.5%

WIA (= 3)

25.7%

Sector of Occupation

   (background)

Agriculture/Fishery/Foods (= 1)

4.4%

Construction (= 2)

6.3%

Industry (= 3)

9.1%

Retail/Wholesale (= 4)

9.4%

Transport (= 5)

3.3%

Financial Services(= 6)

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6.1%

Employment Agencies (= 7)

5.5%

Health and Care(= 8)

14.1%

Education(= 9)

3.0%

Other Governmental (= 10)

4.8%

Other company/profession (= 11) (ref)

34.2%

Diagnosis

   (background)

Cardiovascular (= 1)(ref)

5.1%

Musculoskeletal (= 2)

32.2%

Mental (= 3)

34.3%

Other(= 4)

28.5%

Objectification of Complaints

   (background)

Yes (= 0) (ref)

48.1%

No (= 1)

51.9%

No Acceptable Capacities Larboard Extended

   (outcome measure)

No (= 0) (ref)

65.0%

Yes (= 1)

35.0%

Maximum Assignment Affliction Class

   (outcome measure)

< 80% (= 0) (ref)

57.2%

80 – 100% (= 1)

42.8%

Client characteristics: accessible accomplishments variables and aftereffect measures for allotment of the audience in the analysis* (n = 64190 – 64398)

Standard Balance per month

   (background)

€ 0 – € 917 (= 1)

10.1%

€ 918 – € 1127 (= 2)

22.4%

€ 1128 – € 1535 (= 3)

35.3%

€ 1535 – € 2069 (= 4)

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22.5%

(€ 2070 – accomplished (= 5)

9.7%

Mean (sd) average account (scale 1..5)

3.0 (1.1) 3.0

Standard Alive Hours per week

   (background)

≤ 20 hours (= 1)

13.1%

21 thru 32 hours (= 2)

21.5%

32 thru 38 hours (= 3)

44.0%

39 thru 40 hours (= 4)

16.6%

> 40 hours (= 5)

4.8%

Mean (sd) average account (scale = 1..5)

2.8 (1.0) 3.0

Education Level

   (background)

Grade 1(= 1)

4.4%

Grade 2 (= 2)

23.1%

Grade 3(= 3)

31.8%

Grade 4 and 5 (= 4)

30.1%

Grade 6 and 7(= 5)

10.6%

Mean (sd) average account (scale 1..5)

3.2 (1.0) 3.0

Mental Incapacities

   (background)

Not or Slightly (= 0) (ref)

85.6%

Moderate (= 1)

7.5%

Rather able or Able (= 2)

6.8%

Physical Incapacities

   (background)

Not or Slightly (= 0) (ref)

84.6%

Moderate (= 1)

5.6%

Rather able or Able (= 2)

9.8%

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Autonomous Incapacities

   (background)

Not or Slightly (= 0) (ref)

92.3%

Moderate (= 1)

3.5%

Rather able or Able (= 2)

4.2%

Functional Affliction Score

   (outcome measure)

(Nearly) none incapacities (= 0)

69.9%

Score (1)

11.1%

Score (2)

13.1%

Score (3)

2.8%

Score (4)

2.7%

Score (5)

0.2%

Maximum astringent incapacities (= 6)

0.1%

Mean (sd) average account (scale 0..6)

0.6 (1.0) 0.0

The applicant accomplishments variables are abbreviated in Table 1. The accomplishments variables accessible for all audience were: gender, ten-year age group, area of occupation, assay accumulation and objectification of complaints. The absolute age was missing for 85 clients. To use the absolute age for all audience in the analysis, we again assigned these 85 audience to the midpoints of the ten-year age accumulation to which they belonged. The assay accumulation capricious was complete on the base of the primary assay for anniversary client. The bifold capricious ‘objectification of complaints’ was complete on the base of insights aggregate by the medical agents at the Dutch Employee Allowance Authority on complaints that are difficult to actualize in practice, i.e. medically alien affection or affection that do not accept a bright medical account (e.g. the abiding fatigue syndrome).

The added accomplishments variables – accepted earnings, accepted alive hours, educational level, and the severity of the three acclaimed incapacities (see Table 2) – were accessible for about 77% of the clients. The allowance physicians had completed a FAL for these clients. As was explained afore with the architecture of the aftereffect admeasurement FIS, we formed three absolute affliction variables from the items of the FAL: brainy incapacities, concrete incapacities and affliction to action autonomously, anniversary denticulate from absent to two.

The labour able added advice to the database on the insured accepted assets of the client, the client’s educational akin and the cardinal of hours ahead formed by the client. We recoded this advice into three about frequently broadcast variables.

Table

contains a arbitrary of the survey-based allowance physician variables which are accordant to this study. As the adjustment for barometer these variables was explained in detail abroad [

,

], we shall confine ourselves actuality to an adumbration of the acceptation of the ASE variables.

Characteristics of allowance physicians who gave a consent: accomplishments variables and ASE-variables* (n = 199)

Gender

Man

58.8%

Woman

41.2%

Age

30-45 years

23.6%

46-50 years

27.7%

51-55 years

25.0%

≥ 56 years

23.7%

Mean (sd) average age (years)

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50.7 (7.0) 50.4

Career as Allowance Physician*

0-10 years

24.1%

11-15 years

25.6%

16-20 years

26.2%

≥ 21 years

24.1%

Mean (sd) average career (years)

16.0 (7.7) 16.5

Former Curative Physician

No (= 0)

84.4%

Yes (= 1)

15.6%

Specialist in Allowance Medicine

No (= 0)

13.6%

Yes (= 1)

86.4%

Standard alive hours per week

< 25 hours (= 1)

18.1%

25-32 hours (= 2)

23.1%

> 32 hours (= 3)

58.8%

Most audience from WIA

No (= 0)

64.3%

Yes (= 1)

35.7%

Most audience from WAO

No (= 0)

70.4%

Yes (= 1)

29.6%

Most audience from WAJONG

No (= 0)

86.9.%

Yes (= 1)

13.1%

Average cardinal of assessments per week

1-5

23.1%

6-15

29.7%

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16-22

25.6%

23-28

21.6%

Mean (sd) average assessments (number)

14.0 (8.4) 15.0

ASE variables**

Attitude

Mean (sd) median

0.0 (1.0) 0.0

Social Norm

Mean (sd) median

0.0 (1.0) 0.0

self-Efficacy

Mean (sd) median

17.6 (3.2) 18.0

Barriers

Mean (sd) median

0.0 (1.0) 0.0

Knowledge

Mean (sd) median

0.0 (1.0) 0.0

Intention

Mean (sd) median

0.0 (1.0) 0.0

Behaviour: process

Mean (sd) median

0.0 (1.0) 0.0

Behaviour: assessment

Mean (sd) median

0.0 (1.0) 0.0

The implications of a college account for the eight ASE variables are explained below:

Attitude: the allowance physician has a added absolute attitude appear the profession of allowance physician, the affection of one’s work, the able staff, and the (Dutch) amusing allowance system;

Social Norm: the allowance physician performed added autonomously, beneath afflicted or detached by the amusing ambiance (colleagues, organization, society);

Self-Efficacy: the allowance physician has added aplomb in his/her own adeptness to ascendancy the alternation with the applicant during the appraisal interview;

Barriers: the allowance physician adventures added barriers arising from assignment pressure, affecting workload, beneath ambit for decision-making, college levels of burnout, poorer cooperation in the office, beneath incentives from administration and about added ‘difficult’ clients;

Knowledge: the allowance physician has acceptable advice about the medical cachet of the applicant and about the rehabilitation efforts of the employer and the client;

Intention: the allowance physician attaches added accent to: the advance of recovery, resumption of work, self-reflection and re-integration, the appliance of capability, illness, disorders and handicaps in the appraisal and, best of all, able checks for the bendability of advice on the circadian activities and home bearings of the client. To some admeasurement this paints the able attitude that one would apprehend from an allowance physician;

Behaviour apropos the appraisal action (Behaviour: process): the allowance physician has added aplomb in his/her own eyes of the job. A college account suggests an allowance physician who is eager, takes ascendancy and is able to bang a accommodation with the client;

Behaviour apropos the appraisal agreeable (Behaviour: assessment): the allowance physician adheres added to rules and able standards. A college account is archetypal of an allowance physician who sticks to the guidelines, does not accede the specific bearings of the client, thinks as he goes along, but still believes that he engages with the client.

We performed a non-response assay for the allowance physicians and the clients. We compared accordant accomplishments variables of the allowance physicians in the abstraction citizenry with the accessible characteristics of all the allowance physicians at the Employee Allowance Authority. We additionally analysed the aberration amid the physicians whose assay after-effects could and could not be affiliated with the database.

We compared the abstracts on the audience in our assay with the abstracts of all the audience in the database beyond the aforementioned appraisal periods for the three regimes. We acclimated frequencies for all variables, crosstabs and Chi-squared statistics for absolute variables, and agency and t-tests for connected variables, application SPSS 15.0.

Using crosstabs and Chi-squares, we analysed the aftereffect measures univariately beyond allowance physicians and offices. We affected the (arithmetical) mean, the accepted deviation, the minimum and best and aberration accessory (standard aberration disconnected by the mean) beyond allowance physicians and offices by extracting the row percentages of the absorbing categories in the absolute aftereffect measures from the crosstabs tables. For the univariate, anecdotic assay only, we disconnected the (approximately Poisson distributed) Anatomic Affliction Array (0 up to 6) into three parts: (nearly) no affliction (Functional Affliction Account 0), abstinent affliction array (Functional Affliction Array 1 up to 3) and aerial affliction array (Functional Affliction Array 4 up to 6). We produced these descriptives with SPSS 15.0 (crosstabs tables and Chi-square statistics) to acquire the row percentages and acclimated MS Appointment Excel 2003 to account their axial addiction and dispersion.

We performed multilevel assay with MLwin adaptation 2.02 [27] for the aftereffect measures, alignment from low to high, for applicant level, allowance physician akin and appointment level.

We acclimated logistic corruption to analyse the two angled aftereffect measures (NSCE, MWDC) and Poisson corruption to analyse the aftereffect admeasurement approximating a Poisson administration (FIS). Because not all applicant accomplishments variables were accessible for all the aftereffect measures of clients, these aftereffect measures were analysed with altered sets of applicant accomplishments variables. We analysed NSCE with Gender, Age, Area of Occupation, Diagnosis, Objectification of Complaints and Approved Administration as absolute applicant accomplishments variables. The aftereffect admeasurement (FIS) for the accumulation of audience with a FAL (about 77%) was analysed with the fore-mentioned applicant accomplishments variables additional Accepted Earnings, Accepted Alive Hours and Education Level. The MWDC aftereffect admeasurement was analysed for the aforementioned 77% of audience and with the aforementioned set of absolute applicant accomplishments variables additional Brainy Incapacities, Concrete Incapacities and Autonomous Incapacities.

We estimated all the multivariate models in MLwin with Restricted Best Likelihood (RIGLS), the ‘naive’ models with first-order maximized quasi-likelihood (MQL) and the multilevel models with second-order penalized quasi-likelihood (PQL). The acceptation of coefficients was bent with Wald statistics. We chose P ≤ 0.10 as the akin of acceptation because we did not appetite to absence absorbing associations.

The multilevel assay for anniversary aftereffect admeasurement consisted of four accomplish [28]. Firstly, we performed a “naïve” analysis, i.e. an assay after accidental coefficients, with all the accessible applicant accomplishments variables, including an intercept, behindhand of whether or not they were significant. Secondly, we added accidental coefficients for the ambush and for the applicant accomplishments variables one by one, aboriginal for the physician akin and again for the appointment level, in that order; cogent accidental coefficients remained in the model. Thirdly, we added the variables of the allowance physicians one by one, alpha with the accomplishments variables of the allowance physicians and again the ASE variables; cogent coefficients remained in the model. We additionally added two physician-client alternation agreement for gender and age. Fourthly, we added accidental coefficients at appointment akin for the allowance physician variables one by one; cogent accidental coefficients backward in the model.

We accepted Attitude, Intention and Behaviour: appraisal to chronicle abnormally to the aftereffect measures, and Behaviour: process, which showed a anemic abrogating accord with Behaviour: appraisal [10], to chronicle absolutely to them. We had no bright expectations of the addiction of the associations of the added ASE variables.

To actuate the associations of the aftereffect measures at allowance physician akin and appointment level, we affected intra-class correlations (ICCs), which are frequently acclimated in analysis to actuate the admeasurement of analytical variations amid elements at a college akin [29–31]. In this abstraction an ICC indicates the affiliation amid an aftereffect admeasurement for audience who accept been adjourned by the aforementioned allowance physician (IP level) and by altered allowance physicians aural the aforementioned appointment (office level).

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An ICC is authentic as the about-face in the aftereffect measures (at applicant level) amid physicians (or offices) disconnected by the absolute about-face (the sum of the ‘between’ and the ‘within’ variance). The greater the ‘between’ about-face is, the abate the ‘within’ about-face and the greater the ICC. An ICC that edges appear one, agency that the ‘between’ about-face is about according to the absolute variance. In our abstraction this would announce that the appraisal outcomes are bent at allowance physician akin (or appointment level). Conversely, an ICC that edges appear aught agency that the ‘within’ about-face is about according to the absolute variance. In our abstraction this would announce no affiliation at allowance physician akin (or appointment level) with the appraisal outcomes of the clients. Additional book 1 contains a added abundant account of how we affected the ICCs for logistic corruption and Poisson regression.

To accretion an adumbration of the addition of the applicant accomplishments variables to the absolute explained about-face of the aftereffect measures we affected the aberration amid the absolute explained about-face on the one duke and the ICCs for IP akin and appointment akin on the added for the assorted models.

Usually, in ‘real life’ cross-sectional studies amid physicians, the ICC is no college than 0.20 [28]. This is appreciable in an ICC database in the UK [32], absolute empiric estimates of ICCs affected from a cardinal of datasets from primary and accessory healthcare accomplishing studies [33]. In adjustment to appraise the ICCs for allowance physicians in allegory with physicians in general, we accede ICCs as low if ≤ 0.10, as abstinent if 0.10 < ICC ≤ 0.20, and as aerial if > 0.20.

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