Use of a structured functional evaluation process for independent medical evaluations of claimants presenting with disabling mental illness: rationale and design for a multi-center reliability study

Abstract

BackgroundWork capacity evaluations by independent medical experts are widely used to inform insurers whether injured or ill workers are capable of engaging in competitive employment. In many countries, evaluation processes lack a clearly structured approach, standardized instruments, and an explicit focus on claimants’ functional abilities. Evaluation of subjective complaints, such as mental illness, present additional challenges in the determination of work capacity. We have therefore developed a process for functional evaluation of claimants with mental disorders which complements usual psychiatric evaluation. Here we report the design of a study to measure the reliability of our approach in determining work capacity among patients with mental illness applying for disability benefits.Methods/DesignWe will conduct a multi-center reliability study, in which 20 psychiatrists trained in our functional evaluation process will assess 30 claimants presenting with mental illness for eligibility to receive disability benefits [Reliability of Functional Evaluation in Psychiatry, RELY-study]. The functional evaluation process entails a five-step structured interview and a reporting instrument (Instrument of Functional Assessment in Psychiatry [IFAP]) to document the severity of work-related functional limitations. We will videotape all evaluations which will be viewed by three psychiatrists who will independently rate claimants’ functional limitations. Our primary outcome measure is the evaluation of claimant’s work capacity as a percentage (0 to 100 %), and our secondary outcomes are the 12 mental functions and 13 functional capacities assessed by the IFAP-instrument. Inter-rater reliability of four psychiatric experts will be explored using multilevel models to estimate the intraclass correlation coefficient (ICC). Additional analyses include subgroups according to mental disorder, the typicality of claimants, and claimant perceived fairness of the assessment process.DiscussionWe hypothesize that a structured functional approach will show moderate reliability (ICC ≥ 0.6) of psychiatric evaluation of work capacity. Enrollment of actual claimants with mental disorders referred for evaluation by disability/accident insurers will increase the external validity of our findings. Finding moderate levels of reliability, we will continue with a randomized trial to test the reliability of a structured functional approach versus evaluation-as-usual.

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

“…Given the widespread use of evaluation of disability for work to determine claimants’ eligibility for work replacement benefits, our findings suggest that further research to improve reliability is urgently needed. Promising targets include formal training in evaluation of capacity to work, 50 use of standardised instruments to guide disability evaluations, 50 and addressing the conflict of interest that arises when insurers (or lawyers) select their own experts. Further, there might be greater need for strategies to improve agreement when patients present with subjective complaints.…”

Sick-listed workers’ expectations about and experiences with independent medical evaluation: a qualitative interview study from Norway

“…This has been suggested by Clifton who called for a ‘functional IME’ [ 33 ] and by Bachmann et al. in their protocol for a structured functional evaluation process for IMEs of claimants presenting with disabling mental illness [ 11 ].…”

“…The main purpose of the IME was to provide a new perspective on the sickness absence episode, identify RTW resources, explore workers’ expectations and perceived barriers to RTW, and make suggestions for further follow-up and level of sickness absence [ 10 ]. These are important aspects to explore because the IME doctors’ decision may potentially be highly influential, determining the ability to access medical services, lodge legal claims and receiving wage-compensation benefits or not [ 11 ]. Studies in other countries have described IMEs as unethical, superficial, physically, and emotionally painful and stressful, leading to increased pain, emotional stress, and symptom flare-up [ 12–14 ].…”

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

“…During a specially designed training programme in functional evaluation, psychiatrists affiliated with four assessment centres engaged in small-group training with three sessions of three hours each, over a period of three months. The training used lectures, an instruction text, role play, plenary and small group discussion, and homework to practice the new skills (19).…”