Access to this full-text is provided by Springer Nature.
Content available from BMC Medical Informatics and Decision Making
This content is subject to copyright. Terms and conditions apply.
Snoeck‑Krygsmanetal.
BMC Medical Informatics and Decision Making (2022) 22:25
https://doi.org/10.1186/s12911‑022‑01758‑0
RESEARCH ARTICLE
The perceived importance ofprognostic
aspects considered byphysicians duringwork
disability evaluation: asurvey
Sylvia P. Snoeck‑Krygsman1,2,3* , Frederieke G. Schaafsma2,4, Birgit H. P. M. Donker‑Cools1,2,3,
Carel T. J. Hulshof1,2, Lyanne P. Jansen1,2, René J. Kox3 and Jan L. Hoving1,2
Abstract
Background: Assessing prognosis is challenging for many physicians in various medical fields. Research shows that
physicians who perform disability assessments consider six areas when evaluating a prognosis: disease, treatment,
course of the disease, external information, patient‑related and physician‑related aspects. We administered a ques‑
tionnaire to evaluate how physicians rate the importance of these six prognosis areas during work disability evalua‑
tion and to explore what kind of support they would like during prognosis assessment.
Methods: Seventy‑six physicians scored the importance of 23 prognostic aspects distributed over six prognosis
areas. Participants scored the importance of each aspect both “in general” and from the perspective of a case vignette
of a worker with a severe degenerative disease. The questionnaire also covered needs and suggestions for support
during the evaluation of prognoses.
Results: Medical areas that are related to the disease, or the treatment or course of the disease, appeared important
(scores of 7.0–9.0), with less differing opinions among participants (IQR 1.0–3.0). Corresponding verbatim remarks sup‑
ported the importance of disease and treatment as prognostic aspects. In comparison, patient‑ and physician‑related
aspects scored somewhat lower, with more variability (range 4.0–8.0, with IQR 2.0–5.0 for patient‑ and physician‑
related considerations). Participants indicated a need for a tool or online database that includes prognostic aspects
and prognostic evidence.
Conclusions: Despite some variation in scores, the physicians rated all six prognosis areas as important for work
disability evaluations. This study provides suggested aids to prognosis assessment, including an online support tool
based on evidence‑based medicine features.
Keywords: Prognosis (MeSH), Work (MeSH), Disability evaluation (MeSH), International classification of functioning,
Disability and health (MeSH), Evidence‑based medicine (MeSH)
© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco
mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Background
Prognosis is the forecast of an outcome, and in a disabil-
ity evaluation this outcome mainly concerns the func-
tional abilities needed for work [1]. For example, will a
50-year-old nurse with degenerative knee arthritis be able
to climb stairs in the future? [2, 3]. e evaluation of the
prognosis is an important aspect of disability evaluations
[4, 5] and has financial, personal, and legal consequences.
Open Access
*Correspondence: s.p.snoeck‑krygsman@amsterdamumc.nl
1 Department of Public and Occupational Health, Amsterdam Public
Health Research Institute, Amsterdam UMC, Location Academic Medical
Centre, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
Full list of author information is available at the end of the article
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 2 of 10
Snoeck‑Krygsmanetal. BMC Medical Informatics and Decision Making (2022) 22:25
Prognosis assessment is internationally considered to be
one of four main tasks in disability evaluations [6], but
physicians find the assessment of prognosis challenging
[7, 8]. Prognostic questions make up 39% of physicians’
information needs during disability evaluation [9].
A Dutch study identified 23 aspects for consideration
in the prognosis evaluation during disability assessment
[8]. ese aspects fell into six areas: the specific disease
or disorder, any treatment or potential treatment, the
course of the disease, external information from other
specialists or scientific evidence, patient-related aspects
(e.g., coping), and physician-related considerations (e.g.,
role, empathy). However, it is not known how these
aspects are valued and dealt with in practice. Although
this qualitative study provided us with a range of aspects
considered during prognosis assessment, it did not pro-
vide quantitative information on how important phy-
sicians rate these aspects or why some are considered
more or less important. More insight into the importance
of the aspects considered during prognosis assessment
will also guide the development of a prognostic tool in
the future.
erefore, the purpose of this study was to evalu-
ate how physicians rate the importance of six prognosis
areas considered during work disability evaluation and
to explore what kind of support they would like during
prognosis assessment.
Methods
Design
In this study, we asked participants in a workshop to
complete an anonymous paper questionnaire.
Participants
e study participants includes mainly social insurance
physicians and occupational physicians, who assess a
person’s work capacity in the context of a disability ben-
efit claim or with respect to reintegration, respectively.
e participants attended an annual congress of the pro-
fessional association for social insurance medicine in the
Netherlands. e programme comprised several lectures
and workshops, e.g. on prognosis assessment. is work-
shop involved a plenary presentation, followed by a case
demonstration, discussions and the completion of an
anonymous questionnaire. All procedures followed were
in accordance with the ethical principles for medical
research involving human subjects: before participants
attended the workshop, they were informed about the
study aim and procedure. Participation was voluntary;
participants had the opportunity to discontinue at any
time.
The questionnaire
Two authors (RK, JH) developed the questionnaire spe-
cifically for this study, it consisted of three parts. e first
presented the 23 prognosis aspects found by Kox etal.
[8]. e physicians were asked to rate the importance
for the prognosis on a Likert scale ranging from 1 (not
important at all) to 10 (of utmost importance), both for
the presented case vignette (see Fig.1) and “in general,”
that is, for any kind of patient. Each aspect was followed
by an open question asking participants to motivate their
answer, for example: “How important, in your opinion, is
the severity of the disease for the prognosis? Please give
a rating on a scale of 1 (not important at all) to 10 (of
utmost importance) for this case vignette and in general.”
e second part consisted of five questions. Four were
about encountered needs and solutions for the assess-
ment of prognosis. e fifth asked whether the physician
judged that the assessed limitations in functioning for the
case vignette were permanent. e last part of the ques-
tionnaire consisted of questions concerning the respond-
ent’s characteristics, for example, age, sex, job area (e.g.,
social insurance medicine or occupational medicine),
years of experience performing disability evaluations, and
number of hours worked per week.
Statistics andanalyses
e answers were stored and analyzed in IBM SPSS Sta-
tistics for Windows®, version 25.0 (SPSS Inc., Chicago,
IL, USA) using descriptive statistics. As most of the
dependent variables from both the Likert scale ques-
tions and the demographic questions were not normally
distributed, we calculated the median and interquartile
range (IQR) to describe the distribution of the scores.
e open answers were read and entered into SPSS by LJ;
two researchers (SK and BD) double-checked these data.
For the qualitative analyses, one researcher (SK) explored
the answers and grouped them into themes; this process
was then checked by three other researchers (JH, FS, BD,
and LJ.)
Results
Demographics
Of the 78 physicians attending the workshop, 76 com-
pleted the questionnaire and handed it in after the
workshop. e demographic questions in the last sec-
tion of the questionnaire were completed by 53–55 of all
responders. Most of the participating physicians worked
in social insurance medicine (n = 35) or in occupational
medicine (n = 15). ree participants worked in both
these specialties and two worked in another medical
specialty. A slight majority of the physicians were over
55 years old (n = 31, versus n = 23 less than 55years),
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 3 of 10
Snoeck‑Krygsmanetal. BMC Medical Informatics and Decision Making (2022) 22:25
Fig. 1 Case vignette and examples of evidence provided to physicians
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 4 of 10
Snoeck‑Krygsmanetal. BMC Medical Informatics and Decision Making (2022) 22:25
most had been in the profession for over 15years (n = 42,
versus n = 12 less than 15years), and most worked 32h
or more per week (n = 40, versus n = 13 less than 32h).
Ratings ofprognosis aspects relevant fortheassessment
ofprognosis
When the physicians were asked to rate the impor-
tance of the prognosis aspects “in general,” their median
scores varied between 6.0 and 8.0 (see Table 1). e
median importance scores concerning the same prog-
nosis aspects for the case vignette (person with MSA
parkinsonism) were between 4.0 and 9.0. Interquartile
ranges (IQRs) varied between 1.0 and 4.8 “in general” and
between 1.0 and 5.0 for the case vignette.
For the prognosis aspects scored “in general,” the first
four prognostic areas (disease, treatment, course, and
information) had median scores of 8.0, with IQRs of
between 1.0 and 2.0. e remaining two areas—namely
patient- and physician-related considerations—had more
variable scores (i.e., medians ranged between 6.0 and
8.0), with IQRs of between 2.0 and 4.8.
In comparison, the case vignette had a somewhat
higher importance score for severity of the disease (9.0),
while prognosis aspects—such as disease-maintaining
factors and vocational rehabilitation—had a somewhat
lower score (7.0). From the interquartile ranges (IQRs),
it can also be seen that physicians varied more in their
assessment of, in particular, the patient- and physician-
related considerations. Scores in the first four areas
ranged between 7.0 and 9.0 with IQRs ranging from 1.0
to 3.0, whereas scores in the latter two varied between 4.0
and 7.0 with IQRs of between 3.0 and 5.0.
Open questions onthemotivation fortheratings
Illustrative answers are shown in Table2.
Disease
Some physicians stated that the nature and severity of
the disease are a starting point for the assessment of the
prognosis (e.g., #42). Several physicians made it explicit
that the degenerative, progressive nature of the disease
is essential for the prognosis (e.g., #32). It was also noted
that in the case vignette, the progressive nature of the
Table 1 Importance scores of prognosis aspects (n = 76), “in general” and for the case vignette
The number of answers varied per question, ranging from 64 to 76 (= 84–100% of the participants)
Area Prognosis aspects worth considering when evaluating
disability prognosis Importance (1–10)
“In general” Importance (1–10)
Case vignette
Median IQR Median IQR
1. Disease Nature 8.0 1.0 8.0 2.0
Severity 8.0 1.3 9.0 2.0
2. Treatment Type 8.0 2.0 8.0 2.0
Effect 8.0 1.0 8.0 2.0
Alternatives 8.0 2.0 8.0 3.0
3. Course Course 8.0 1.0 8.5 1.0
Cause and disease maintaining factors 8.0 1.5 7.0 3.0
Aspects of revalidation and vocational rehabilitation 8.0 1.5 7.0 3.0
4. Information and evidence Information from specialist/professional 8.0 2.0 8.0 1.0
Evidence from literature/guidelines/protocols 8.0 1.3 8.0 2.0
5. Patient‑related considerations Patients own vision concerning recovery 8.0 4.0 6.0 5.0
Work perspectives 7.0 3.0 7.0 4.0
Indirect advantage of being ill 6.0 4.5 4.0 4.0
Significance of work 7.0 3.0 5.0 4.3
Recovery behavior 7.5 2.0 6.0 4.8
Coping regarding disease or changed role 8.0 2.0 6.0 4.0
Psychosocial factors 7.0 2.3 5.0 4.3
6. Physician‑related considerations Perceived role 7.0 3.0 5.0 4.0
Empathy/compassion for the patient 6.0 4.5 6.0 4.0
Medical ethics 6.5 4.0 7.0 4.8
Influence of employer, colleagues, office culture 6.0 4.8 5.0 4.8
Patient observation and related physician impression 7.0 2.0 7.0 3.0
Anticipation of outcome 6.0 3.0 6.0 4.5
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 5 of 10
Snoeck‑Krygsmanetal. BMC Medical Informatics and Decision Making (2022) 22:25
Table 2 Motivations accompanying the scores of importance (open questions) [Translated by the authors. Original source consisted
of Dutch handwritten texts.]
a Plus symbol in original
b Occupational physician and/or (social) insurance physician; both assess disabilities for work
c Patient in social security setting claiming disability benets
d Permanent disability pension
e Equality symbol in original
f Brackets in original replaced by parentheses
g Ampersand in original
h Inequality symbol in original
Area # Quotes by participants
1. Disease #42 For prognosis of future functioning, [the] disease (nature plusa severity) is [the] starting point for [the physician (]OP/
IPb[)]. […]
#32 Main point being whether or not the disease is progressive
#73 In the case vignette, it concerns a progressive disease; that certainly is determining for the prognosis. In general,
there are also situations in which the patient’s coping is also an important factor, in addition to nature/severity of the
disease
2. Treatment #6 If there are several treatments available after the treatment that the clientc is currently receiving, then [there] may be
a chance of improvement [of] work capacity
#27 [ Treatment] [e]ffect; can be [an] indication for influencing progression. [Judgment on treatment] [a]lternatives;
necessary for me for IVAd. No alternatives left equalse game over (end stage)
#26 In progressive diseases you are postponing [the] final state. In general: are there still valid treatment options?
#52 Treatment in this case vignette is aimed at treating symptoms. Not curative
3. Course #4 Course, the past, tells something about the future
#27 Progressive disease, you want to know where [the patient] is on the downward line. The rest is not that important
4. Information and evidence #15 C/ [Conclusion] of the treating neurologist (progressive complaints of illness)
#23 Evidence preponderates, [it] excludes bias in [the] treating physician
#19 Evidence [is] not necessary in most cases, because [they are] familiar, routine
#36 Especially with a substantial claim ([full disability pension/benefit,] IVA \* MERGEFORMATd): info, evidence
5. Patient‑related considerations #23 With a positive attitude [of the patient], the prognosis can turn out to be more favorable than the expectation [of the
prognosis for that disease mentioned] in the evidence
#45 How the patient perceivesf [his or her] complaints andg limitations plus \* MERGEFORMAT a advantages of being ill,
coping determines the prognosis for recovery
#51 Given [the] age [of the] client \* MERGEFORMAT c, I would assign [a full disability pension/benefit,] IVA \* MERGEFOR-
MAT d
#18 Age. To evaluate doesn’t equalh “to take into account.”i Quality of life when client [is] continuing [to] work
#26 In general, these are rather predictive aspects for success in vocational rehabilitation. Not often part of the considera‑
tions [for] prognosis
#46 [It] [i]s derived from literature that patient’s opinion on duration of incapacity for work is an important prognostic
factor. On the other hand, the perception of the patient can be influenced by the messages physicians provide. So, I
see [the] perception of [the] patient as important and as influenceable
6. Physician‑related considerations #72 Own impression plusa assessment is also very impor tant on [sic] the individual client, in addition to the info practi‑
tioner plusa available evidence
#32 I try to take these factors into account as little as possible
#50 [ There] is [a] good chance that [the physician,] OP/IPb[,] takes “ethical” [sic] aspects into account; and certainly not if
there is a less serious/threatening condition
#73 As [a physician performing disability evaluations,] IPj[,] you have to deal with a legal framework. The judgment must
be based on medical examination. The impression of the client can in my opinionk not always be leading. Especially
since there’s a financial interest. [This] [a]lso applies to eg [sic] empathy/compassion for the client. […]
#45 Physician bias plays a role too in assessing the prognosis
#42 A client should receive the same outcome with every [individual physician,] OP/IPb. Role interpretations OP.IP [sic]
play no role then. I notice that I take patient’s age into account. Say [the patient is] 25 years old…
#24 Difficult to assign [a] gradation [to the] importance, because many factors are subconscious [“unconscious” in
original]
#29 Is influence [of ] your personal blind spot too
#27 I base prognosis in [sic] a theoretical framework. I try to be as objective as possible, but aware of my own experiences
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 6 of 10
Snoeck‑Krygsmanetal. BMC Medical Informatics and Decision Making (2022) 22:25
disease was most important for prognosis, whereas in
other cases other prognosis aspects might also be rel-
evant (e.g., #73).
Treatment
Considering treatment, many physicians evaluated the
effect of the current one and looked for future options
that could bring about a change (e.g., #6, #27). It was
also pointed out that one should distinguish short-term
treatment effects from long-term disease outcomes.
In addition, physicians distinguished between relief of
symptoms and curation (e.g., #26, #52).
Course
Regarding the course of the disease, physicians consid-
ered that the rate of progression of the disease and the
results of treatment up to the moment of the disability
evaluation forecast future developments (e.g., #4). For the
case vignette with a progressive medical disease, it was
mentioned that the course of the illness (amount of dete-
rioration over time) was of main importance (e.g., #27).
Information andevidence
Information from the treating physician is considered
important to get an insight into the patient’s unique
course and progressive symptoms (e.g., #15). Some phy-
sicians stated that they preferred research evidence (e.g.,
#23). Others pointed out that you may not need scientific
literature in all cases (e.g., #19), but you may need more
evidence when a patient claims a large number of ongo-
ing disabilities (e.g., #36).
Patient‑related considerations
Several patient-related factors, such as coping and the
way patients perceive their illness, were considered
important (e.g., #23, #45). Others spontaneously men-
tioned age as a patient-related ADP that either guides
the decision (#51) or does not (#18). One physician (#26)
stated that patient-related factors can be important for
vocational rehabilitation, but that they inform the physi-
cian conducting a disability evaluation to a lesser degree.
Physicians also mentioned that it was important to
assess whether patient-related prognosis aspects can be
changed (e.g., #46).
Physician‑related considerations
Regarding the importance of physician-related fac-
tors, differing opinions were found, ranging from “very
important” (e.g., #72) to “as little as possible” (e.g., #32),
and some mentioned them to be case-dependent (e.g.,
#50, #73). Some physicians said that ethical aspects
were considered (e.g., #50) and that the physicians’ own
impressions were important (e.g., #72), while others indi-
cated that these should not be a part of the evaluation
as they could unintentionally influence their judgment
(e.g., #73, #32) or could bias the physician (e.g., #45), and
efforts should be made to ensure that a client receives
similar outcomes from different assessors (e.g., #42).
However, it was also stated that these prognosis aspects
are often hard to recognize, given their often subcon-
scious nature (e.g., #24). ey are interrelated with a phy-
sician’s “blind spot” (#29), but it is important to be aware
of those (e.g., #27).
Specic support thatphysicians suggest would aid them
duringtheprognostic assessment
Several answers illustrate additional needs, sugges-
tions, and support for physicians during the assessment
of prognosis (see Table3). Principles of evidence-based
medicine (EBM) were suggested as an integral part of the
support (e.g., #45, #73), which could include evidence-
based information on the nature (e.g., #45) or course of
a disease (e.g., #73), treatment options, (e.g., #45, #73)
and prognostic factors (e.g., #8, #16, #32, #77) that could
be supported by figures, facts, and references (e.g., #46).
Some physicians mentioned that a potential tool should
provide information about relevant prognosis aspects
(e.g., #58). e case vignette used might illustrate rel-
evant prognostic information (e.g., #41) as an example.
A diagrammatic way of presenting information (such as
checklists, programmed instructions, or flow charts) was
also suggested (e.g., #17).
Type ofaid
As a preferred medium, digital aids were most frequently
chosen (e.g., “website” n = 38, “app” n = 17). A desk pad
format (a leaflet summarizing key remarks) was also con-
sidered useful (n = 16).
Discussion
In this study we evaluated how physicians working in the
field of disability evaluation rated the importance of six
areas of prognosis, namely disease, treatment, course of
the disease, external information, patient-related aspects,
and physician-related aspects. Although all six areas were
considered important, there was more consensus among
i Quotation marks added for clarity
j Insurance physician. Evaluates functional abilities for work for claimants requesting disability benets
k Abbreviated in original
Table 2 (continued)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 7 of 10
Snoeck‑Krygsmanetal. BMC Medical Informatics and Decision Making (2022) 22:25
physicians concerning the three medical areas (disease,
treatment, and course). e scores and verbatim remarks
regarding the patient- and physician-related considerations
(non-medical areas) reflected a more varied appreciation of
importance among physicians.
Our use of a clear and severe medical case vignette may
have influenced the physicians’ more limited appreciation
for non-medical prognosis aspects during the progno-
sis assessment. Verbatim remarks were made to the effect
that medical considerations sufficed, and the importance of
medical prognosis aspects appeared relatively high. In con-
trast, physicians’ remarks regarding prognosis assessment
of cases “in general,” suggested that non-medical prognosis
aspects could become more important in cases with a less
clear medical background. Physician-related considerations
appeared not to be given an explicit role in the assessment.
Some physicians actually mentioned this and scores within
this area appeared lower. However, it was also mentioned
that they do play a relevant, though often implicit or sub-
conscious, role.
As a form of support, physicians mentioned some kind
of overview of prognosis aspects and relevant scientific evi-
dence. A digital form of support was preferred.
Comparison withtheliterature
The importance ofthesix areas ofprognosis: diverging
opinions onnon‑medical prognosis aspects
In disability evaluations, the framework of the Interna-
tional Classification of Functioning, Disability and Health
(ICF) [10] has been adopted by and used in several coun-
tries [11, 12]. is classification system can also be used
to describe work functioning, taking contextual and per-
sonal factors into account. However, there is some criti-
cism that the ICF scheme is suggestive of the dominance
of a medical perspective rather than a biopsychosocial
one. erefore, suggestions for a revision of the ICF have
been made [13, 14]. For prognosis assessment in work
disability evaluations, there is another problem with the
ICF: e dynamic aspect of functioning and health over
time is not addressed, nor are any consequent changes in
activities or participation over time. As such, the use of
the ICF during social–medical history taking and prog-
nosis assessment is limited [11]. ese two issues with
the ICF (i.e., suggestive dominance of the medical per-
spective and absence of a time frame) leave room for
diverging opinions [15, 16], especially regarding non-
medical aspects, which corresponds to our findings.
Table 3 Potential elements of supportive aid for prognosis assessment (open and checkbox questions)
a Plus symbol in original
b Substituted for abbreviated jargon in original
Ingredients:
What should a prognosis assessment method provide you with? #46 A simple instrument that can easily be used in practice
#73 It must be evidence‑based, identify treatment options for the disorder, course
of the disease
#8 I would prefer to have a document in which the pros and cons of the forecast
are weighed on the basis of current evidence
#77 Model to weigh factors
Information in prognosis aid:
What information should this prognosis assessment aid contain? #41 All items mentioned in the case vignette
#58 Summary of relevant aspects
#45 Evidence‑based information, info on the nature [of the] disease in time plusa
therapeutic options
#46 Figures, facts, and substantiation (references)
#55 All necessary: (1) [is there complete work disability according to the labor
expert]b (2) search path (to be copied) in case of [a] possible [search in] Pub‑
Med/Medline or other search (3) info [sic] about prognosis of the most com‑
mon diseases (from relevant literature such as systematic reviews)
#16 [ T]he most important factors you should take into account and what weight
they carry for your judgment
#32 Summary of known research about the disease. Prognostically favorable/unfa‑
vorable factors
#17 [I]nstruction or checklist in a general sense. [W ]ith psychological complaints
pay attention to a, b, c etc.[,] with neurologic [ones]: pay attention to a, b, c, etc.
So disease‑related
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 8 of 10
Snoeck‑Krygsmanetal. BMC Medical Informatics and Decision Making (2022) 22:25
The importance ofthesix areas ofprognosis: non‑medical
prognosis aspects
Our study shows that the perceived relevance of patient-
related considerations varies in prognosis assessment. In
the case of a clear medical condition, they might not all
be necessary or might make a smaller contribution to the
prognosis evaluation, whereas for medically unexplained
physical symptoms (MUPS) or in vocational rehabili-
tation settings, physicians may attribute more value to
them.
In a study on arguments used in disability prognosis
[17], medical clarity contributed to the type and num-
ber of arguments used. In less clear medical cases, more
arguments were used, including non-medical aspects
such as coping or education. In addition, Ankersmit etal.
[17] found that the expected outcome reception played
a role: when disability claims were substantial or the
chances of appeal were considered high, physicians pre-
ferred a more comprehensive evaluation of all potentially
relevant aspects, including patient-related considerations
(a preference that was also mentioned by physicians in
our study). Another study [18], which concerned aspects
for consideration in disability evaluation, suggested that
the timespan covered in the evaluation (e.g., 5 days,
3months, or 5years) determined the value of the aspects
used: For longer timespans, less relevance was attributed
to patient-related factors. Some physicians in our study
made explicit comments that in vocational rehabilita-
tion settings, they would attribute more value to those
patient-related prognosis aspects and that these could be
targeted by interventions. Prognostic systematic reviews
have shown that, regardless of context, patient-related
factors, such as coping and self-efficacy, have more prog-
nostic value for participation in work than factors of
a medical nature [19–22] and could inform prognosis
assessment and re-evaluations over time.
The importance ofthesix areas ofprognosis: implicit role
ofphysician‑related considerations
Physician-related considerations were regarded by the
physicians in our study as often subconscious factors that
influence the physician’s judgment. e consequences
of those influences for prognosis assessment are men-
tioned in various medical studies within several fields
[8, 23–25]. For example, physicians tend to express the
prognosis in a way that is too optimistic. is could origi-
nate from, for example, a tendency to provide hope or to
stimulate healthy rehabilitation and recovery behavior
[8] and “not to harm” by taking those away [8, 24]. For
example, an earlier study found that physicians perform-
ing disability assessments did not want to permanently
deny young adults any hope or chance of future work
participation [15], given the positive aspects of work. To
overcome some of those consequences, physicians in our
study said that the important thing is to be aware of these
influences.
The way tosupport physicians: EBM ascore ingredient,
covering relevant prognosis aspects
e physicians in this study wanted support, includ-
ing evidence-based prognostic information, preferably
pre-appraised. Evidence should ideally be tailor-made,
as suggested by earlier studies [7, 8]. Even if prognostic
evidence is present, it requires skills to find, appraise,
and apply it in a particular case and within the country-
specific legislative context [26–28]. However, studies
have demonstrated that training in evidence-based medi-
cine may improve the quality of disability evaluations,
prognosis assessment, and job satisfaction [4, 29]. Some
physicians in our study mentioned that useful prognos-
tic search strings might be provided, thus meeting the
demand for help in finding prognostic evidence. is
demand was also reported in other studies [26, 30], which
led to research providing potential search strategies, fil-
ters, or strings regarding themes such as prognosis and
work participation [30–32]. e desire for user-friendli-
ness, simplicity, and help in overseeing the various prog-
nostic aspects was also identified by Kox etal. [8] and
Louwerse etal. [33], both of whom were exploring pos-
sible prognostic tools. In contrast, when presented with
possible prognostic tools, physicians also stressed the
importance of preserving their professional autonomy
to make unique, tailored evaluations. [34, 35] Moreover,
they needed to become acquainted with them and they
wanted to estimate their validity. [35]
Strengths andlimitations
A strength of our study is that it combined insights from
the quantitative data with qualitative data from corre-
sponding remarks from physicians. However, our ques-
tionnaire was not suited for an in-depth exploration of
the reasons why the importance was scored higher or
lower. Also, we cannot exclude a selection effect, as the
physicians attending the workshop may be more inter-
ested in this topic, but it is not clear how or in which
direction this could have influenced the results.
e fact that the case vignette concerned a clear, severe
medical condition might explain why the physicians did
not elaborate much on the functional abilities of the
patient. Some commented that this patient had no abili-
ties for work at all and referred to the medical condition.
It would be useful to evaluate the importance of prognos-
tic aspects in a similar study that includes a case vignette
with a less severe, chronic health condition (e.g., rheu-
matoid arthritis) or a condition with less medical clarity
(e.g., MUPS). However, we tried to partially counter this
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 10
Snoeck‑Krygsmanetal. BMC Medical Informatics and Decision Making (2022) 22:25
disadvantage by asking for opinions on the prognosis for
“general” cases, although we acknowledge that what is
“general” could mean different things for the participants
in this study.
Conclusions
is study demonstrated that all six areas of prognosis
are important and that their individual contribution dur-
ing prognosis assessment may vary from case to case.
ere is a need for evidence-based prognostic decision-
making as well as tools to assist physicians in searching
for, appraising, and applying prognostic evidence to sub-
stantiate their prognosis assessments.
Abbreviations
ADP(s): Aspect(s) of disability prognosis; EBM: Evidence‑based medicine;
ICF: International Classification of Functioning, Disability and Health; IQR:
Interquartile range; MSA(‑P): Multiple system atrophy (parkinsonism); MUPS:
Medically unexplained physical symptoms; WMA: World Medical Association.
Acknowledgements
Not applicable.
Authors’ contributions
All authors (SK, FS, BD, CH, LJ, RK and JH) contributed to the study conception
and design. Material preparation and data collection were performed by JH
and RK. Data transcription was performed by LJ and checked by SK and BD.
Data entry into SPSS was performed by LJ. Data analysis was performed by SK
and checked by LJ, BD, JH and FS. The first draft of the manuscript was written
by SK. FS, JH, BD commented on previous versions of the manuscript. All
authors (SK, FS, BD, CH, LJ, RK and JH) read and approved the final manu‑
script. All authors (SK, FS, BD, CH, LJ, RK and JH) have agreed to be personally
accountable for his or her own contributions and have ensured that questions
related to the accuracy or integrity of any part of the work, even ones in
which the author was not personally involved, are appropriately investigated,
resolved, and the resolution will be documented in the literature. All authors
read and approved the final manuscript.
Funding
The project was financed by the Dutch Institute of Employee Benefit Schemes
(UWV), Amsterdam, on behalf of the Research Center for Insurance Medicine
(KCVG). However, no funding bodies had any role in the study design, data
collection, and analysis, decision to publish, or preparation of the manuscript.
Availability of data and materials
The datasets generated during and/or analyzed during the current study are
available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study did not entail medical research, because the human subjects were
not patients nor were they involved in clinical health care. Their data, namely
their responses to a questionnaire on content and opinions, were retrieved
anonymously and were never identifiable. Therefore, the research team con‑
cluded that the research was not subject to the WMA Declaration of Helsinki
[36].
Consent for publication
Not applicable.
Competing interests
The authors declare no conflict of interest nor any competing interests.
Author details
1 Depar tment of Public and Occupational Health, Amsterdam Public Health
Research Institute, Amsterdam UMC, Location Academic Medical Centre,
Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands. 2 Research Center
for Insurance Medicine (KCVG): collaboration between AMC–UMCG–UWV–
VUmc, Amsterdam, The Netherlands. 3 Department of Social Medical Affairs
(SMZ), The Dutch Social Security Institute: The Institute for Employee Benefits
Schemes (UWV), La Guardiaweg 94‑114, 1043 DL Amsterdam, The Nether‑
lands. 4 Department of Public and Occupational Health, Amsterdam Public
Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van
der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
Received: 30 October 2020 Accepted: 15 January 2022
References
1. LISV. Professionele herbeoordeling verzekeringsarts ‑ Standaard. [Dutch
National Institute for Social Security (LISV): professional re‑evaluation
by the insurance physician ‑ Standard.] Amsterdam: Landelijk Instituut
Sociale Verzekeringen; 2000. p. 1–11.
2. Emanuel EJ, Emanuel LL. The promise of a good death. Lancet.
1998;351:SII21–9.
3. Mathers CD, Loncar D. Projections of global mortality and burden of
disease from 2002 to 2030. PLoS Med. 2006;3(11):e442.
4. Kok R, Hoving JL, Verbeek JH, Schaafsma FG, Smits PB, van Dijk FJ. Evalu‑
ation of a workshop on evidence‑based medicine for social insurance
physicians. Occup Med. 2008;58(2):83–7.
5. Anner J, Kunz R, Boer WD. Reporting about disability evaluation in Euro‑
pean countries. Disabil Rehabil. 2014;36(10):848–54.
6. de Boer W. Quality of evaluation of work disability. Academisch proefschrift
Universiteit van Amsterdam Hoofddorp 2010.
7. Hoving JL, van der Voort R, Kok R, Verbeek JH, Hulshof CT. Het belang van
een onderbouwde prognose en de rol van evidence daarbij: een survey
onder verzekeringsartsen [The importance of a substantiated prog‑
nosis and the role of prognostic evidence: a survey among insurance
physicians]. TBV–Tijdschrift voor Bedrijfs–en Verzekeringsgeneeskunde.
2016;24(10):465–71.
8. Kox RJ, Hoving JL, Verbeek JH, Schouten MJ, Hulshof CT, Wind H, Frings‑
Dresen MH. Assessment of prognosis by physicians involved in work
disability evaluation: a qualitative study. PLoS ONE. 2019;14(2):e0212276.
9. Kok R, Hoving JL, Verbeek JH, van Dijk FJ. What knowledge questions
do physicians have while performing disability evaluations and which
sources do they use? Evid Based Disabil Eval. 2014;1:19.
10. World Health Organization. International classification of functioning,
disability and health: ICF. Geneva: World Health Organization; 2001.
11. Anner J, Schwegler U, Kunz R, Trezzini B, de Boer W. Evaluation of work
disability and the international classification of functioning, disability and
health: what to expect and what not. BMC Public Health. 2012;12(1):470.
12. LISV: Medisch arbeidsongeschiktheidscriterium ‑ Richtlijn. [Dutch
National Institute for Social Security (LISV): Criterium medical disabili‑
ties for work ‑ Guideline.] Amsterdam: Tijdelijk Instituut Coördinatie en
Afstemming (TICA); 1996. p. 1–25.
13. Heerkens YF, de Weerd M, Huber M, de Brouwer CP, van der Veen S,
Perenboom RJ, van Gool CH, ten Napel H, van Bon‑Martens M, Stallinga
HA. Reconsideration of the scheme of the international classification of
functioning, disability and health: incentives from the Netherlands for a
global debate. Disabil Rehabil. 2018;40(5):603–11.
14. Heerkens YF, de Weerd M, Huber M, de Brouwer CP, van der Veen S,
Perenboom RJ, van Gool CH, Ten Napel H, van Bon‑Martens M, Stallinga
HA. Reconsideration ICF scheme. Disabil Rehabil. 2018;40(1):121–2.
15. Anner J, Brage S, Donceel P, Falez F, Freudenstein R, Oancea C, de Boer
W. Validation of the EUMASS Core Set for medical evaluation of work dis‑
ability. Disabil Rehabil. 2013;35(25):2147–56.
16. Brage S, Donceel P, Falez F. Development of ICF core set for disability
evaluation in social security. Disabil Rehabil. 2008;30(18):1392–6.
17. Ankersmit JF, Chan WK, Kok R, Wind H, Hoving J. Onderbouwing van de
duurzaamheid bij Wajong 2015 beoordelingen. [Substantiation of the
permanence [of disabilities for work ‑ 24 Ed.]] in assessments accord‑
ing to Wajong 2015 [Dutch law regarding benefits for handicapped
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 10 of 10
Snoeck‑Krygsmanetal. BMC Medical Informatics and Decision Making (2022) 22:25
•
fast, convenient online submission
•
thorough peer review by experienced researchers in your field
•
rapid publication on acceptance
•
support for research data, including large and complex data types
•
gold Open Access which fosters wider collaboration and increased citations
maximum visibility for your research: over 100M website views per year
•
At BMC, research is always in progress.
Learn more biomedcentral.com/submissions
Ready to submit your research
Ready to submit your research
? Choose BMC and benefit from:
? Choose BMC and benefit from:
youth ‑ Ed.].] TBV–Tijdschrift voor Bedrijfs-en Verzekeringsgeneeskunde 2018;
26(10):518–525.
18. Slebus FG, Sluiter JK, Kuijer PPF, Willems JH, Frings‑Dresen MH. Work‑
ability evaluation: a piece of cake or a hard nut to crack? Disabil Rehabil.
2007;29(16):1295–300.
19. Vooijs M, Leensen MC, Hoving JL, Daams JG, Wind H, Frings‑Dresen
MH. Disease‑generic factors of work participation of workers with a
chronic disease: a systematic review. Int Arch Occup Environ Health.
2015;88(8):1015–29.
20. Detaille SI, Heerkens YF, Engels JA, Van Der Gulden JW, Van Dijk FJ. Com‑
mon prognostic factors of work disability among employees with a
chronic somatic disease: a systematic review of cohort studies. Scand J
Work Environ Health. 2009;35:261–81.
21. Cornelius L, van der Klink J, Groothoff J, Brouwer S. Prognostic factors of
long term disability due to mental disorders: a systematic review. J Occup
Rehabil. 2011;21(2):259–74.
22. Dekkers‑Sánchez PM, Wind H, Sluiter JK, Frings‑Dresen MH. What factors
are most relevant to the assessment of work ability of employees on
long‑term sick leave? The physicians’ perspective. Int Arch Occup Environ
Health. 2013;86(5):509–18.
23. Pontin D, Jordan N. Issues in prognostication for hospital specialist
palliative care doctors and nurses: a qualitative inquiry. Palliat Med.
2013;27(2):165–71.
24. Muller E, Hoving J. Visie van verzekeringsartsen op de claimbeoorde‑
ling van mensen met een beperkte levensverwachting [Opinions of
insurance physicians on the claim assessment for patients with poor life
expectancy]. TBV–Tijdschrift voor Bedrijfs–en Verzekeringsgeneeskunde.
2018;26(10):533–7.
25. An HJ, Jeon HJ, Chun SH, Jung HA, Ahn HK, Lee KH. Kim M‑h, Kim JH,
Cheon J, Kim J: Feasibility study of physician orders for life‑sustaining
treatment for patients with terminal cancer. Cancer Res Treat Off J Korean
Cancer Assoc. 2019;51(4):1632.
26. Kok R, Hoving JL, Verbeek J, Schaafsma FG, van Dijk FJ. Integrating
evidence in disability evaluation by social insurance physicians. Scand J
Work Environ Health. 2011;37:494–501.
27. Schaafsma F, Hoving J. Prognose en het gebruik van evidence bij
werkhervatting [Prognosis and the use of evidence in [assisting with
‑ Ed] return to work]. TBV–Tijdschrift voor Bedrijfs–en Verzekeringsge‑
neeskunde. 2016;24(10):487–90.
28. Van der Hoek W. Prognose van depressie in het kader van de claim‑
beoordeling voor de nieuwe WAO. [Prognosis of major depressive
disorder in the context of the claim assessment for the new WAO [Dutch
disability insurance law ‑ Ed.].] TBV–Tijdschrift voor Bedrijfs-en Verzek-
eringsgeneeskunde 2006;14(4):192–197.
29. Hoving JL, Kok R, Ketelaar SM, Smits PB, van Dijk FJ, Verbeek JH. Improved
quality and more attractive work by applying EBM in disability evalua‑
tions: a qualitative survey. BMC Med Educ. 2016;16(1):77.
30. Haafkens J, Moerman C, Schuring M, van Dijk F. Searching bibliographic
databases for literature on chronic disease and work participation. Occup
Med. 2005;56(1):39–45.
31. Geersing G‑J, Bouwmeester W, Zuithoff P, Spijker R, Leeflang M, Moons K.
Search filters for finding prognostic and diagnostic prediction studies in
Medline to enhance systematic reviews. PLoS ONE. 2012;7(2):e32844.
32. Kok R, Verbeek JA, Faber B, van Dijk FJ, Hoving JL. A search strategy to
identify studies on the prognosis of work disability: a diagnostic test
framework. BMJ Open. 2015;5(5):e006315.
33. Louwerse I, Huysmans MA, van Rijssen JHJ, Overvliet J, van der Beek AJ,
Anema JR. Preferences regarding the way of use and design of a work
ability prognosis support tool: a focus group study among professionals.
Disabil Rehabil. 2019;43:2031–7.
34. van Muijen P, Duijts SF. Kornet‑van der Aa DA, van der Beek AJ, Anema
JR: Work disability assessment of cancer survivors: insurance physicians’
perspectives. Occup Med (Lond). 2015;65(7):558–63.
35. Louwerse I, Huysmans M, van Rijssen H, Gielen C, van der Beek A, Anema
J. Use of a decision support tool on prognosis of work ability in work dis‑
ability assessments: an experimental study among insurance physicians. J
Occup Rehabil. 2020;31:185–96.
36. World Medical Association. World Medical Association Declaration of
Helsinki: ethical principles for medical research involving human subjects.
JAMA. 2013;310(20):2191–4.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub‑
lished maps and institutional affiliations.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com
