• Work Loss Data Institute. Fitness for duty. Corpus Christi (TX): Work Loss Data Institute; 2006. 72 p. [94 references]

This is the current release of the guideline.

This guideline updates a previous version: Work Loss Data Institute. Fitness for duty. Corpus Christi (TX): Work Loss Data Institute; 2005. 72 p.

The Official Disability Guidelines product line, including ODG Treatment in Workers Comp, is updated annually, as it has been since the first release in 1996.

Health of employees in relation to their specific jobs

Evaluation

Family Practice
Internal Medicine
Physical Medicine and Rehabilitation

Advanced Practice Nurses
Health Care Providers
Health Plans
Nurses
Physician Assistants
Physicians

To offer evidence-based step-by-step decision protocols for the assessment of fitness for duty

Workers considering entry into employment and assignment to a specific job (e.g., firefighters, commercial drivers, military)

1. Fitness to work examinations
2. Disability evaluations and certifications

See the original guideline document for further information.

• Disability symptoms
• Disability recurrence after return to work

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

Work Loss Data Institute (WLDI) conducted a comprehensive medical literature review (now ongoing) with preference given to high quality systematic reviews, meta-analyses, and clinical trials published since 1993, plus existing nationally recognized treatment guidelines from the leading specialty societies. WLDI primarily searched MEDLINE and the Cochrane Library. In addition, WLDI also reviewed other relevant treatment guidelines, including those in the National Guideline Clearinghouse, as well as state guidelines and proprietary guidelines maintained in the WLDI guideline library. These guidelines were also used to suggest references or search terms that may otherwise have been missed. In addition, WLDI also searched other databases, including MD Consult, eMedicine, CINAHL, and conference proceedings in occupational health (i.e. American College of Occupational and Environmental medicine [ACOEM]) and disability evaluation (i.e. American Academy of Disability Evaluating Physicians [AADEP], American Board of Independent Medical Examiners [ABIME]). Search terms and questions were diagnosis, treatment, symptom, sign, and/or body-part driven, generated based on new or previously indexed existing evidence, treatment parameters and experience.

In searching the medical literature, answers to the following questions were sought: (1) If the diagnostic criteria for a given condition have changed since 1993, what are the new diagnostic criteria? (2) What occupational exposures or activities are associated causally with the condition? (3) What are the most effective methods and approaches for the early identification and diagnosis of the condition? (4) What historical information, clinical examination findings or ancillary test results (such as laboratory or x-ray studies) are of value in determining whether a condition was caused by the patient's employment? (5) What are the most effective methods and approaches for treating the condition? (6) What are the specific indications, if any, for surgery as a means of treating the condition? (7) What are the relative benefits and harms of the various surgical and non-surgical interventions that may be used to treat the condition? (8) What is the relationship, if any, between a patient's age, gender, socioeconomic status and/or racial or ethnic grouping and specific treatment outcomes for the condition? (9) What instruments or techniques, if any, accurately assess functional limitations in an individual with the condition? (10) What is the natural history of the disorder? (11) Prior to treatment, what are the typical functional limitations for an individual with the condition? (12)  Following treatment, what are the typical functional limitations for an individual with the condition? (13) Following treatment, what are the most cost-effective methods for preventing the recurrence of signs or symptoms of the condition, and how does this vary depending upon patient-specific matters such as underlying health problems?

Criteria for Selecting the Evidence

Preference was given to evidence that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reports a cohort study, whether prospective or retrospective, or (5) The article reports a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

More information about the selection of evidence is available in "Appendix. ODG Treatment in Workers' Comp. Methodology description using the AGREE instrument" (see "Availability of Companion Documents" field).

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Review of Published Meta-Analyses
Systematic Review

The Work Loss Data Institute (WLDI) reviewed each article that was relevant to answering the question at issue, with priority given to those that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reported a cohort study, whether prospective or retrospective, or (5) The article reported a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

Especially when articles on a specific topic that met the above criteria were limited in number and quality, WLDI also reviewed other articles that did not meet the above criteria, but all evidence was ranked alphanumerically (see the Rating Scheme of the Strength of Evidence field) so that the quality of evidence could be determined when making decisions about what to recommend in the Guidelines. Articles with a Ranking by Type of Evidence of Case Reports and Case Series were not used in the evidence base for the Guidelines. These articles were not included because of their low quality (i.e., they tend to be anecdotal descriptions of what happened with no attempt to control for variables that might effect outcome). Not all the evidence provided by WLDI was eventually listed in the bibliography of the published Guidelines. Only the higher quality references were listed. The criteria for inclusion was a final ranking of 1a to 4b (the original inclusion criteria suggested the methodology subgroup), or if the Ranking by Type of Evidence was 5 to 10, the quality ranking should be an "a."

Not stated

Not applicable

The guideline developers reviewed published cost analyses.

External Peer Review

Prior to publication, select organizations and individuals making up a cross-section of medical specialties and typical end-users externally reviewed the guideline.

Fitness-to-work examinations are objective assessments of the health of employees in relation to their specific jobs, in order to ensure they could do the job and would not be a hazard to themselves or others. Fitness-to-work examinations should always be conducted with reference to the specific job the worker holds or intends to hold. The circumstances that require such examinations occur at the time of application or consideration for entry into employment and assignment to a specific job (pre-placement), return to work after illness or injury (return to work).

To be useful to the employee and employer and to be consistent with human-rights legislation, pre-placement examinations must be structured so that they are specific to the working conditions and job requirements medically and are timed after a job offer has been made. An employer cannot arbitrarily deny a person a job opportunity on the basis of a physical or emotional disability. However, the job offer can be made contingent upon passing a medical examination that indicates the employee would be able to perform the job and would not be a hazard to him or herself or others while working in that job. The employee may be refused the job only if the health of the employee is not compatible with the working conditions, and the job requirements cannot reasonably be altered.

There are six possible judgments, the appropriateness of which may depend on the type of fitness-to-work examination being done: fit, temporarily fit, fit subject to work modifications, temporarily fit subject to work modifications, temporarily unfit, and permanently unfit. These categories are defined below:

• Fit: This judgment means that the employee is able to perform the job without danger to self or others, without reservation. The subcategory "temporarily" can be used for all types of medical assessments except pre-placement. "Permanently" should never be used with a judgment of "fit" since physicians cannot see into the future.
• Fit subject to work modifications: A judgment in this category indicates that the employee could be a hazard to self or others if employed in the job as described but would be considered fit to do the job if certain working conditions were modified (e.g., changing the way the work is performed or the working environment). The modifications required must be clearly described in the comments section. If these can be accommodated, the employee is considered fit for the modified job. If the modifications cannot be reasonably accommodated, the employee is deemed temporarily or permanently unfit. "Temporarily" means that if the person's condition improves with time, the requirement for work modifications may be lifted. "Permanently" means that the employee will never be fit for the job without the modifications. Any employee considered fit subject to work modifications must be fully informed of both the medical findings and the modifications.
• Unfit: This category describes the employee who is unable to perform the job without being a hazard to self or others. This judgment and the subcategories "temporarily" and "permanently" can be used with any type of fitness-to-work examination. "Temporarily" means that the medical condition may improve with time, thus allowing return to work or transfer to some other job. "Permanently" usually means that the employee will never be fit for the job and that no modification of the working conditions is reasonably possible or medically relevant; if "permanently" means that the employee is unable to do any available job, with or without work modifications, a statement to this effect should be made in the comments section.

Key Elements of a Fitness-for-Duty Examination Under the Americans with Disabilities Act

1. Determine the presence or absence of a permanent impairment that substantially limits one or more major life activities.
2. Evaluate the patient's work capacity (mental and physical) and delineate workplace restrictions.
3. Assess workplace demands (mental and physical) and essential functions of the job.
4. Ascertain the patient's ability to perform the essential functions of the job with, or without, accommodations.

Practical Pointers on Disability Evaluations and Certifications

1. Do not confuse the terms "impairment" and "disability." Impairment can be defined as a loss of physiologic function or anatomic structure. By contrast, disability can be defined as a reduced ability to meet occupational demands as a result of impairment and other associated factors. Therefore, disability is a broad term that encompasses not only impairment but also a multitude of other factors.
2. Obtain appropriate consents signed and dated by the patient.
3. Clearly delineate the nature and extent of all impairments (mental and physical); segregate those pertaining to the claim.
4. Document all patient limitations (mental and physical) and workplace restrictions.
5. Assess the patient's workplace demands (mental and physical) and essential functions of the job by obtaining a functional job analysis from the employer.
6. Assess fitness for duty and employability by comparing the patient's work capacity to workplace demands. Obtain a functional capacity examination if needed. (See Procedure Summary in the original guideline document.)
7. Ascertain the type and definition of disability being applied to the claim.
8. Determine disability status and address issues of temporary versus permanent, as well as partial versus total disability.
9. List patient's capabilities, limitations, and restrictions.
10. Do not address issues of permanency (including impairment or disability) until the patient has reached maximum medical improvement.
11. Complete disability certification forms objectively, accurately and in a timely manner.
12. Beware of hidden patient agendas and secondary gain from disability.

When considering whether a worker is fit for duty, an appreciation for the workplace in general and the specific task(s) is crucial. The physician needs a detailed job description from the employer. Ideally, this information should be corroborated by the worker. The physician's role includes: (1) providing a critical assessment of the available medical information as to completeness and validity, (2) identifying impairments that can "reasonably be anticipated" to affect performance of essential functions, (3) determining if impairments are permanent, and (4) identifying impairments that may result in a sudden or gradual adverse consequence (e.g., incapacitation in a safety-sensitive job, communicable disease) or a "direct threat" (i.e., significant risk of substantial harm to the health or safety of self, co-workers, or the public that cannot be eliminated by reasonable accommodation).

None provided

During the comprehensive medical literature review, preference was given to high quality systematic reviews, meta-analyses, and clinical trials over the past ten years, plus existing nationally recognized treatment guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure Summary (see the original guideline document), which provides a concise synopsis of effectiveness, if any, of each treatment method based on existing medical evidence. Each summary and subsequent recommendation is hyper-linked into the studies on which they are based, in abstract form, which have been ranked, highlighted, and indexed.

These guidelines unite evidence-based protocols for medical treatment with normative expectations for disability duration. They also bridge the interests of the many professional groups involved in assessing workers for fitness for duty.

Not stated

An implementation strategy was not provided.

Living with Illness
Staying Healthy

Effectiveness
Patient-centeredness

• Work Loss Data Institute. Fitness for duty. Corpus Christi (TX): Work Loss Data Institute; 2006. 72 p. [94 references]

Not applicable: The guideline was not adapted from another source.

2005 (revised 2006 Dec 3)

Work Loss Data Institute - Public For Profit Organization

Not stated

Not stated

There are no conflicts of interest among the guideline development members.

This is the current release of the guideline.

This guideline updates a previous version: Work Loss Data Institute. Fitness for duty. Corpus Christi (TX): Work Loss Data Institute; 2005. 72 p.

The Official Disability Guidelines product line, including ODG Treatment in Workers Comp, is updated annually, as it has been since the first release in 1996.

This NGC summary was completed by ECRI on January 30, 2006. This summary was updated by ECRI on March 29, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.