Swiss Disability Insurance Research Articles

Evolution of disability pension after renal transplantation: methods and results of a database linkage study of the Swiss Transplant Cohort Study and Swiss Disability Insurance.

In Switzerland, certain patients with disabilities and reduced working ability are entitled to a disability pension granted by the Swiss Federal Social Insurance Office (FSIO). The aim was to assess the evolution of disability pension and work capacity after kidney transplantation and thereby pilot the procedures linking FSIO data with Swiss Transplant Cohort Study (STCS) data. The current study pilot tested the record linkage of FSIO data with data from the STCS in a single-centre, observational setting. Patients were requested to consent to the use of their Swiss social security number (SSSN) for the purpose of record linkage. A privacy preserving trust centre approach was implemented with blinded statistical analysis. Between May 2008 and December 2015, 282 working-age renal transplant recipients of the University Hospital of Basel transplant centre were eligible for inclusion and 136 (48%, median age 48 years) consented to the use of their social security number and record linkage. The FSIO datasets of all patients were successfully retrieved and linked to STCS data in the trust centre and were numerically analysable. Yearly FSIO allowance data were available for the entire study duration. Fifty-five patients (40%) were registered as disability insurance recipients (DIR). In the entire population, the proportion of working patients slightly decreased from 76% to 72% between the pre-transplant and the post-transplant period. This was due to the lower proportion of patients working after transplantation in DIR compared with non-recipients (non-DIR) (DIR: 60% before vs 44% after; non-DIR: 83% before vs 88% after). In the DIR group, the proportion of patients not working increased from 36% to 49%, whereas in non-DIR the proportion changed only marginally (14% to 12%). The average disability insurance allowance was CHF 1172 per month. It changed from CHF 1135 before transplantation to CHF 1209 after transplantation (p = 0.59). In the Swiss healthcare and social insurance system, record linkage studies combining clinical datasets with data from FSIO are feasible but associated with great efforts and resource needs. The lack of changes in disability allowances after kidney transplantation should be further investigated in the nationwide setting.

Activation, Non-Take-Up, and the Sense of Entitlement: A Swiss Case Study of Disability Policy Reforms

Abstract Based on the case of the Swiss disability insurance (DI), the article questions the impact of activation on the (non-)take-up of social policies. It investigates the aim and content of activation policies (as found in official texts and discourses) and their subjective perception among recipients. Inspired by Kerr’s model and Hobson’s notion of “sense of entitlement”, analysis reveals the paradoxical outcomes of DI reforms. It underlines the importance of the subjective dimension of entitlements in the sociological understanding of non-take-up.

Paradoxes of Universalism: The Case of the Swiss Disability Insurance

Social policies rely on specific expectations vis-a-vis their beneficiaries, who have to abide by certain eligibility criteria or behavioral standards to access the benefits or services provided. As such, they draw boundaries between the deserving and undeserving, which results in the following paradox: While social policies claim to be universal, they actually exclude potential beneficiaries by imposing on them the compliance with these eligibility criteria and behavioral standards. In other words, purportedly universal social policies may have exclusionary effects, in the form either of selectivity (street-level bureaucrats select what they perceive as legitimate beneficiaries) or of self-exclusion and non-take-up (people entitled do not claim benefits or services). Based on the case of the Swiss disability insurance, this article explores the extent of, and the reasons underlying, the paradoxes of universalism within active social policies. It relies on a mixed-methods research design, combining sequence analysis (showing the selectivity of active reforms regarding people’s access to disability benefits) and in-depth interviews. The conclusion of this article suggests that not all forms of universalism are equally exposed to such paradoxes and proposes a hypothesis to be explored in further research: The more requiring and precise in terms of eligibility criteria and behavioral standards social policies and activation strategies are (hard universalism), the higher the risk that they lead to selective practices in contradiction with their universal ambition. By contrast, fuzzier eligibility or behavioral criteria (soft universalism), which allow for adjustment to individual circumstances, may lead to more genuinely universal and inclusive social policies.

The ‘compliant’, the ‘pacified’ and the ‘rebel’: experiences with Swiss disability insurance

Switzerland’s social policies in the field of disability have been significantly reshaped over the last two decades by reducing the number of allowances awarded and by increasing the recourse to vocational rehabilitation measures. What stances do individuals who experience the implementation of these policies adopt? What kind of tests are they subjected to? How can we explain the posture they adopt – be it ‘compliant’, ‘pacified’ or ‘rebellious’ – when facing the (re)assignations of their identity and professional status? Drawing on interviews conducted with individuals who have recently been involved in programmes set up by Swiss disability insurance, we highlight their uncertainties and concerns relating to their place in society, as well as their reactions to disability insurance’s interventions.

Standardized evaluation of vocational reintegration abilities – The Rheinfelden modular assessment tool

One of the main objectives of rehabilitation is the restoration of working capacity. In some cases, physical and mental performance cannot be achieved to the degree that was possible before the onset of illness or accident. Conventional medical examination alone often leads to a deficit-oriented assessment of work-related contents and limitations on work ability. Alternative employment opportunities are rarely recommended. For this reason, a modular assessment tool was developed in cooperation with a regional Swiss disability insurance. The results of the reintegration assessment tool reflect not only medical but also performance as well as motivation-related aspects of individual vocational rehabilitation ability and lead to immediate occupational recommendations within the conclusions. Several modules are combined to achieve a case-related, task-oriented review with solutions for reintegration. The assessment of occupational reintegration capacity consists of: – clinical examination; – performance tests and questionnaires; – roundtable with patient and insurer. Optionally, additional modules for psychiatric or specific medical questions can be integrated as needed. In addition to the examinations, validated assessments of general and disease-related function as well as quality of life and standardized physical tests including assessment of willpower, motivation and test consistency are used. The concluding round table discussion represents the novel key feature of this reintegration assessment tool. By explaining all the results to the patient in an understandable way, together, the remaining physical and mental resources can be worked out and further steps can be defined that take the individual situation into account. Consequences to the patient can be directly matched with the possibilities of the insurer. The final assessment report, approximately 12 plus 12 pages, is largely standardized but highly individualized in terms of conclusions and recommendations, which makes it applicable by the insurer to further activities. More than 100 cases were completed - examples are given.

Case-study of a user-driven prosthetic arm design: bionic hand versus customized body-powered technology in a highly demanding work environment

BackgroundProsthetic arm research predominantly focuses on “bionic” but not body-powered arms. However, any research orientation along user needs requires sufficiently precise workplace specifications and sufficiently hard testing. Forensic medicine is a demanding environment, also physically, also for non-disabled people, on several dimensions (e.g., distances, weights, size, temperature, time).MethodsAs unilateral below elbow amputee user, the first author is in a unique position to provide direct comparison of a “bionic” myoelectric iLimb Revolution (Touch Bionics) and a customized body-powered arm which contains a number of new developments initiated or developed by the user: (1) quick lock steel wrist unit; (2) cable mount modification; (3) cast shape modeled shoulder anchor; (4) suspension with a soft double layer liner (Ohio Willowwood) and tube gauze (Molnlycke) combination. The iLimb is mounted on an epoxy socket; a lanyard fixed liner (Ohio Willowwood) contains magnetic electrodes (Liberating Technologies). An on the job usage of five years was supplemented with dedicated and focused intensive two-week use tests at work for both systems.ResultsThe side-by-side comparison showed that the customized body-powered arm provides reliable, comfortable, effective, powerful as well as subtle service with minimal maintenance; most notably, grip reliability, grip force regulation, grip performance, center of balance, component wear down, sweat/temperature independence and skin state are good whereas the iLimb system exhibited a number of relevant serious constraints.ConclusionsResearch and development of functional prostheses may want to focus on body-powered technology as it already performs on manually demanding and heavy jobs whereas eliminating myoelectric technology’s constraints seems out of reach. Relevant testing could be developed to help expediting this. This is relevant as Swiss disability insurance specifically supports prostheses that enable actual work integration. Myoelectric and cosmetic arm improvement may benefit from a less forgiving focus on perfecting anthropomorphic appearance.

IV-Gutachten der Jahre 2004/2005 der Medizinischen Abklärungsstation MEDAS am Universitätsspital Basel – Eine kritische Analyse

Medical assessments of patients seeking disability benefits are one of the most important services provided by MEDAS/asim Basel for the Swiss Disability Insurance scheme. An evaluation of 593 assessments from 2004 and 2005 was carried out in order to gain initial insights into the characteristics of this special patient population. Information about sociodemographic background, diagnoses and certified fitness to work was collected and evaluated. The majority of the assessed patients were immigrants (61%) from southern and south-eastern Europe, 86% of whom suffered from chronic pain conditions and depression. At the time of the assessments, only 101 patients (17% of the total) were working full- or part-time. For 38% of the patient population under investigation, the last work period in mostly unskilled occupations varied from a few months to several years and had ended 1.5-2.5 years previously.

Three-year cost analysis of function-centred versus pain-centred inpatient rehabilitation in patients with chronic non-specific low back pain

To compare costs of function- and pain-centred inpatient treatment in patients with chronic low back pain over 3 years of follow-up. Cost analysis of a randomized controlled trial. A total of 174 patients with chronic low back pain were randomized to function- or pain-centred inpatient treatment. Data on direct and indirect costs were gathered by questionnaires sent to patients, health insurance providers, employers, and the Swiss Disability Insurance Company. There was a non-significant difference in total medical costs after 3 years' follow-up. Total costs were 77,305 Euros in the function-centred inpatient treatment group and 83,085 Euros in the pain-centred inpatient treatment group. Likewise, indirect costs after 3 years from lost work days were non-significantly lower in the function-centred in-patient treatment group (6354 Euros; 95% confidence interval -20,892, 8392) and direct medical costs were non-significantly higher in the function-centred inpatient treatment group (574 Euros; 95% confidence interval -862, 2011). The total costs of function-centred and pain-centred inpatient treatment were similar over the whole 3-year follow-up.

Nützen Behandlungsempfehlungen in psychiatrischen versicherungsrechtlichen Gutachten?

In recent years the total number of people drawing a pension - especially for psychiatric reasons - from Switzerland's Federal Disability Insurance ("IV") has been steadily climbing. As we have revealed in earlier studies of persons applying for a disability pension for psychiatric reasons only 64 % had received psychiatric treatment and only 20 % adequate drug treatment .In this study we examined whether, treatment recommendations given by medical experts were followed and if so, how successfully.In 40 patients who had got a psychiatric expertise in 2004 at the Psychiatric Outpatient Department, University of Basel, on behalf of the Swiss Disability Insurance, a 1-year follow-up was done and the results were compared.At reassessment significantly more patients (58 %) were in psychiatric-psychotherapeutic treatment than at first assessment (32 %). The recommended drug treatments were fully complied with in only 43 % of the cases; the recommended psychotherapy in only 9 % of the cases; and recommended in-patient treatment at a psychiatric hospital in only 14 % of the cases. During the time between evaluations, the seriousness of the condition had altered in a number of cases: in 33 % the condition had noticeably improved (e. g. from severe to mild depression) or was no longer present, and in 9 % the condition had worsened (e. g. from mild to severe depression). No significant relationship was found between compliance (full, partial or no implementation of recommended treatments) and change in illness severity. Partnership has been identified as the factor with the strongest influence on illness severity: in subjects who were married or living with a partner illness course was much better than in subjects without a stable partnership.

Dans quelle mesure les maladies cardiovasculaires sont-elles la cause d’incapacité de travail et d’invalidité en Suisse?

Cardiovascular diseases (CVD) are a major cause of morbidity and mortality in industrialized countries, and also in Switzerland. In 2004/2005, CVD were in first line of all medical diagnosis by primary care physicians (12.4%) and of all causes of hospitalisation (9.6%). However, statistical data of work incapacity and disability related to CVD remain still insufficient. Based on medical publications and official Swiss statistics, CVD accountedfor only 2.3% among all medical causes of sickness certification for > 6 days established by primary care physicians in patients aged 15 to 64 years. Furthermore in 2006, CVD were involved only in 2.5% of women and 5.5% of men receiving a pension of Swiss disability insurance. Between 1987 and 2006, the proportion of diagnosis of CVD at medical office decreased from 14.6 to 12.4% (-15%), while during the same period, the reduction of the proportion of disability pension was more pronounced, from 9.6 to 4.1% (-57%). The magnitude of these changes reinforce the need for more detailed statistical data in order to evaluate the appropriateness between the expenditures devoted to the prevention and the therapy of CVD, and the economical consequences on work absenteeism and disability.

Utilisation de la classification internationale des maladies dans l'assurance-invalidité en Suisse: Étude de reproductibilité

The International Classification of Diseases (ICD-10) was introduced in a pilot phase for coding of diagnoses in a sample of cases encountered in the Swiss Disability Insurance (SDI), as a substitute for the SDI codes, judged unsuitable for the description of disability. The goal of this study is to evaluate the reliability of use of these codes, by studying the coding reproductibility between the Medical Observation Centers (MOC) and the Evaluation and Coordination Center. A second goal was to evaluate the feasibility of coding by non-physicians. Reliability of diagnoses was examined by level of precision: chapters, groups, categories and subcategories. The agreement between the two coding Centers varies from 78%, at the chapter level, to 29% at the most detailed level. This agreement is improved if taking into account the three main diagnoses for the comparison, reaching 91%. The results of the physician coder, concerning the precision and reliability of coding, are significantly superior to those of an economist coder and a medical secretary coder. To improve coding agreement, it is proposed to train coding professionals, provide coding tools, clarify which diagnosis is the main one, and seek a consensus for cases of systematic disagreement. The ideal level of precision should not be so high as to produce diagnostic codes with low reliability. It should, however, be precise enough to give a satisfactory description of the problems encountered.

Quality of work incapacity assessment in the Swiss disability insurance system.

Quality of medical assessment of work incapacity has been poorly investigated, despite the enormous costs engendered by transient incapacity of work and permanent disability. This study examined some indices of quality from a stratified, random sample (n = 120) of assessments performed by expert assessors of the Swiss disability insurance. The distribution of work incapacity (WI) percentages over a 100% scale showed a clustering around key values significantly associated with financial disability benefits. The precision of WI, expressed as the level of quantitative exactness, was found to be high in 74% (95% CI: 66-82%) of current WI assessments, and in 62% (95% CI: 53-71%) of maximal WI assessments. Disagreement was observed in 17% of cases when comparing two ways of expressing WI by the same physician (95% CI: 10-23%). This exploratory study is limited by the general lack of objective criteria and standards. Further theoretical and empirical developments are needed to determine standardized criteria and clear guidelines for medical assessments of WI, as well as for evaluating their quality.

Cross-coding from the Swiss Disability Insurance listing to the ICIDH.

It has been suggested that converting, via a process of cross-coding, the listing used by the Swiss Disability Insurance (SDI) for their statistics into codes of the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) would improve the quality and international comparability of disability statistics for Switzerland. Using two different methods we tested the feasibility of this cross-coding on a consecutive sample of 204 insured persons, examined at one of the medical observation centres of the SDI. Cross-coding is impossible, for all practical purposes, in a proportion varying between 30% and 100%, depending on the method of cross-coding, the level of disablement and the required quality of the resulting codes. Failure is due to lack of validity of the SDI codes: diseases are poorly described, consequences of diseases (disability and handicap, including loss of earning capacity), insufficiently described or not at all. Assessment of disability and handicap would provide necessary information for the SDI. It is concluded that the SDI should promote the use of the ICIDH in Switzerland, especially among medical practitioners whose assessment of work capacity is the key element in the decision to award benefits or propose rehabilitation.